Devpro Resource Centre
Prioritizing maternal health in Sri Lanka
|Thruppathi Vidhyalaya School in the eastern Ampara District of Sri Lanka. The school was rebuilt following the tsunami.|
Context and challenge: A lower middle-income country with exceptional progress in maternal and child health and education
Sri Lanka, a lower middle-income country, has experienced a protracted civil conflict and the devastation of the 2004 Indian Ocean tsunami. Yet the country’s progress in human development, particularly in maternal and child health and education, has been one of the key success stories among developing countries in recent decades. Sri Lanka’s maternal mortality ratio declined from 340 per 100,000 live births in 1960 to 43 per 100,000 live births in 2005, and 98 per cent of births now take place in hospitals. Rates of antenatal care (at least one visit) and skilled attendance at birth stand at 99 per cent. These results have also had positive effects on child survival: The under-five mortality rate has fallen from 32 per 1,000 live births in 1990 to 21 per 1,000 live births in 2007. The latest available data suggest that the neonatal mortality rate has also fallen, to around 8 per 1,000 births in 2004. In basic education, too, Sri Lanka’s performance has been outstanding. According to the latest international estimates, net primary school enrolment stands at more than 97 per cent for both girls and boys, while literacy rates among young people aged 15–24 are 97 per cent for males and 98 per cent for females. Administrative data suggest that the completion rate for primary school is 100 per cent. Given the positive correlation between education and maternal and child survival, these are the results of sustained investment in all three areas.
|Women weigh their babies and toddlers on a paediatric scale at a ‘Gramodoya’ (village reawakening) health centre in the town of Kalmunai in the eastern Ampara District of Sri Lanka.|
Action: Health and social services to reach the poor
The key to Sri Lanka’s outstanding improvements in maternal health was the expansion of a synergistic package of health and social services to reach the poor. The country’s health system, which dates back to the late 19th century, first targeted universal provision of improved health care, sanitation and disease management. It subsequently added specific interventions to improve the health of women and children. Over the years, successive governments have followed a prudent approach of prioritizing health-care services to mothers and the poor while spending economic and human resources judiciously. The resulting improvements in women’s health are supported and strengthened by measures to empower women socially and politically through education, employment and social engagement.
|A nurse instructs a new mother on breastfeeding her baby in the maternity ward in Pottuvil Government Hospital in the eastern Ampara District of Sri Lanka.|
Impact and opportunities: Government efforts lead to low maternal mortality rates and high female literacy rates
Due to these efforts by the government, maternal mortality was halved between 1947 and 1950. Thirteen years later, maternal mortality rates were cut in half again. Once health structures and networks were in place, increasingly better organization and clinical management have allowed Sri Lanka to cut the maternal mortality ratio by 50 per cent every 6 to 11 years. In addition, women’s literacy rose from 44 to 71 per cent between 1946 and 1971. The rates of skilled attendance at birth and institutional delivery also grew. The public health midwife’s role became more that of an institutional delivery assistant, as home midwife-assisted deliveries declined from 9 per cent in 1970 to just 2 per cent in 1995. Beginning in 1965, midwives also played a role in expanding government family planning services. Sri Lanka’s development of its health system has long been a model for other developing countries, demonstrating the degree of success that can be achieved in maternal and child health when sound strategies, sufficient resources and political commitment are judiciously applied.
Despite its noteworthy advances in maternal and child health, challenges remain. In recent years, the country has faced a shortage of health workers; according to the World Health Statistics 2008, in the 2000–2006 period the country had only 6 doctors and 17 nurses and midwives per 10,000 inhabitants. In addition, services have deteriorated as financial resources have been squeezed, with health spending at around 4 per cent of GDP in 2005. Private spending on health, most of which is out-of-pocket, accounts for more than half of total health expenditure. A further challenge for Sri Lanka will be to ensure food security, particularly if global food prices remain high. The country still has marked levels of undernutrition among newborns and children under five. According to the latest international estimates, more than 1 in every 5 newborns are born with low birthweight, and 23 per cent of children under five are moderately or severely underweight. Improving the level of exclusive breastfeeding for children less than six months old from its current level of 53 per cent will be vital to sustaining Sri Lanka’s gains in neonatal and child mortality.
9 March 2009