First of the Series of Interviews Conducted with the Doctor, Staff and Parents of NICU Babies by Jaffna-based Journalist Thulasi Muttulingam in Collaboration with Global Innovators

Cradling the Future: Investing in NICU & Newborn Care in Northern Sri Lanka

Sri Lanka’s public healthcare system, which is freely available to its citizens, is considered one of the best in the world. It has continued to function and deliver vital services to its largely low-income population through a 30-year civil war, as well as numerous natural and human-made disasters.

Today, however, it faces one of its greatest threats. The country’s economic crash in 2022, followed by loan bailouts with strict conditions, has left the government unable to invest in public healthcare at previous levels. Among the many services impacted is the Neonatal Intensive Care Unit (NICU) at the Jaffna Teaching Hospital.

The following is an in-depth interview with Dr. Nithyaruban, head of the NICU in Jaffna, on the crucial services they provide and the funding they urgently require to continue their work.

Interview of Dr. Nithyaruban- Consultant Neonatologist at Jaffna Teaching Hospital by Thulasi Muttulingam

Thulasi: Hello Doctor, thank you for this interview. Could you explain to us your current role in the Neonatal Intensive Care Unit (NICU) at the Jaffna Teaching Hospital, Sri Lanka?

 Dr Nithyaruban: I am a consultant neonatologist at the Teaching Hospital, Jaffna. I have been working here for three years. I graduated from Jaffna University and did my postgraduate education in Colombo.  

Thulasi: You are the head of the unit?  

Dr Nithyaruban: Yes.

Thulasi: How many staff members do you have there?

Dr Nithyaruban: Currently there are 11 doctors, 30 nurses and 2 midwives. There are also 3 health assistants appointed by the government. They are the gofers who keep the unit running. One of them is on maternity leave currently so we have two. Two are not enough to do all the work in a NICU unit of our size so we also employ 7 ‘volunteer’ health assistants. This is what our fundraising drive is really about. They do full time jobs but we cannot pay them adequately. In order to retain their essential services to our unit, we depend on well-wishers.

 We have 13 NICU beds and we also have a special care unit with 12 beds and a mother-baby unit with 13 beds; 3 sub units across the NICU.
For the normal deliveries, there are 4 post-natal wards with 15-20 beds each. Mothers and babies are cared for there, if the baby is healthy. That is the structure of our neonatal unit at present.

Thulasi: Are there enough beds and facilities to cater to all the births in the region at present?

Dr Nithyaruban: Not really enough, no. We manage the needs for the beds by sharing with other wards. A new building has been approved for us for the next year by an Asian Development Bank project.  It will be a 10 storey building. We will have adequate space for our unit once we relocate there. Currently though, we are in a temporary makeshift location.
Last year, our unit was on the ground floor of the Teaching Hospital and was affected by severe flooding. Water came into the building. Since we have to take extra care of NICU babies, this unit on the 4th floor was hastily arranged – although it had not originally been intended for our specific needs. We are operating it as a temporary measure therefore till we can move into the spacious new building.

Thulasi: Will your problems regarding staff capacity be resolved alongside space, once you move in there?

Dr Nithyaruban: That building project will start only next year. It’s intended as a 5-year project just to construct the building. Given contractor delays around here, finishing on time in 5-6 years would be an optimistic estimate. We don’t envision moving in there anytime soon.

As for whether our current financial issues and staff capacity would also be sorted, that depends on the economy of the country sustainably improving. If that happens, then yes. It’s the economic crisis affecting all the sectors here including ours.

Thulasi: What kind of cases do you generally see in the NICU?

Dr Nithyaruban: Mostly premature babies. When babies are born after 36 weeks or more, they usually do not need ICU care. But if they are born earlier than 36 weeks, their internal systems would not be developed adequately. So they need ICU care. Their lungs or their heart would not be properly developed for example and they would need support. We have babies born as early as 25 weeks and we work hard to help them survive.  

Thulasi: What kind of funding issues do you have in the NICU?

 Dr Nithyaruban: The cost of running an ICU is very high compared to a normal ward. And because the infection rate for newborn babies is very high, we cannot reuse things we would otherwise use in other ICUs; we have to discard them. So the expenditure here is much higher than even other ICU units. In a private hospital, to care for a baby born at 25 weeks and to hand over as a healthy baby, people pay about Rs 8.5 million (USD 28,000).

