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Quo Vadis? Private sector medicine in Sri Lanka

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Image courtesy Ministry of Health

Dr B. J. C. Perera
MBBS(Cey), DCH(Cey), DCH(Eng), MD(Paediatrics), MRCP(UK),
FRCP(Edin), FRCP(Lond), FRCPCH(UK), FSLCPaed, FCCP,
Hony. FRCPCH(UK), Hony. FCGP(SL)
Specialist Consultant Paediatrician and Honorary Senior Fellow,
Postgraduate Institute of Medicine, University of Colombo, Sri Lanka.
An independent freelance medical correspondent.

Quo Vadis? Where are you going?

It is a vexed and troubling question I have increasingly found myself asking after working in the Ministry of Health and engaging in concurrent Private Practice for three decades, followed by nearly two decades working exclusively in Sri Lanka’s private health sector, after I retired from the Sri Lankan Government Health Service. It took a lot of soul-searching to write this article. Finally, I felt that if I kept it bottled inside, it would amount to blatant dishonesty and a total lack of empathy towards suffering humanity, even in the face of possible consequences for me following this attempt.

At the outset, this is not a total indictment of private medicine, nor an attack on the many excellent doctors, nurses, technicians, and other healthcare workers who serve patients in private institutions. There are innumerable numbers of doctors in the private sector who continue to practise with dedication, empathy, compassion and a deep sense of professional responsibility. Many go out of their way to accommodate even patients who cannot afford expensive investigations or prolonged treatment. The same applies to other healthcare workers in the private sector, too. However, a healthcare system cannot be judged only by the integrity of its individual practitioners. It must also be judged by the operational structures within which they work. That is where I believe we have a real major problem.

We should acknowledge something else as well. It is ever so true to say that some of the finest people in Sri Lankan medicine work in the State sector, often under extraordinarily difficult circumstances. They cope with enormous patient loads, shortages, administrative frustrations and, many a time, having to manage with totally inadequate resources. Yet for all that, even in the face of many obstacles, the services they provide are often nothing short of remarkable and magnificent. Why, then, does a substantial section of the population turn to private medicine? Quite honestly, the answer is not all that difficult to find.

A patient who has been waiting for months for a consultation, an investigation or an operation may decide that he or she simply cannot wait any longer. A working person may not be able to spend an entire day at a crowded government clinic. A working mother, with a sick child, may understandably prefer to see a paediatrician at a convenient time. A patient may have experienced a shortage of a particular medicine or a diagnostic facility in a Government Hospital. Industrial action, long queues, delays and the sheer pressure on government hospitals can all influence such decisions.

Private medicine, therefore, fulfils a genuine need. Yet for all that, the problem is that the patient who walks into a private hospital is not merely entering a place of healing. Increasingly and perhaps most unfortunately, he or she is entering a commercial environment. Regrettably, such a patient would be in some danger when the patient is regarded primarily as a commercial customer.

When treatment becomes a business transaction

There is nothing inherently wrong with a private hospital making a reasonable profit. Hospitals have to pay doctors, nurses, technicians, pharmacists, cleaners, engineers and administrative staff. They have to maintain buildings, laboratories, operating theatres, intensive-care units, ambulances and sophisticated equipment. Modern medicine could be quite expensive.

But there is a fundamental difference between reasonable remuneration for providing a service and extracting every possible cent from a patient because the patient is vulnerable and has little or no ability to question the bill. In a most disturbing situation seen over the recent past, quite a few private hospitals, in Colombo, have increased their hospital charges on Channelled Consultations to the same as, or even to an amount more than, the Consultation Charge levied by the Consultant. These prohibitive charges are for providing an air-conditioned waiting area, chairs to sit, wash-room facilities and the services of hospital staff that manage the channelling services. When this writer first started seeing channelled patients, 48 years ago, in the remote underdeveloped area of Badulla, in Sri Lanka, the Consultant’s Channelling Fee was Rs. 25 and the Hospital charges were Rs. 5. That was a reasonable and most justifiable levy, one fifth of the charges made by the Consultant. By the financial standards prevalent during that time, these were so fair.

