Sri Lanka’s Care Crisis
Sri Lanka’s economic crisis has quietly devastated the lives of children, the disabled, the elderly, and their caretakers.
Mawannalla Hospital, Pre-Natal and Post-Natal Care Units, Sri Lanka. Image: Simone D. McCourtie / World Bank
“The economic crisis devastated us,” Vadivel Vasanthy, a 40 year-old maid based in Vavunathivu in Batticaloa told me. Prior to the economic crisis, Vasanthy ran a small business which sold spices and peanuts in her local area, but had to close it because of a rise in supply costs. In 1998, Vasanthy lost one eye and half her face in a shell attack. The incident left her with multiple disabilities such as a loss in hearing, sun sensitivity, and constant headaches. Vasanthy and her husband separated fourteen years ago so she is currently responsible for her son and her elderly parents. Her father, who is 86 years old, is vision-impaired and bedridden. As she is the sole breadwinner in her family, she has recently started a job as a domestic worker, where she cooks food, cleans the house, and washes clothes for 600 rupees per day, of which 200 rupees is lost to transport. While Vasanthy works, her elderly mother who is 68 years old looks after her father and her son.
Prior to the economic crisis, the public hospital in Vasanthy’s local area provided medication for free. However, the economic crisis resulted in a scarcity of medicine, which had to be sourced from private pharmacies. This has impaired her further. She has also been denied a disability allowance, which would provide some economic relief for her household. Batticaloa also has no easily accessible support services or accessibility schemes for the disabled community.
“My physical limitations and the lack of money mean that I cannot provide the support, care, and life my family deserves,” Vasanthy told me. The family’s overall food intake has fallen from three to two meals per day. Vasanthy skips meals so there’s more food left for her child. Despite this, she is still unable to completely provide for him. “I cannot cover the costs for his school uniform or stationery,” she said.
Sri Lanka’s Economic Crisis
In early 2022, Sri Lanka’s economy collapsed. A series of structural reasons such as a current account deficit, budget deficit, and an external debt crisis acted as the root causes. The Easter Sunday attacks in 2019 and the pandemic crippled one of the most important forms of revenue: tourism. Bad policies such as tax cuts, a fertiliser ban, and a decision to use money from the reserves to finance debt led to a crisis of essentials. Queues could be seen across the country as people lined up for fuel, gas, and kerosene in the early months of 2022. The prices of staples such as rice and lentils skyrocketed. Medicine and medical equipment became scarce. Power cuts lasted for 13 hours in April 2022, the hottest month of the year.
Women sit near an empty fuel station hoping to buy kerosene oil for cooking in Colombo, Sri Lanka. Image: HRW
As a response, a number of protests started across the country and culminated in the expulsion of the former president, Gotabaya Rajapaksa. The Rajapaksa family’s Sri Lanka Podujana Peramuna (SLPP) party still held a two-thirds majority and chose Ranil Wickremasinghe as his replacement. The Rajapaksas, in turn, cemented their control over the country, but with a proxy in place. Trade unionists, student union leaders, and other activists have been intimidated and harassed into silence. An illusory veil of stability pervades the country.
“The economic crisis has slipped into people’s households and continues to impact people’s personal lives on a daily basis — especially in the form of a care crisis.”
As senior researcher, Dr. Gayathri Lokuge, said: “The economic pressures in the household unit are enormous at the moment.” The economic crisis has slipped into people’s households and continues to impact people’s personal lives on a daily basis — especially in the form of a care crisis. Every family has a vulnerable person, be it a child, a disabled member, or an elderly parent, that has had their quality of care crumble over the past year.
With the crisis of essentials in 2022, the prices of diapers, medication, food, and transport skyrocketed. A World Bank report noted that national poverty had doubled to 25 percent and urban poverty had tripled to 15 percent in 2022. The WFP stated that 6.3 million people are food insecure — three in ten households in June 2022. Children’s education has been impacted as they dropped out of school or have stopped tuition classes and extracurricular activities.
The complex care needs of disabled people, which sometimes overlap, have been pushed to the background. “In the economic crisis, disabled people are deprioritised in a resource-scarce environment,” disability activist and researcher Niluka Gunawardena told me. The homelessness of people who have psycho-social and intellectual disabilities have risen. Medication and rehabilitation devices, such as ear implants, have become expensive and their impairments have increased. “There is no infrastructure to support their physical, emotional or economic independence so disabled people have to face their problems alone,” Rasanjali Pathirage, Secretary General of the DOJF (Disability Organization Joint Front) said.
Sri Lanka's economic crisis has impacted the lives and livelihoods of the disabled. Image: Voice
Older people too have been hit by the care crisis. They are released prematurely by public hospitals that are treating them. Many cannot buy the medications they need for their non-communicable diseases. Basic materials such as soil-sheets cannot be found and many families have used quick-fixes such as polythene sheets that have led to bedsores. Their mental health has been impacted by the stress that their families and caretakers experience.
