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‘Public health midwives understaffed and overburdened’

28 Jan 2021

  • Study highlights shortage of 4,500 field PHMs 

  • By Ruwan Laknath Jayakody

  At present, there is a shortage of around 4,500 field public health midwives (PHMs) in Sri Lanka, with the current service requirement being one PHM for a population of 1,878, a research article noted recently. Therefore, immediate steps should be taken to increase the number of field PHMs, who are considered the backbone of the primary health care system in Sri Lanka, the authors of the article added. This article titled the “Burden of work and workload indicator-based staffing needs of PHMs in the primary health care system in Sri Lanka” was authored by M.D.K. De Silva and N.I. Talagala (both attached to the Family Health Bureau), P. Karthikeyan (attached to the Ministry of Health), and M.S. Rubasinghe (attached to the Lady Ridgeway Hospital) and was published in the Journal of the College of Community Physicians of Sri Lanka recently. As part of the preventive care system, groups of primary care workers provide primary preventive, and promotive care to families. This group, mainly comprising medical officers of health (MOHs), PHMs, and public health inspectors (PHIs) are attached to 343 islandwide MOH offices. Around 7,087 PHMs are employed in the field services. The success of this system is evident through the country's health indicators, such as low maternal mortality (33.8 per 100,000 live births), neonatal mortality (5.6 per 1,000 live births) and infant mortality (eight per 1,000 live births) which are among the lowest figures in the Asian region. Among primary care workers, the PHMs can be considered to play the most crucial role as the grassroots-level contact for people and are primarily responsible for providing maternal and child care. Components of the field PHMs’ workload, also known as interventions to be performed, are related to maternal and newborn care, child care (child development and other early child care interventions), nutrition, immunisation, other child care, family planning, well women care, and premarital care programmes, and includes providing services for pregnant women in antenatal clinics, clinic preparation, documentation and record keeping, taking anthropometric measurements, conducting tests, assisting medical examinations, giving tetanus injections and other vaccinations, issuing supplies and further instructions, and supporting and additional activities. Though PHMs were originally enrolled for the provision of maternal and child care, their role has gradually broadened to include family planning, school health, well woman care, preconception care, elderly care, noncommunicable disease prevention, and dengue prevention, among others. The target population assigned to PHMs at their introduction – 3,000 people (600 households) – has remained at the same level, without being revised based on the gradual expansion of their scope of work. Further, due to the increased population, the actual target populations of many PHMs around the country exceed the normative levels. The addition of new roles would also have considerably reduced their time available for maternal and child care activities, the authors noted. These factors are considered to constrain the PHMs’ work time, giving rise to task abandonment and the reduction in the quality of care. Many stakeholders are of the view that staffing requirements or full-time equivalents (FTEs) of the existing PHMs cadre in the primary health care system is not adequate for performing all the tasks assigned to them. In this study, 277 PHMs were selected using a multi-stage random cluster sampling method, from 16 MOH areas in four provincial health directorates. PHMs have seven hours of work per day. The analysis of the time requirements of various programme-related interventions indicated that the major share of PHMs’ time is utilised by maternal and newborn programmes (45%) and child care programmes (45%). Nutrition-related activities conducted in the field consumed around 7% of staffing requirements or FTEs. Other care services i.e. family planning, well women clinics, and preconception care, are attributed to a relatively smaller proportion of the PHMs’ time. The researchers also found that based on the current programme guidelines and assumed 100% coverage of all target populations in need, the country will be requiring 11,622 PHMs. The estimated requirement of 11,612, therefore, reflects the staff required for implementing direct patient-oriented interventions, support activities, and additional activities. As there are only 7,087 field PHMs in the system, this gives rise to a PHM staff gap of 4,525 in relation to the work demand created by the existing programmes. The ratio of existing staff to the calculated staff requirement thus indicates a fairly significant staff gap at the national level. Further, the analysis shows that the Western Province is having the largest staffing shortages compared to other provinces. The ratio reported for the Western Province indicates that the province has only 40% of its estimated requirement. The Eastern and Uva Provinces seem to have around 80% of their required PHM cadre based on the estimated requirement. The current national norms for PHM employment require one PHM per a population of 3,000. However, findings of this study show that at least one PHM is required per a population of 1,878 (21,803,000/11,612) to meet the current service demands. Sri Lanka needs to increase the number of PHMs by 64% to meet the current needs. On the other hand, with the existing number of field PHMs (7,087), it would be a near impossible task to provide the services expected from them. Whether the current health system is able to train the required number in the short run is a serious concern, the authors noted. The total training duration of PHMs is 18 months where basic training of one-year duration is carried out at the provincial nursing training schools. Considering all the available training schools, the maximum total training capacity is about 800 per batch. However, the production of PHMs has been around 400 per year over the last six years. Even if retirement and attrition are totally disregarded, it would still take around 11 years to produce the number needed to satisfy the current service needs, the researchers pointed out. The main limiting factor for the reduced intake of trainees is the lack of qualified applicants, they further noted. At present, to be selected to follow the PHM course, the candidate should be aged 18-30 years at the time of the commencement of the training, while all candidates should be unmarried females with a minimum height of four feet and 10 inches. Further, they should have passed the General Certificate of Education (GCE) Advanced Level (A/L) examination in the bioscience stream, with a minimum of three simple passes. Candidates should have obtained four credit passes and have passed in six subjects including English at the GCE Ordinary Level (O/L) examination in not more than two sittings. Therefore, the authors suggested that in order to increase the intake of PHMs, it is timely for the authorities to change the entry requirements for PHMs. The Ministry of Health should take steps to train at least 1,000 PHMs per year for a foreseeable period until the target amount is met, they further recommended. In order to achieve this objective, not only should the recruitment criteria be changed but the training facilities should be expanded. One possible approach, they propose, would be to select from any stream at the GCE A/L examination. Though in the recent past this approach has been adopted for certain districts/provinces through cabinet papers, this, the researchers noted, has been done in an ad hoc manner. Moreover, they add that the recruitment of applicants from any GCE A/L stream should be expanded to the entire country and continued as a policy. The Ministry of Health is currently discussing this issue with the Public Service Commission in order to change the scheme of requirement. However, according to the authors, science stream students may be given first preference.


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