This distinction between reasonable charges and extortion appears to be getting increasingly blurred in recent times. Patients frequently complain about laboratory charges which are terribly excessive by any reasonable standard. Radiological investigations can be extraordinarily expensive. In-patient bills can contain a bewildering variety of charges that the ordinary patient is simply incapable of understanding.

Then there are the less obvious charges. A patient admitted to a private hospital may find “Medical Officer Charges” appearing on the bill. Another may see “Nursing Charges” or various institutional fees. The patient naturally assumes that these amounts are going to the medical officers or nurses who actually provided the service. Are these workers, like doctors and nurses, really getting the monies charged to the account of the patient? We have yet to hear of instances where these reach these service providers. In the case of this anomaly, the terminology deserves scrutiny.

The principle should be extraordinarily simple: No surprise charges or non-justifiable charges in healthcare.

Sri Lanka already possesses a regulatory framework for private medical institutions. The Private Medical Institutions (Registration) Act No. 21 of 2006 established the legal basis for registration and regulation, while the Private Health Services Regulatory Council (PHSRC) states that its responsibilities include monitoring standards, quality assurance and patient-care services in registered private medical institutions.

The PHSRC has also issued regulations and notifications concerning consultation charges, hospital charges and laboratory tariffs. Indeed, regulations, dating from 2007, require medical practitioners to inform patients of their fees and to display a complete table of professional fees at their premises.

So, the issue is not that Sri Lanka has no regulatory mechanism. The structure is already there, but it is a different matter to see whether they are genuinely operational. The important question is also to see whether the existing mechanisms are sufficiently comprehensive, transparent and effectively enforced.

The bill that the patient cannot understand.

Consider the ordinary family. The father may earn a modest salary. The mother may be a teacher. They have two children. One child develops a persistent fever. They decide to consult a specialist privately because they cannot afford to lose an entire day in a government hospital. The consultation is manageable.

Then come the investigations. A blood test, an X-ray, perhaps an ultrasound scan and even a CT or MRI. There may be another blood test and, perhaps, admission “for observation”. By the time the family receives the final bill, the original consultation fee may be the smallest component.

This is where the private health sector needs to examine its conscience. The Ministry of Health itself recognises laboratory testing as an area requiring attention. The PHSRC publishes tariffs for commonly performed laboratory investigations, with ranges specified for various tests.

Why, then, should a patient have difficulty obtaining a clear answer to the most basic question: “How much will this cost me?” Before a major investigation, the patient should be given the price. Before admission, the patient should be given an estimate of the daily institutional cost. Before surgery, the patient should receive a written estimate covering hospital charges, professional fees, theatre charges, anaesthesia cost and the likely additional expenses. If complications arise, the family should be informed before costs escalate whenever circumstances permit. This is not anti-private-sector rhetoric. It is ordinary ethical behaviour. The consultant is not necessarily the culprit.

There is another point that must be made clearly. It would be unfair to blame consultants collectively. There are doctors in the private sector who charge reasonable fees and who will even waive or reduce their charges for those in need. There are specialists who deliberately avoid unnecessary investigations. There are doctors who tell patients that a particular scan or blood test is not necessary. There are consultants who spend far more time with patients than the fee would justify. There are doctors who participate in government service as well as private consultation practice and continue to uphold the same professional standards in both places.

Naturally, there are exceptions. No profession is immune from individuals who put personal financial gain before professional ethics. Where such behaviour occurs, it must be addressed. But we should not confuse the behaviour of a minority of doctors with the behaviour of an entire profession.

The larger problem may actually lie elsewhere; in the commercial architecture surrounding medical practice. A consultant may recommend an investigation because it is clinically indicated. But the patient has a right to know whether the institution has any financial relationship with the service being recommended.

Similarly, when hospitals belong to large corporate groups, with multiple subsidiaries and affiliated businesses, the public is entitled to expect robust transparency concerning related-party transactions and incentives. A hospital exists primarily to treat sick people. It must never allow the financial interests of an associated enterprise to become more important than the interests of the patient.