The daily charge in these hospitals range from Rs 50 – 100,000 (USD 200-400). Even if you take away their profit margin, the cost could be estimated at about two thirds of this amount. In our public hospitals, the government bears this cost and offers the service free to our affected families. As such the NICU is an extremely expensive unit to run.
Alongside this, back-to-back crisis like the Covid pandemic and the Sri Lankan economic crash didn’t help. The government was obliged to take massive international loans and due to the IMF bonds that were enforced after that, we are unable to hire more staff.
This is the reason we are unable to hire more health assistants as needed.  The so-called volunteer force we’ve collected are currently being funded through NGOs and private well-wishers. They do full time jobs however though they cannot be employed directly by the government. Funding for them is the main problem we face now. We have 7 volunteers. They have been working for a few years at least now, some of them. They are dedicated workers essential to keep the unit running but we are unable to pay them proper salaries. Currently, we are paying them just 1/3 of what they could reasonably expect to get as a public sector employee in the same capacity. Usually, a health assistant is paid about Rs 65,000 (USD 250) per month and would also get overtime payments if they work extra.  But we can afford to pay only one third of this currently.
If we could get consistent funds to pay their salaries, we can pay them better. Right now, the funding is not consistent, and so we cannot afford to pay them proper salaries in case we run out later.

They are essential service workers who work extremely hard though. They do night shifts too and they work as much as the government employees. Even though they are termed ‘volunteers,’ it doesn’t mean they come to work whenever they want. They come to work at the proper time and work full-time shifts, sometimes more. We cannot manage the unit without them and so, they need to be compensated appropriately.  

Thulasi: Can you tell me more about their role? What do the health assistants do?

Dr Nithyaruban: They are responsible for cleaning the units and setting up equipment. They have to sort and discard medical waste responsibly.  There would be plastics, needles, cloths and they need to be separated out first. If we are sending blood from our unit to be tested, they have to take it to the lab, and bring back the report. They have to bring the medicines that we need from pharmacies and stores. They have to bring the oxygen cylinders. If babies need to be brought in from other wards, they have to transport them in their incubators. It’s a lot of hard and high responsibility work. They should also fold the cloths and prepare the gauze used to apply medicines and to clean wounds, and send them for sterilization. Doing this for about 31 babies is a lot of work. Usually there will be only three of them in a shift. One will be doing outside work such as taking the blood samples to the lab and only two of them will be working inside. They will be continuously on their feet as we do not have enough staff to do this work. The government employs only 3 for our unit; with even 7 extra, we are still running them off their feet. We need even more but cannot afford any more at the moment. So we somehow make do.

Thulasi: How can donations be made to your unit? Can they be transparently tracked?

Dr Nithyaruban: We have a patient welfare society registered in our hospital. If the donations are sent to the Society in our name, they will pass the funds to us as requested.  

Thulasi: Noted, thank you. Could you also relay your experience in the field? You said you’ve been working in this NICU unit for 3 years. What did you do before?

Dr Nithyaruban: Before that, all my work was outside Jaffna. I worked in Kilinochchi for 4 years and then in Kandy for 2 years and in Peradeniya for one and a half years. Then in Horana for one year and in Colombo for 4 years. Because public health doctors are required to work across the country, I have experienced work in many places.  

Thulasi: So how does our mother and baby care facilities compare with the rest of the country? 

Dr Nithyaruban: All public health services have to maintain a national standard. We are not allowed to be behind any other part of the country. There might be some small variations regionally but the national standard is still being maintained.

Thulasi: So all the public hospitals regionally have the same equipment, the same level and number of staff?

Dr Nithyaruban: Depends on whether they are Teaching Hospitals, which would be the largest tertiary care center in each province versus district hospitals serving rural villages. Ours is the Teaching Hospital for the Northern Province and so we have all the facilities available in tertiary public healthcare in the other provinces including Colombo. Availability of specialist equipment is not a problem here; they are updated as required regularly and we can get them when needed. Staff shortage, including doctors and nurses is a problem but we are not the only hospital facing that issue. It is a problem that the whole country is facing. So we can say we provide the same kind of care here as in the capital city, Colombo.

Thulasi: Are there cases where you need to tell patients to go to more advanced healthcare providing countries like India or Singapore due to lack of capacity in Sri Lanka, or does Sri Lanka have the necessary capacity to deal with our health problems?

Dr Nithyaruban: There are some treatments that cannot be done in Sri Lanka, for example certain cancer treatments and bone marrow transplants as we don’t have the necessary tech and infrastructure here. Sri Lanka has adequate treatment available for about 80% of the diseases we see here. The other 20% are rare diseases not commonly seen in our population. The cost would be unsustainably high to develop the infrastructure necessary to treat them so we recommend such patients to seek treatment abroad.   

 Thulasi: Which country is the best option in such cases?

Dr Nithyaruban: India is the most popular option among our people because their private healthcare is the most affordable for us as well as the most advanced in the region.   Some go to USA or Singapore too but that’s beyond most people’s budgets here.

Thulasi: And how about our private hospitals? You said they would charge up to Rs.8.5 million for one to two months of care at the NICU. Are there people here accessing private healthcare at such rates?

