The contribution of Public Health Midwives to better health in rural communities in Sri Lanka

Author: Dr. A. Pubudu de Silva
Country: Sri Lanka

Public Health Midwives (PHMs) have been an important part of the primary healthcare system in Sri Lanka since early in the twentieth century. Traditionally these health workers focused only on midwifery, but now PHMs have evolved into a professional cadre, playing a role in preventive health covering many aspects other than midwifery. Their services are immensely valued in rural settings where health resources are scarce.

Nurse attending patients in rural Sri Lanka
© A. Pubudu de Silva
Nurse attending patients in rural Sri Lanka

Challenges

Sri Lanka has a population of 20 million, with approximately 72% living in rural areas. Like other developing countries, Sri Lanka faces challenges in providing health services and retaining its health workforce in remote rural areas. This is due to a lack of qualified medical personnel as well as reluctance on the part of those qualified to work in remote areas, where they are cut off from continuous professional development and other services that are available in urban hubs.

Policy description

Public Health Midwives (PHMs) have been an important part of the primary healthcare system in Sri Lanka since early in the twentieth century. Traditionally these health workers focused only on midwifery, but now PHMs have evolved into a professional cadre, playing a role in preventive health covering many aspects other than midwifery. Their services are immensely valued in rural settings where health resources are scarce.

The government of Sri Lanka has adopted a number of strategies to encourage these health professionals to work in rural settings. Preference is given to recruitment of PHMs in remote rural areas and higher proportions of PHMs are allocated to areas with poor health indicators. More than 90% of the trainees attending the PHM training course are posted rural settings after completion of their training course. Each province in the country has at least one regional training centre where PHMs are trained in maternal and child health to ensure that they have an appropriate level of technical knowledge to delivery quality healthcare services. They are also given access to continuous professional development opportunities once in their posts, even if based in particularly remote areas of the country. PHM trainees are required to serve a bond period of 5 years once they have qualified, and have to be prepared to work anywhere in the province in which they are trained. This ensures that areas which are particularly under-resourced are able to fill healthcare posts. Financial incentives are also in place to encourage PHMs to remain in rural areas with various benefits in place such as allowances, pension schemes and subsidized mobile communication facilities.

Outcomes

Government programmes have ensured that skills gaps in remote areas have been reduced and that qualified healthcare professionals provide services in poor and remote areas of the country. The success of PHM recruitment, training and posting systems in the rural sector can be seen by its impact on health indices. Over the past years, the maternal mortality ratio (MMR) has dropped from 265 in 1935 to 5.3 per 10,000 live births in 2003 and the infant mortality rate (IMR) from 263 in 1935 to 11.2 per 1,000 live births in 2003.

Conclusions

The success of the Sri Lankan primary health care system lies in its ability to produce vital healthcare skills in rural areas whilst also retaining grass root level primary health workers in remote regions of the country. The system has contributed to the dramatic reductions in both child and maternal mortality in the country and has helped fill the gap that had existed in health care availability in rural areas.

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