The danger of vertical integration

Modern business has a perfectly respectable concept known as vertical integration: different parts of a business are owned or controlled within the same corporate structure. To the unperceptive naïve eye, there is nothing automatically wrong with this.

However, healthcare is different. If the same corporate family has interests in hospitals, laboratories, pharmacies, imaging services, as well as insurance or other health-related enterprises or even totally unrelated commercial pursuits, there is an obvious need for transparency. A patient should not have to wonder whether an investigation is being recommended because it is medically necessary or because it generates revenue to be used elsewhere within the corporate family. It means that the system should be designed so that the patient does not have to guess. Transparency is the obvious answer. Declarations of ownership and related interests, independent clinical governance, external auditing, published tariffs and proper patient grievance mechanisms would go a long way towards restoring confidence.

What should the State do?

The answer is not to destroy private medicine. Nor should the State attempt to make every private hospital charge the same price for every service. Costs may legitimately differ according to technology, staffing, infrastructure and quality. However, there should not be exorbitant differences between institutions providing the services to patients. What the state can do is to specify the maximum that can be charged for a given service. Then it might even set up a healthy competition in private medicine with some smaller institutions able to offer the same service at a lower cost.

But there are certain things the State should insist upon. Some of them are listed below:

First – Complete transparency of charges.

Every private hospital should publish an easily accessible schedule of all standard charges. Not merely professional fees. Everything.

Second – Itemised bills.

A patient should be able to identify precisely what was charged, why it was charged and, where appropriate, who received the professional fee.

Third – Advance estimates.

For planned admissions, procedures and major investigations, patients should receive written estimates.

Fourth – Independent complaints mechanisms.

A patient who believes he or she has been unfairly charged should not have to complain to the very institution that issued the bill. There should be a genuinely independent mechanism for investigation and redress.

Fifth – Regular audits.

Hospitals and diagnostic institutions should be subject to meaningful audits of billing practices, clinical governance and patient safety.

Sixth – Clear separation of professional and institutional charges.

The patient should know what belongs to the consultant, what belongs to the hospital and what relates to ancillary services.

Seventh – Stronger public reporting.

The regulatory authority should publish meaningful information about registered institutions, standards, complaints, inspections and enforcement actions, while protecting patient confidentiality.

Finally, we need a national conversation and a tangible discussion and assessment about the relationship between public and private medicine.

The beneficial concept of two arms of one health system

The public and private sectors should not be enemies. Indeed, they are already deeply interconnected. Many specialists serving in private hospitals have spent most of their professional lives in the government system. Private hospitals depend upon doctors trained by the State. The private sector benefits from nurses, pharmacists, laboratory personnel and other professionals educated within Sri Lanka’s public educational system.

The private sector is therefore not an alien appendage to the national health system. It is a part of it, and precisely because it is a part of the national health system, it must accept a corresponding degree of public accountability.

Sri Lanka’s reliance on out-of-pocket spending makes this particularly important. WHO data indicate that out-of-pocket expenditure accounted for about 40% of current health expenditure in Sri Lanka in 2022. Earlier Sri Lankan National Health Accounts data showed an even higher household share: around 49% in 2018. These are not merely accounting figures. Behind every rupee paid out of pocket is a family, someone’s salary, someone’s savings, someone’s children’s education, someone’s mortgage, sometimes, someone’s entire life’s savings.

Healthcare is totally unlike purchasing a television or a motor car. The patient cannot walk away from the transaction simply because the price has risen. A person with chest pain cannot bargain over the cost of an ECG. A parent with a desperately ill child cannot shop around for three quotations before agreeing to admission. That vulnerability imposes a special moral responsibility on everyone involved in healthcare.

Quo vadis?

So, where are we going?

If private medicine becomes increasingly commercialised without adequate regulation, we risk creating a two-tier system in which access to timely treatment depends not merely on clinical need but increasingly on purchasing power.

