As a clinician whose journey in medicine began from the lecture halls of the Colombo Medical Faculty, in 1965, and then matured through securing the coveted MBBS(Ceylon) degree in 1970, followed by a further kaleidoscopic journey down the specialist corridors, from 1978 onwards, I have witnessed the remarkable evolution of healthcare in Sri Lanka. I have seen the admirable resolve of a nation that managed to offer free healthcare, at the point of delivery, to all its citizens, and I have seen many a battle being fought to bring state-of-the-art treatments for the benefit of sick patients, even despite some of the initial scepticism on the part of some.

However, as we now try to navigate the turbulent waters of 2026, I find myself compelled to speak even impulsively. This is not a mission of fault-finding, or a manifestation of a desire to “ruffle feathers,” for the sake of fanning a fire. Rather, it is a reflection offered in good faith, born from the “Spirit of an Enthusiast” who has seen both the brickbats as well as the accolades bestowed on our profession. My goal is relatively simple: which is to bring to light the silent, sometimes extremely difficult, situations faced by patients, doctors, and relatives, and to urge for a compassionate and collective solution to a crisis that threatens the very foundation of the care we provide.

The Generic Gamble: The Lament of the Ward

The cornerstone of our health service has always been the provision of free medicine to all who come to our state medical facilities. For decades, the “generic-only” policy served as a vital safety net. But, today, that net is fraying, not just at the edges but virtually as a whole. In our hospital wards, the clinician’s heart sinks when a patient fails to respond to a standard course of treatment.

We are increasingly haunted by the fancy terminology, “Quality Failure”, as alerts on medicinal drugs. When an anti-infective medicine lacks the potency to clear an infection, or when a poor-quality generic drug fails to stabilise the circulation of a little gasping child who is fighting for his life, the treating doctor is left in a state of agonising clinical despair. It is a profound lament to realise that while the medicine is “available” on the shelf, its efficacy remains as a question mark. The “free health service” becomes tragically and obstinately expensive when it leads to prolonged hospital stays, complications, or, in the worst cases, even the loss of a life that could have been saved with a more reliable formulation of an essential medicine. We must acknowledge that a cheap drug that does not work is the most expensive drug of all. For the doctor, this turns every prescription into a calculated risk, a far cry from the “best possible care” we were trained to deliver. These situations are certainly not the whims of fancy of a wandering mind, but real-time occurrences in our health service.

The Vanishing Innovators and the Small Market Reality

In the private sector, the situation is equally dire, though the causes are different. We must face a hard truth: Sri Lanka is a comparatively small market in the global pharmaceutical landscape. For the world’s leading manufacturers of proven, branded medicines and vaccines, our island is often a small, rather peripheral, consideration.

When the National Medicines Regulatory Authority (NMRA) fixes prices at levels that do not even cover the “Cost, Insurance, and Freight” (CIF) value, let alone the massive research and development costs of these innovator drugs, these companies inevitably reach a breaking point. They do not “bail out” through a lack of compassion, but do so even reluctantly sometimes, because they simply cannot sustain their operations at a loss.

Over the last few years, we have watched in silence as reputable international companies have closed their shops and departed our shores. With them have gone some of the vaccines that provided a lifetime of immunity, and the so-called branded drugs that offered predictable, life-saving results. When these “Gold Standards” vanish, the void is often filled by products from regions with lower regulatory oversight, leaving the patient with no choice but to settle for what is available or just what is left.

The Shadow Economy of “Baggage Medicines”

Perhaps the most heartbreaking symptom of this broken system is the rise of the “baggage medicine” market. Walk into any major private hospital today, and you will hear the whispered conversations of relatives trying to source drugs from abroad, in a clandestine manner.

Reputed branded drugs are being brought into the country in the suitcases of international travellers. While these relatives are acting out of pure, desperate love, the medical risks are astronomical. These medicines sometimes bypass the essential “Cold Chain” requirements for temperature-sensitive products like insulin or specialised vaccines. There is no way to verify if the drug in the suitcase is genuinely effective, or if it has been rendered inert by the heat of a cargo hold of an aircraft.