Dr Nithyaruban: Not in our Northern Province, no. People here mostly cannot afford that kind of fee and so the private hospitals here have not developed NICU units either. They are available in Colombo however.

Thulasi: The reason I asked is, the main reason people go to private hospitals here is because there is a long waiting list in government hospitals for heart diseases and such.  

Dr Nithyaruban: For ordinary diseases, as the numbers are high here (in the government hospitals) people go to private hospitals. But if the diseases are severe, the Teaching Hospital is the best option, because it has all the facilities. But the delay is unavoidable because the number of patients is high and our capacity is limited.  

Thulasi: I understand. But why are people paying Rs.8.5 million at a private hospital when the facilities are available at the government hospitals?

Dr Nithyaruban: Mostly because it is comfortable. Here in the government hospitals, we cannot give them individual rooms. Everyone will be in a dormitory styled ward with common bathrooms. In a private hospital, you will get you own room and an attached bathroom with privacy. It will be spacious and air conditioned. Particularly when someone has given birth or had caesarean surgery, she would feel uncomfortable, so these considerations could be important.  

Thulasi: What percentage of live births end up in the NICU here?

Dr Nithyaruban: In Jaffna, about 25% need an ICU.  But at the national level, it is 13%. The reason it is higher in Jaffna, is that many of the babies born here are high risk babies. Either the mother or the baby would have some illness. Because this is a tertiary care center, pregnant mothers from all over the Northern Province who have illnesses or whose babies have illnesses come here to give birth. So the admission rate is also high here.  

Thulasi: What health complications do you commonly see among the mothers?

Dr Nithyaruban: They commonly have diabetes, epilepsy or high blood pressure. Or problems in their kidneys, lungs or heart. Or high obesity or cancer. In these cases, it would be risky to treat them in the district general hospitals. Facilities may be lacking there. Doctors of all specialties are here in the Teaching Hospital – kidney or lung specialists, neurologists and so on.

So it would be possible to get their advice instantly and treat them accordingly here. But we cannot expect similar standards in the rural District hospitals as such specialists cannot be appointed there.

Similarly babies may also have complications at birth such as their bodies not being formed properly in the womb, they can have blockage in their intestines, or defects in their lungs, heart or nervous system. As they might require surgery, they are more often admitted to the Jaffna Teaching Hospital. Sometimes the problems are detected through scans before birth and they are sent here. But sometimes they are not found and they are sent here after the birth for further treatments. So the load is very high here. Higher than our capacity. That is common in a tertiary care center.  

Thulasi: What kind of cases do you have in your NICU currently?

Dr Nithyaruban: More than half are prematurely born babies. That’s generally the case. Some are there due to infections, some have a hole in their heart. Sometimes they would need surgeries. Sometimes, a baby’s intestines might have moved into the chest cavity and a surgery might be needed to move it back to the right position. Sometimes, because the spine is not developed properly, the spinal cord might be protruding at birth. It is called Meningomyelocele. A surgery would be needed to correct it. We have the best neurosurgeons in our hospital. The protruding nerves are placed back in and fully stitched in. Infections are also another common problem. There can be many reasons why babies can get infections. Babies have very low immunity. Even an infection which is normal to an adult can cause severe effect on a baby. They might have gotten an infection through their mother’s birth canal during delivery. Mothers often ask how their newborn babies got an infection. But the infection would have been there already.  

Thulasi: And what is your success rate at the Unit?

Dr Nithyaruban: It’s reasonably high although we need to catch up to the national standard. The neonatal mortality rate is about 4.4 babies per 1000 nationally; in Jaffna currently, our rate is about 5 per 1000. We are slightly behind them. (Global rate is 17 per 1000).

Thulasi: Generally, what are the parents’ feedback to you after using your NICU’s services?   

Dr Nithyaruban: They are of course relieved and grateful when the babies are cured and can safely be taken home. But the babies have to be here for at least a week and in some cases, up to three months. They don’t feel comfortable here. Because there might be 7 or 8 mothers in a room. And the bathroom facilities are also limited. Their satisfaction is low in that regard. 

Thulasi: Understood. That’s a common issue in public hospitals providing free healthcare.  Thank you very much Doctor. We’ve covered the basics, I think. Do you have anything to add?

Dr Nithyaruban: Mainly I want to stress upon the fundraising needed to pay our health assistants. They are essential to keep our unit functioning well and need to be compensated adequately. That’s my primary concern at the moment.

Thulasi: We will do our best Doctor. That is what this interview is mainly for. We would also like to relay some success stories, mainly about premature births or other birth complications requiring extended care at your NICU. If you can direct us to some parents who are willing to be interviewed for our case studies, that would be helpful too. Thank you.