That would be quite a significant tragedy. However, the answer is not to abolish private medicine. The answer is to make private medicine worthy of the trust that patients place in it. Whether we like it or not, it would need the state to bring in controls on it.

Sri Lanka’s Free Health Service is one of our national treasures. We should protect it, strengthen it and properly finance it. We should address the reasons that drive people unnecessarily towards private care. At the same time, we should recognise that private medicine is here to stay and can make an important contribution to national healthcare.

But private medicine must also remember one thing. A hospital is not a supermarket. A patient is not a customer in the ordinary commercial sense, and illness is not a commodity. Profit is legitimate. Professional remuneration is justified. Investment in healthcare is valid. But none of these can be allowed to supersede the first obligation of medicine: to place the welfare of the patient at the centre of the enterprise.

The time has come for the State, the regulators, the medical profession and the private hospital industry to sit down together and establish clear rules of engagement. That endeavour should not be to punish private medicine. It should not be to protect public medicine from competition. It should be to unequivocally protect the public.

If that requires the Government to tighten regulation, publish tariffs, scrutinise hospital billing, strengthen the PHSRC and introduce effective avenues for patients to challenge unfair charges, then so be it. It will need to be done. The private sector should welcome such measures. After all, an honest bill, a transparent system and a satisfied patient are not enemies of good business. They are the foundations of trust. Without that all-important trust, medicine, whether public or private, loses something much, much more valuable than money. It most definitely loses its soul and a service-oriented conscience of a healthcare system that protects the patient.



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Features

Regime change and the vacuum:Strategic lessons of Iraq and Libya

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Post-Gaddafi Civil war: the rebellion triggered by the arab spring of 2011 soon toppled the regime of Muammar Gaddafi. the power vacuum created by Gaddafi’s ouster has been exploited by local actors, as well as extraneous actors, with the only intention of making libya a war theatre for proxy wars and political disintegration

by Col. (R) Nalin Herath

There is a question that the international community must periodically ask itself: What happens to a State after its regime has been ousted?

The question is particularly relevant when examining Iraq and Libya. Saddam Hussein and Muammar Gaddafi were authoritarian rulers. Their governments were associated with political repression, human-rights violations and the suppression of political opposition. None of this should be ignored or excused. But recognising the failures of authoritarian rule does not prevent us from asking another, equally important strategic question:

Did the removal of these regimes adequately prepare for what came next?

The experience of Iraq and Libya suggests that removing a ruler is considerably easier than replacing the political, administrative and security architecture around that ruler.

Danger of confusing regime change with State reconstruction

A state is more than its leader. It consists of institutions, security forces, civil servants, courts, political structures, infrastructure, economic systems and, perhaps most importantly, an accepted monopoly over the legitimate use of force. When an authoritarian system has concentrated enormous power around one individual, removing that individual can expose weaknesses that were previously hidden. The strategic mistake is to assume that once the dictator has gone, a democratic and stable state will naturally emerge. History does not support such an assumption. The aftermath of Iraq demonstrates this particularly clearly. Following the 2003 invasion, the Coalition Provisional Authority issued Order No. 2, formally dissolving the Iraqi Ministry of Defence and the Iraqi Army, among other security institutions. A US congressional report later documented the enormous consequences of this decision, including the disappearance of hundreds of thousands of military personnel from the institutional framework of the state. Whatever the intentions behind the decision, the strategic consequence was that an established security structure had to be rebuilt while the country was simultaneously experiencing political upheaval and growing violence. That is a dangerous combination.

Iraq: Removing the structure before building the replacement

Saddam Hussein’s government was unquestionably authoritarian. It also reflected a complicated sectarian and political structure in which members of the Sunni minority occupied disproportionate positions of power despite being a demographic minority. But the question for strategic planners should not simply be whether Saddam deserved to remain in power. The question should have been:

What institutional structure would replace the system once he was removed?