Carers have also been impacted. Malika Kumari (52) is a paid carer from Kandana, a city near Colombo. Malika provides 24/7 care to her patients, either in hospitals or in homes. She starts her day at 4.00am when she cleans and bathes her patients. She has to also provide medicines, which have to be pounded into a powder if the patient is bedridden. Three times a day, she prepares their meals and feeds them, which is a delicate process if they have to be fed liquified food from a tube. Wound prevention is another concern where she has to either help patients exercise or move their bodies across the bed. Another aspect of her job is companionship, as she and her patient spent time in shared activities.
Malika has to provide for her older husband and her adult daughter, who is a stay-at-home mother with a toddler and a newborn. She needs 90,000 rupees per month to help her entire family out, but has been exploited as clients have delayed or reduced her payment. “Women’s lives, in particular, have changed. There’s a lot of resentment, apprehension, and frustration about the family’s future. It is a bleak situation for a lot of women,” a member of the Progressive Women’s Collective, Vraie Balthazar told me.
The History of Care in Sri Lanka
Historically, care in Sri Lanka has been shouldered by the family. A study described the traditional family as “extended” because it included multiple generations such as grandparents, parents and children, and also multiple members in terms of proximity, such as close and distant relatives. They shouldered many roles within the family, such as the care of vulnerable family members like children and the elderly. In contemporary society, the family structure evolved into a nuclear family to include parents and children only.
Meanwhile, members of the family who are simultaneously vulnerable and poor have to seek institutionalised care in orphanages, disabled homes, or elder care homes. “Part of the reason care is institutionalised is because of factors such as poverty, the inability to provide care if there are complex care needs inside a home and shame,” Niluka told me. Many of these venues have a charity-driven model where people donate money, host danays (free meals), and sing songs of praise. “It is very dehumanizing for a person or a community to depend on this model to meet their basic needs,” Niluka added.
Vulnerable people consist of a sizable portion of the overall population. Data by the United Nations Population Fund (UNFPA) notes that 0-14 year-olds make up 22 percent of the population in 2023. A study by the International Center for Ethnic Studies revealed that 1.7 million persons in Sri Lanka have a disability, which amounts to 10 percent of the population. A study by the UNFPA predicted that Sri Lanka’s elderly population could amount to 5.1 million by 2037, which is equivalent to a 103 percent increase within 25 years.
Economist Ramani Gunatileke’s research focused on the care economy in the country. Her quantitative analysis, which, as of yet, is unpublished, noted that the number of paid carers inside the country has reduced from 38,000 in 2014 to 12,000 in 2018. Women are the majority of paid carers and make up 84 percent of the industry. Unpaid carers, who are usually members of the household, amounted to five million people. Of these, 3.5 million were women. “There is a very strong social expectation and norm, where it's the adult woman who is the carer,” Director of Women and Media Collective, Dr. Sepali Kottegoda said. “Caring for others is supposedly an innate part of being a woman, but it is socialization which puts that responsibility on women.” A time use-survey in 2017 noted that women spent 38.4 percent of their total time on the care of the household and family members. As economist Dileni Gunawardena said, “Women are subsidizing the economy.” With unpaid care labour, they contributed 14-16 percent of the Gross Domestic Product (GDP).
With the economic crisis, workers have left the country at record rates. Local media reported that 311,269 left the country in 2022. Marxist feminists such as Silvia Federici and Nancy Fraser described the care crisis as a result of globalization and the international division of labour, as many people have moved from the Global South to the Global North for employment. While Sri Lanka has a history of domestic labourers traveling to the Middle East, the numbers have sharply increased and has included doctors, nurses and paid carers. This has been complemented by rural-urban relocation. This movement of people has disrupted the informal ecosystems, routines, and rituals of care. “It has put a lot of pressure on the nuclear family,” feminist anthropologist at the University of York Asha Abeysekera told me.
A study by the UNFPA raised another important point: Women have a projected longer life expectancy than men. They are, as a consequence, likely to comprise the majority of the elderly population. “Who then cares for the carer then?” Dr. Kottegoda questioned.
The Limitations of the Public Sector
There is a lack of state-led and state-funded initiatives to support vulnerable people. While the country has universal access to primary and secondary education, this is not the case for pre-primary education. The state has understood that there is a demand for childcare and there have been some initiatives to provide services for the families of civil servants. For example, there is a daycare centre in Sethsiripaya office complex and there are some childcare centres run by the Provincial Councils. One limitation is accessibility, because these initiatives only cater to a limited group. “These centres are trying to fill a demand for childcare, but they feel ad-hoc. It is not done in a standardized or systematic manner,” said early childhood development specialist Renu Warnasuriya.
