Beginning of the End of Sri Lanka’s Free Healthcare Service? Or the Beginning of Policy Maturity?
A Response to Dr. Ajith Amarasinghe’s Politically Framed Critique
In recent commentary, Dr. Ajith Amarasinghe has warned that Sri Lanka stands at the brink of dismantling its free public healthcare system, alleging that recent Cabinet decisions signal an intention to privatise the National Health Service in all but name. The headline is emotive, the language urgent, and the conclusion foreboding. Yet a closer examination of both the Cabinet decisions themselves and comparative international experience reveals that this claim is not only overstated but fundamentally misconstrues the policy direction under discussion.
What is being proposed is not privatisation of Sri Lanka’s free healthcare system. It is the structured use of Public–Private Partnerships (PPPs) to address specific capacity gaps within an otherwise publicly funded and publicly delivered system. To frame this as the “beginning of the end” is less an act of policy analysis than one of political positioning.
Privatisation Versus Partnership: A Basic Distinction
At the outset, it is essential to clarify terminology. Privatisation involves the transfer of ownership, control, and risk from the public sector to private entities, usually accompanied by user fees or market pricing. A PPP, by contrast, is a contractual arrangement in which the state retains policy control, ownership of infrastructure, and responsibility for universal access, while the private sector is engaged to deliver defined services under regulated terms.
The Cabinet Decisions of 5 January 2026, which Dr. Amarasinghe characterises as “revolutionary” threats, fall squarely into the latter category. The state is not withdrawing from healthcare provision, nor is it introducing charges at the point of delivery. The government remains the payer, the regulator, and the guarantor of access. Patients continue to receive services free of charge.
Conflating PPPs with privatisation is analytically inaccurate. It may be rhetorically effective, but it does not withstand scrutiny.
What the Cabinet Decisions Actually Say
The two Cabinet proposals cited relate to highly capital intensive, technology driven services: advanced diagnostics and dialysis. These are areas where rapid technological obsolescence, maintenance complexity, and global supply chain volatility have increasingly strained public systems worldwide.
The proposals do not suggest selling hospitals, outsourcing clinical decision making, or dismantling the public health workforce. Instead, they propose:
Using privately owned diagnostic equipment within government hospitals, with the state paying for services delivered.
Engaging private operators to supply and maintain dialysis machines and consumables, while the government provides infrastructure and clinical oversight.
In both cases, the government remains responsible for patient care pathways, eligibility, clinical standards, and financing. This is supplementation, not substitution.
Sri Lanka’s Free Healthcare System Is Not Being Abandoned
Sri Lanka’s free healthcare model is rightly celebrated. Its outcomes relative to expenditure are among the best in the developing world. But celebrating success does not require pretending that the system faces no structural pressures.
Non-communicable diseases, an ageing population, and rising expectations for advanced diagnostics have fundamentally altered demand patterns. CT scanners, MRI units, angiography labs, and dialysis machines are no longer peripheral luxuries; they are core components of modern medicine. Managing these technologies efficiently is a challenge even for high income countries.
The argument that the private sector has “never functioned as a capital investor” in state healthcare is historically incomplete. Private pharmacies, diagnostic labs, ambulance services, and specialist consultancies have long operated alongside the public system in Sri Lanka, often filling gaps the state could not immediately address. The question is not whether private participation exists, but whether it is governed transparently and aligned with public objectives.
The UK NHS and the Misuse of the Thatcher Analogy
Dr. Amarasinghe invokes Margaret Thatcher’s reforms of the UK National Health Service as a cautionary tale. This comparison is frequently deployed in Sri Lankan debates, but it is rarely presented with historical or institutional accuracy.
First, the UK NHS did not deteriorate solely, or even primarily, because of private sector involvement. Many of its current crises stem from decades of underinvestment, demographic pressures, workforce shortages, and political reluctance to align funding with demand. Private Finance Initiatives (PFIs), introduced after Thatcher and expanded under subsequent governments, were not PPPs in the Sri Lankan sense but long term financing mechanisms that transferred construction risk at high cost due to poor contract design.