An army can be politically controlled without being politically representative. A bureaucracy can serve an authoritarian government while still providing essential state functions. A security institution can be reformed without necessarily being destroyed. The distinction between reforming institutions and eliminating institutions is therefore critical. The post-2003 experience demonstrated the consequences of institutional disruption. Security vacuums contributed to insurgency and instability, while the process of rebuilding Iraq’s security forces took place amid an increasingly deteriorating security environment. The lesson is not that authoritarian institutions should never be reformed. The lesson is that state capacity should not be casually destroyed without a credible replacement.

Libya: prosperity, authoritarianism and institutional fragility

Libya presents an even more complicated case. Gaddafi’s government was authoritarian and deeply personalised. Political freedom was severely restricted, and the security apparatus was deliberately structured around regime survival. Yet Libya, under Gaddafi, also used substantial oil revenues to fund education, healthcare, infrastructure and social services. World Bank data from around the end of the Gaddafi era show life expectancy reaching approximately 75 years by 2011, skilled attendance at birth at 100 percent and measles immunisation at 98 percent. This does not prove that Gaddafi’s system was politically legitimate. It demonstrates something different: economic and social outcomes can coexist with authoritarian political structures.

The Great Man-Made River illustrates the scale of Libya’s investment ambitions. The World Bank described the project as one of the world’s largest engineering schemes, involving thousands of kilometres of planned pipelines to transport water from deep desert aquifers toward the populated coastal belt. The original project was estimated at approximately US$ 25 billion over several phases. Again, this should not become nostalgia for dictatorship. It should become a lesson in state capacity.

What happened after Gaddafi?

The post-2011 experience is perhaps the clearest illustration of the vacuum problem. Libya did not simply move from dictatorship to a consolidated democratic state. Instead, competing armed groups, political factions and institutions emerged. A UN economic and social affairs analysis concluded that the fall of the Gaddafi regime exposed weak state institutions and that the post-Gaddafi period was characterised by the proliferation of armed militias and institutional fragmentation.

The World Bank has similarly described how the security vacuum allowed armed groups to expand, while attempts to integrate them into the formal security apparatus produced a hybrid system in which state institutions and powerful armed groups operated alongside one another. This is the heart of the lesson. The consequences of regime change were also evident in Libya. The 2012 Benghazi attack, later portrayed in 13 Hours: The Secret Soldiers of Benghazi, illustrated the security vacuum that emerged after Gaddafi’s fall. The collapse of central authority allowed militias and competing armed groups to fill the space left by weakened state institutions. The lesson is clear: removing a regime may achieve military victory, but without a credible plan to rebuild the state, victory can quickly become a security vacuum.

When the state withdraws, something else occupies the space. If the replacement is not a legitimate national institution, the vacuum can be filled by militias, tribes, ideological movements, criminal networks or competing political authorities. The vacuum does not remain empty.

Terrorism question

There is another uncomfortable issue. Authoritarian regimes frequently suppress political and armed movements through coercive security systems. When those systems disappear abruptly, previously contained organisations can find new operating space. This does not mean that dictatorship is an appropriate method of counterterrorism. It means that counterterrorism cannot be separated from State capacity. The international community therefore needs to distinguish between defeating a particular terrorist organisation and maintaining the institutional conditions that prevent multiple armed actors from competing for power. The destruction of one regime does not automatically eliminate the forces that created insecurity. Sometimes it creates an environment in which those forces multiply.

Strategic mistake: winning the war but losing the peace

Military intervention can have a clearly defined operational objective. State reconstruction does not. A military campaign may successfully remove a government in weeks or months. Building legitimate institutions can take decades.This creates a fundamental strategic asymmetry. The shorter the planning horizon for intervention, the greater the danger of a long-term vacuum. The international community therefore needs to think beyond the first question: How do we remove the regime?

It must ask: Who governs the country the next morning? Who controls the borders? Who controls the security forces? Who pays government employees? Who maintains electricity, water and hospitals? Who protects critical infrastructure? Who administers justice? Who prevents armed groups from becoming alternative governments? Who provides political legitimacy? And perhaps most importantly: Who possesses the authority to enforce the decisions of the new state? If there are no convincing answers, regime change is only the beginning of the problem.