Disabled people have limited assistance from the state too. There is a disability allowance which amounts to 3000 rupees for disabled members from low-income families. “How is that benefit calculated? It is calculated on the basis that someone else is looking after that person. It is not calculated for the actual care that this person requires,” Kottegoda told me. Further, cash transfer schemes are also limited. They do not cover the basic needs of recipients, and they only cover a small proportion of recipients because of limited funds. They also have a complex application process and a selection process that is politicized. There are self-employment assistance programs but these are a failure because of the limited markets, the inability to secure loans, and the lack of financial security they offer to participants. These initiatives fail to lead to and sustain the physical, social, and economic independence of disabled people.
The elderly have access to some welfare schemes. Former public servants receive a pension and employees in the private sector have either the Employees Provident Fund (EPF) or the Employees Trust Fund (ETF). Poverty alleviation schemes such as the recently discontinued Samurdhi Scheme have failed to meet the basic needs of the elderly. A World Bank study noted the limitations of the scheme such as the inadequacy of money provided, problems with distribution, and the reduction of funds for savings and social security funds. Elders, who are from low-income areas, are also able to access daycare centres. There are currently 662 daycare centres across the country, but the quality of care is impacted by the limited funds available. As a result, the elderly rarely have economic independence in the country.
The health sector does not accommodate their medical needs. There is one Geriatric Unit at Colombo South Hospital for the entire country. There are limited mechanisms to prevent non-communicable diseases in the elderly. While there are local non-communicable disease clinics available, these are not specific to the elderly. “There’s no follow-up care for the elderly, only the immediate problem is addressed,” researcher Nadhiya Najab told me. Medicines and operations are free in public hospitals, but if the medication is rare or if the operation is complex, they incur out-of-pocket expenses.
A public pharmacy in Sri Lanka. In 2022, Sri Lanka experienced a severe shortage of medicine and medical equipment, alongside a lack of electricity, fuel and kerosene oil. Image: SciDev
However, health care for the elderly population is an important concern for the future. “If there is no prevention of non-communicable diseases, there is going to be a burden on the health system. With the pandemic and the economic crisis, the public health system became overburdened and resource-scarce. The added pressure of non-communicable diseases in older people is likely to lead to a crash,” Lokuge said.
The Limitations of the Private Sector
The private sector provides a number of childcare facilities such as standalone child care centres, preschool-daycare combination models, and employer-supported childcare. Employer-supported childcare includes in-house daycare facilities, outsourced facilities, and consortium models jointly run by several employers. The plantation sector has Child Development Centers that combine childcare and pre-schools for children from 6 months to 5 years. These services are limited because of a number of reasons such as cost, quality, and regulation. Many of these centres have reached over-capacity and are housed in premises unsuitable for small children. Centres also have a lack of trained childcare professionals. While regulations and standards for best practices exist, Warnasuriya questions if they are actually practiced by caregivers. “Whether any of these standards are met is questionable,” Warnasuriya told me. Early childhood is a key period in a child’s life because it influences a child’s overall development, educational performance, and social skills later in life. “Childcare is more than just child-minding. Children require care, support, and stimulation—all important for their development,” she added.
The number of paid services available for disabled people are limited. Many of the care homes, for instance, are run on a voluntary basis by NGOs such as Prithipura Communities, Daya Nivasas (charity houses) and Sandeepani Homes. These institutions have to be registered under the Provincial Departments of Social Services. As a result of a lack of funds, the quality and scale of care is impacted.
All elder care services have to register under the National Council for Elders. There are 25 home-based care services in the country, but the exact number is uncertain. A recent paper by the Women and Media Collective noted measures are being created to combat the bureaucratic process of elder care services. The National Secretariat for Elders is the main regulatory body for elder care services. Nevertheless, sources have revealed that infrastructure and supported living service (SLS) standards rather than the quality of care are monitored.
The Impact of the Care Crisis
With the erosion of the nuclear family there is likely to be a demand for quality care, and the private sector is likely to respond to this demand. However, the limitation of this shift is that care is not guaranteed anymore. Who can access care? Will care be equal and equitable? The availability and accessibility of care has already become tiered and hierarchical. The poor, previously supported by the extended family, are the least likely to have their basic care needs met.
“The availability and accessibility of care has already become tiered and hierarchical. The poor, previously supported by the extended family, are the least likely to have their basic care needs met. ”
Studies have noted that a child’s development is impacted by economic deprivation. For example, those in the informal sector depend on charities or informal arrangements for childcare. “Many people leave their children at centres funded by churches or temples and some depend on relatives and neighbours. The lack of choice sometimes means that they are forced to compromise on the quality of care,” Warnasuriya told me.