As a physician, it is an agonising dilemma: do I administer a drug brought in a suitcase to save a life, knowing very well that I cannot certify its safety? We are forcing our citizens into a shadow economy of survival, stripped of the protections a modern regulatory body should provide.

The Unavoidable Storm: Geopolitical Shocks

Adding to this internal struggle is the current unrest in the Middle East. As of March 2026, the escalation of conflict has sent shockwaves through global supply chains. With major maritime routes, like the Strait of Hormuz effectively halted and air cargo capacity from Middle Eastern hubs, like Dubai, slashed by over 50%, the cost of transporting medicine has become a moving target.

* Skyrocketing Logistics: Freight surcharges and war-risk insurance premiums have added “unavoidable costs” that simply cannot be absorbed by local importers under a rigid price cap.

* Delayed Transport is delayed healing:

Shipments rerouted around the Cape of Good Hope add weeks to delivery times, leading to stockouts of even the most basic medical consumables.

These are global forces beyond our control, but our regulatory response must be agile enough to recognise them. If we ignore these external costs, we are not just controlling prices; we are ensuring that the medicine never arrives at all.

The Rights of Patients Seeking Private Healthcare

Whatever the reason for patients seeking private healthcare, all of us have an abiding duty to respect their wishes. It is their unquestionable right to have access to drugs and vaccines of proven high quality, if they decide to go into Private Fee-levying Healthcare. This is particularly relevant to the immunisation of children. Sometimes the child receives the first dose of a given vaccine in a Private Hospital, but when he or she is taken for the second dose, that particular vaccine is not available, and they are not able to tell the parents when it would be available as well.

Some of the abiding problems, associated with immunisation of children and adults in the Private Sector, were graphically outlined at the Annual General Meeting of the Vaccines and Infectious Diseases Forum of Sri Lanka, held on the 10^th of March, 2026. This needs to be attended to as a significant proportion of vaccines are administered to patients, both children and adults, in the Private Sector.

In other cases, the drug or drugs of proven quality is or are not available in the Private Sector as the company, or importing authority, has wound up the operations in our country due to their inability to sustain the operations, resulting from factors entirely beyond their control. Let us face it, the current pharmaceutical industry is significantly profit-oriented, and they will continue to operate only in countries where their profit margins are quite lucrative.

A Humane Call to All Stakeholders

The current scenario is a shared burden, and it requires a shared, compassionate solution. We must look at this, not through the lens of policy or profit, but through the eyes of the patient waiting in the clinic or in the ward.

* To the Ministry of Health and the NMRA:

We recognise the extremely difficult task of balancing affordability with quality. However, we urge a “Middle Path.” We need a dynamic pricing mechanism that reflects the reality of global trade logistics and the unique challenges of a relatively smaller market. Let us prioritise the restoration of “Quality Assurance” as the primary mandate, ensuring that every generic drug in the state sector is as reliable as the branded ones we have lost. To be able to provide such an abiding certificate of good quality, we need a fully-equipped state-of-the-art laboratory.

* To the Private Sector and Importers:

We ask you to remain committed to the people of Sri Lanka. Your role is not just commercial; it is a vital part of the national health infrastructure. A transparent dialogue with the regulator is essential to prevent more companies from leaving.

* To our Patients and their Families:

We hear your lamentations. We see the struggle in your eyes when a drug is unavailable or when you are forced to seek alternatives from abroad. We respect your right to seek the best possible treatment, and we are advocating for a system that honours that choice legally and safely.

Finally, the Spirit of Care

In the twilight of my career, I look back at my work and the thousands of patients I have treated. The “Spirit of an Enthusiast” is certainly not one of resignation, but of persistent hope. We have the clinical talent and the commitment of our healthcare professionals, we have the history of a strong health service, and we have a populace that deserves the best. For us, in this beautiful land, hope springs eternal.

Let us stop the “baggage medicine” culture. Let us invite the innovators back to our shores by treating them as partners in health, not just as vendors. Let us also ensure that our state-sector generics are beyond reproach.

This is a mission to find a way forward. For the sake of the child in the ward, the elderly patient in the clinic, and the integrity of the medical profession. We desperately need to act now, together, hand in hand, and with a pulsating heart of concern, for the entire humanity we are committed to serve.

by 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.