The lesson should not be that the United States or its allies should never intervene. Nor should it be that Saddam Hussein or Muammar Gaddafi should be rehabilitated as models of governance. The lesson is more practical. Regime change must never be confused with state-building.

Before dismantling an established political order, external powers need a credible understanding of the institutions that will replace it. Security-sector reform should normally distinguish between individuals who must be removed and institutions that must be preserved. A national army may need reform. A ministry may need restructuring. A security service may need accountability and civilian oversight. But destroying institutional capacity without having an operational replacement can create consequences far beyond the original objective.

Wider geopolitical lesson

The consequences of Iraq and Libya did not remain within their borders. State fragmentation affects neighbouring countries, migration, organised crime, arms trafficking, terrorism, energy markets and regional power competition. In today’s interconnected world, a failed transition in one country can become a security problem for an entire region. That is why intervention planning should include not only military objectives but also political, economic, humanitarian and security-sector objectives. The most important planning document may therefore not be the operational plan for removing the regime. It may be the plan for Day One after the regime has disappeared.

History should not be written as a simple choice between dictatorship and democracy. The real strategic challenge is more complicated. Saddam Hussein and Muammar Gaddafi were dictators. Their governments committed serious abuses, and their populations had legitimate grievances. But the failures of authoritarian rule do not automatically justify the destruction of state institutions without a credible plan for rebuilding them. The experience of Iraq and Libya demonstrates a fundamental principle of international security: A political vacuum is not neutral space. Someone will fill it. If legitimate national institutions cannot fill that space, armed groups, sectarian interests, extremist organisations or foreign-backed factions may do so. The ultimate lesson for the United States, its allies and the wider international community is therefore straightforward:

Removing a regime may win the immediate battle. Building a legitimate, functioning and secure state determines whether the intervention succeeds in the long term. The world should learn to ask not only “How do we remove the dictator?”. It must also ask:

“What happens to the country when he is gone?”

That may be the most important strategic question of all.

(The writer is the Secretary General of the Ceylon Chamber of Shipping, former Director General of the Institute of National Security Studies (INSS), and former Spokesman of the Ministry of Defence. He is also a Non-Resident Fellow at the London Dialogue. His areas of expertise include international relations, geopolitics, maritime affairs, national security, economic policy, and strategic governance. He is a consultant at JITT Group and a member of World Pace Board.).

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‘Death at the Sign of the Rook’

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Tales of Mystery and Suspense – 23

By Prof. Rajiva Wijesinha

As I have noted with regard to the adventures of John Rebus, I am indebted to Dinali Fernando and her husband Steve for whole hosts of thrillers. The latter strongly recommended Kate Atkinson when I borrowed four books. I wondered about this, for I had not been too impressed with her debut novel, Behind the Scenes at the Museum, which was amongst the entries I had to judge for the Eurasian section of the Commonwealth Writing Prize. Two decades later, I had forgotten what it had been about.

But I am glad Steve persuaded me to read her. Kate Atkinson is distinctively British, and Death at the Sign of the Rook is set in a country house and the surrounding village, and seems a modern descendant of the laidback Agatha Christies I so much enjoy.

There are, however, many differences in that we have a policeman who can go rogue, like Rebus, with again a female sidekick who has a mind of her own, again like Rebus. But Jackson Brodie has retired and set up as a private investigator, while Reggie, a young lady, is still in the police.

There is a lesbian couple living in the converted dairy of the manor house, as has occurred in Agatha Christie too, in A Murder is Announced. But they are peripheral to the story, unlike Ben, the brother of one of them who left the army after losing a leg in Afghanistan. When he turns up at the Manor House to shelter from a snowstorm, along with its chatelaine, Lady Milton, he is asked to answer the door as various characters turn up, including Jackson and Reggie, who then starts fantasising about him.