Many families told me that there is a lack of quality care from private elder care services. “Quality care includes the utmost respect, confidentiality, and accountability for the recipient,” former nurse and entrepreneur, Nadeeka Jayasinghe told me. Many families have described that carers were unprofessional and unsuited for their roles. Kumari, for instance, had to learn on-the-job and never had any exposure to elder care before. Carers have a number of complex care tasks to complete which may appear simple on the surface but require education, expertise, and experience. When certain dimensions of vulnerability overlap the complexity of care needed increases, for example for disabled elderly or disabled children. “There is no uniformity in these private sector initiatives. Regulation of fees, maintenance of standards, and monitoring of the quality of services are mostly absent from the care sector,” Kottegoda told me. As the recipients are vulnerable there is an emotional dimension to the role. Many families have complained that carers are not properly suited for the job as they lack compassion and bedside manner.
Sri Lanka's economic crisis has impacted the lives and livelihoods of the elderly. Image: HelpAge
Women are likely to have limited choice, whether it is to stay-at-home or join the labour force. With the continued contraction of the economy, they are likely to be pushed into the labour force. What then happens to the care of vulnerable people? “The economic crisis has amplified the quantity of care labour. Women leave the labour force. Women enter the labour force. However, their care load has not reduced,” Vraie told me. The financial capacity, health outcomes and emotional relationships within a household and between households have been impacted. Citizens’ quality of life and standard of living has decreased even further since last year.
Visions for Care
As a result, the state’s intervention into the subject of care is absolutely needed. However the question remains: “Should the state provide care or subsidize care?” Gunawardena posed. This means an expansion of state-run care centres, such as childcare, disabled care and elder care. Or, the provision of incentives for employers that provide care services or businesses in the care industries. Another option is for a private-public partnership but the fees should be nominal, primarily for low-income households.
In Sri Lanka, care is rooted in the provision of basic needs. In disabled care, there is an absence of quality care in both the public and private sector, but also care which considers the recipients’ personal needs and choice. “Who do they choose to live with? Who do they choose to provide care for them? What kind of care are they on the lookout for? We seldom ask vulnerable people these questions,” Niluka told me.
Care as a subject is multi-dimensional. Childcare, for instance, includes health, nutrition, education, development, and protection. As a result, there are a variety of stakeholders involved in the field. Warnasuriya recommends that better collaboration is a “first step” to combat the care crisis.
Another problem is the limited consideration and protection for the carer by both the public and private sector. “The care sector is considered very low, in terms of status,” Nadhiya told me. Many roles such as nurses, teachers, early childhood professionals, and carers are underpaid and undervalued. Women occupy the majority of these roles and their labour and expertise are invisibilized.
Carers are also severely underpaid. At the Victoria Home for Incurables, a charity for disabled patients who cannot recover from their condition or injuries, carers with 20-25 years of experience are only being paid 850-900 Sri Lankan rupees per day. In Australia, unlike Sri Lanka, home health carers are paid $35-50 per hour. Nadeeka told me that the payment of $10 is a “stretch” in Sri Lanka, even if customers like hers are based overseas and remit money for their parents’ care. Carers need a basic salary and also other benefits, such as added pay for late hours and public holidays. With many of these sources, the responsibility of a breadwinner, the complexity of paid care labour, the unpaid care labour in households and emotional labour from all spheres intersected. Studies have proved that many carers are at risk of dementia, vicarious trauma, and compassion fatigue from this massive toll. In her book Just Care, Akemi Nishida notes that care recipients and care providers experience oppression “together and through one another” (i.e. it is connected and inextricable) . Therefore it is essential that “care justice” is achieved for the provider, if the conditions for the recipient are to improve.
“it is essential that ‘care justice’ is achieved for the provider, if the conditions for the recipient are to improve. ”
To ease the shift from the nuclear family into service providers, care inside the country needs to be reconceptualised. In a number of Scandinavian countries, families do not have to make choices between family and paid care, because the state provides childcare, disabled care and elder care. “What happens, then, to the ethics of care is a separate question. Do you want to be taken care of by a system or by your family?” Abeysekera told me. She believes that the kinship-family structure is special as neither the public nor the private sector can replicate it. There is an important emotional element provided by the family. “Care labour is deeply emotional and depends on close bonds between the recipient and the carer. Can impersonal institutions do this labour? Can emotions such as love and commitment be professionalised?” Nishida focuses on the circulation of care in her book—all people are care recipients and care providers to some extent. This means that a vulnerable person such as a disabled person or an elderly person can be a care recipient but also a care provider to another member of a family, such as a child. Therefore, care is co-shared and co-experienced. Policymakers need to consider this human element.
Recipients should be able to receive care inside their homes within the family structures which already exist, whether it is temporary care or more complex care. They should have access to an entire ecosystem of care that has a mix of formalised and informalised structures, practices and resources. Recipients should be able to have their basic needs such as healthcare and their emotional needs such as connection met. The care that a recipient receives is closely tied to their experiences of life and their very personhood (i.e. their humanity).