Second, Thatcher did not privatise the NHS. It remains publicly funded, publicly owned, and free at the point of use. Market mechanisms were introduced at the margins, largely for procurement and ancillary services. To suggest that any engagement with the private sector leads inexorably to systemic collapse is historically inaccurate.
Third, the UK spends over USD 6,000 per capita on healthcare not because of PPPs, but because it is a high income country with an ageing population and high treatment expectations. Comparing this figure to Sri Lanka’s USD 260 without adjusting for income, demographics, and disease burden is misleading.
Ironically, if there is a lesson to be drawn from the UK, it is not that PPPs must be avoided at all costs, but that they must be carefully designed, transparently managed, and tightly regulated. That is a governance challenge, not an ideological one.
On Capital Constraints and Administrative Reality
Dr. Amarasinghe disputes the Cabinet’s claim that capital constraints justify PPPs, citing underutilised budget allocations in 2025. This argument oversimplifies public finance realities.
Unspent allocations often reflect procurement delays, foreign exchange constraints, global supply disruptions, or administrative bottlenecks, not the absence of need. The fact that funds were returned to the Treasury does not mean that hospitals suddenly ceased to require equipment. It means the state apparatus struggled to deploy capital efficiently within a given fiscal year.
Moreover, owning equipment is only one part of the cost equation. Maintenance contracts, spare parts, software updates, calibration, and trained technicians represent ongoing obligations. PPPs, when properly structured, can shift some of these operational risks to providers better equipped to manage them, while allowing the state to focus on clinical delivery and oversight.
Profit and Public Service: Not an Inherent Contradiction
The claim that profit and public service are inherently incompatible is philosophically appealing but empirically weak. Airlines, utilities, telecommunications, and even defence procurement operate through hybrid public–private models across the world. The critical variable is not profit itself, but whether profit is regulated, capped, and aligned with performance.
A well drafted PPP contract can include service level agreements, penalties for non performance, audit requirements, and termination clauses. Poorly drafted contracts invite abuse. The difference lies in state capacity, not ideology.
To argue that any private involvement will automatically lead to service withdrawal if payments are delayed is to imply that the state is incapable of managing contracts. If that is the case, the problem lies deeper than healthcare policy.
Academic Authority and Policy Credibility
Public debate benefits from expertise, but expertise must be grounded in evidence. Dr. Amarasinghe’s article relies heavily on emotive framing, selective international comparison, and assumptions about intent that are not supported by the text of the Cabinet decisions.
Policy credibility is not derived from titles alone, but from methodological rigour, historical literacy, and familiarity with comparative systems. Complex subjects such as PPPs, health economics, and institutional reform demand nuance. Reducing them to slogans about “the end of free healthcare” does a disservice to public understanding.
What Sri Lanka Should Be Debating Instead
The real debate Sri Lanka should be having is not whether PPPs equal privatisation, but:
How contracts will be structured and monitored
How value for money will be assessed
How corruption risks will be mitigated
How clinical autonomy will be protected
How equity of access will be ensured across regions
These are legitimate concerns. They require scrutiny, not alarmism.
Ideology Versus Governance
Sri Lanka’s free healthcare system is not being dismantled by stealth. It is being tested by modern medical realities that demand adaptive policy responses. Public–Private Partnerships, if designed intelligently, can strengthen the system rather than weaken it.
To portray these proposals as an existential threat is to substitute ideology for analysis. The true danger lies not in pragmatic experimentation, but in refusing to evolve while clinging to slogans that belong to a different era.
The question is not whether Sri Lanka should protect its free healthcare system. It must. The question is whether it can do so while responsibly engaging with private capacity to deliver better outcomes for patients. On that question, fear based narratives offer little guidance.