The others who turn up are two couples, one from America, who have paid for a murder weekend at the hotel. The family is impoverished, and has sold lots of pictures to survive, but most recently a Turner had been stolen, almost certainly by Lady Milton’s housekeeper Sophie, who vanished one night along with the picture. Reggie had been involved in that investigation, but there had been no trace of either picture or young lady.

Jackson Brodie suspects a connection between that theft and the one he has been called in to investigate, which has not been reported to the police. The picture hung opposite the bed of an old woman whose carer vanished after she died, along with it. Her children, adopted twins, have asked Jackson to investigate and also try to trace the carer, though he suspects something strange in that they did not go to the police.

Kate Atkinson

Brodie, in studying the stolen art, is also struck by the disappearance of a Rembrandt from a house in Scotland, along with a member of the cleaning staff. He thinks the three women might be the same one.

But Brodie’s assumption that the three women who vanished when valuable pictures did were identical would not have helped except that Beatrice, as she was also called, kept turning up, including to the funeral home where the old lady’s body was kept. And then that picture turned up, in the village church, and was found by the local vicar, Simon Cate, whose life story is also a prominent feature of the novel. He was an aspiring actor but then smitten by faith, and became a priest, but in time he lost his faith. His wife left him after the death of their son, and he is now in this backwater, where he feels he is of no use to anyone. But he has a great feel for living beings, and his most successful service has been one in which he blessed pets. And he was deeply concerned about the bees that Ben looks after for his sister and her wife.

He too staggers into the manor house in the midst of the storm, in which everyone concerned loses their way comprehensively. But amongst those Ben lets in is a man in a tracksuit with cuts and bruises, who then vanishes after he has been led to a bedroom, when Ben went in search of brandy. We soon work out that it is the escaped murderer about whom Reggie has been alerted.

Simon also turns up, through the back door, carrying the picture and also a gun, for he has found the dead body of one of his parishioners when he went to her house in search of his mobile phone. She had been shot and he had picked up the gun he found there. But he could not tell the police, for though he called he had lost his voice, and for the last few days had communicated only through writing.

This chaotic mix of characters at the manor house is further complicated by the group of players putting on the murder mystery play though some members have either cried off or died before reaching the venue. So, there is much doubling up and confusion over who is an actor and who is not.

The grand now largely empty rooms of the manor house, and its various odd passages and multiple doors, make it a splendid set for the lunacy that runs on and on. Reggie finds herself in a pantry Atkinsonwith a dead body, though this turns out to be the nanny who fell down the stairs and was put there by Lady Milton’s younger son. And there is high drama on the roof when the murderer nearly kills Ben, but he is saved by Reggie, and when he tries to kill Brody with an axe, he is shot by Beatrice, who has been the maid who served at the dinner before the murder mystery play, and explains to Brody how she has managed all her thefts.

And then in the melee, she vanishes on a motorbike, along with the daughter of the old lady’s adopted daughter, the only person who seemed to grieve at the funeral, and to whom the old lady had left her house in a codicil to her will, which her children have not known about. She leaves the picture to the carer, but it is brought to Simon Cate as he lies in hospital, recovering from a heart attack which adds confusion to the play.

Wonderfully convoluted, but all very clear, despite the headlong pace of the book and its shifts from one scene to another, from one character to another (or rather combinations of them) and from one-time span to another. A writer and a detective well worth looking out for. e more books by her on Dinali’s shelves.

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Safety, security and teamwork in aviation

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Indian Captain Smit Machchhar injured in the cockpit attack

by Capt. (Ret.).G.A. Fernando, MBA

There are three essential components to a commercial airline operation: safety, security and teamwork.

Aviation and teamwork at the ‘sharp’ end of a commercial aircraft, i.e. the flight deck, is unique. Unlike many other teams, it may be quite literally the first and the last time a particular combination of small teams of two, three, or four individual airmen (or women) will fly together. Sometimes even in the same airline that employs them.

Therefore, to make conditions safe and practical, while understanding and trusting tech other, they have to rely on a series of Standard Operating Procedures (SOPs), and ‘Normal’ and ‘Emergency’ checklists for every conceivable situation. That is, to be able to do the right things, and do things right. In fact, there is a saying in aviation to the effect that ‘if you make a mistake in aviation, be original and make a new one’.

To ensure that safety standards are constantly maintained, airline pilots’ proficiency is tested every six months, in simulators, under the supervision of examiners from the civil aviation regulator. In Sri Lanka that organisaton is the Civil Aviation Authority-Sri Lanka (CAASL). Three simulator checks are conducted every 12 months in keeping with the tenet that ‘practice makes perfect’. A pithy adage not confined to the world of aviation warns that ‘prior preparation prevents piss-poor performance’.

The simulator exercises include rejected takeoffs, including in cross-wind situations, landings, engine fires and/or engine failures from a variety of causes, cabin pressurisation failure, precision and non-precision approaches, and landings in bad visibility – amongst other conditions that could be expected in actual flight.

In addition, a flight in a real airplane, on a regular passenger service under the supervision of an examiner from the airline, is undertaken to ensure that the company’s standard practices and procedures are carried out and maintained as prescribed in the airline’s manuals. These publications are in turn approved by the national regulator.

Crash axe

Finally, flight crew members must take a written test annually, on emergency equipment locations and procedures, with 90% as the pass mark.

Since the mid-1980s it has been mandatory for airline pilots to undertake a Crew Resource Management (CRM) programme once every two years. This training essentially emphasises what to do and what not to do to, in a specific emergency situation, or even during normal operations, to make the team cohesive and effective. During the course, the CRM facilitators discuss recent incidents and accidents that have occurred. Results of those events are recorded and could be retrieved, when necessary, by the official aviation bodies.

Not unexpectedly, it is demanding on a pilot to fulfill these requirements on a regular basis throughout his/her career, along with presenting for a bi-annual medical examination, all with the objective of retaining one’s licence to operate an aircraft. It may not be understood, therefore, by persons outside the aviation industry, or even some working in other aspects of an airline organisation, that it is often the passion for flight that keeps many pilots doing what they do to earn a living.

Security

Another important factor is the challenge of maintaining security in all aspects of airline operations, not least in the cockpit. The challenges are many, with new ones surfacing almost every day. It is therefore essential to be always prepared for the activities and ‘methods’ of perpetrators seeking to wreak evil on an aircraft and its occupants. As it is impossible for any airline or national security organisation to cover all aspects, systematic management of risks to effect a safe outcome becomes imperative.

Flydubai Incident

In the recent Flydubai incident of 30 September, 2026, a first officer (co-pilot) attacked the captain of the flight with a crash axe to accomplish his sinister motives, into which investigations are continuing. For the time being, it prompts the questions: should the crash axe be easily accessible to the flight crew? Or even be there at all? I believe it is a case of assessing the greater risk.

With regard to that event, and the circumstances that led to it, other deterrents could have been applied more thoroughly. For example, more thorough screening of pilots’ and other crewpersons’ backgrounds, with emphasis on their mental health, ideological affiliations and previous employment history. Separately, during a time of conflict in the Middle East, should Flydubai have even been operating between Dubai and Tel Aviv? Notwithstanding that cost-cutting and profit maximisation are key aims of any business, an airline’s apparent failure to conduct adequate psychological profiling of flight crew members, while continuing to operate ‘profitable’ routes, regardless of potential danger, can only be regarded and condemned as greed and disregard for human lives.

( Captain. Fernando, RCyAF, SLAF, Air Ceylon, Air Lanka, Singapore Airlines (SIA), SriLankan Airlines, Former Chief Pilot, Air Lanka Boeing 737, Former Deputy Chief Pilot, Lockheed L 1011, Former Crew Resource Management (CRM) Facilitator, SIA, Former Deputy Director (Air Operations) CAASL, Former President, Aircraft Owners and Operators Association Sri Lanka (AOAOASL), President, The Colombo Flying Club, Representative for Aviation, Organisation of Professional Associations (OPA), Hony, and Member Sri Lanka Society of Transport and Logistics.)

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