Sri Lanka has experienced armed conflict for over two decades since the Liberation Tigers of Tamil Eelam (LTTE) launched a civil war against the Sri Lankan government with the aim of establishing an autonomous Tamil state in the Northeast of the country. According to Human Rights Watch, the war has claimed over 64,000 lives and displaced more than one million people. In February 2002, the government of Sri Lanka and the LTTE signed a Memorandum of Understanding for a long-term ceasefire. By 2003, more than 230,000 internally displaced people (IDPs) had spontaneously returned to their home villages but an estimated 800,000 remained scattered throughout the country. Despite the ceasefire, continued outbreaks of violence cause ongoing displacement.

The government aims to provide primary health care and basic curative medicine for all Sri Lankans at their nearest health institution. However, this approach effectively excludes vast number of IDPs who are settled in informal camps and communities or in remote areas. Most IDPs have limited or no means of transportation, which also affects their ability to access government services. In response to the needs of the displaced population, PSL began working in IDP communities in 1995 and currently provides clinic and outreach services in six regions of the country (Vavuniya, Puttalam, Anuradhapura, Trincomalee, Ampara and Mannar). This programme is part of the Marie Stopes International Global Partnership Initiative and supported by DFID and the European Commission.

Overall, the majority of the people served by the programme are Tamils. The vast majority of those served by the Mannar, Vavuniya and Trincomalee clinics are Tamils. The majority served by the Puttalam and Ampara clinics are Muslims and the majority served by the Anuradhapura clinic are Sinhalese. There are significant cultural and religious differences between these groups; Tamils are generally Hindus and are Tamil-speaking, as are the Muslims. Most Sinhalese are Buddhists and speak Sinhala.

Stationary and mobile clinics

Prior to establishing services among the displaced populations, extensive consultations were held with communities at refugee welfare centres and in resettlement areas, with local and international agencies, and with relevant government officials at the national, regional and district levels. In addition to stationary clinics situated in main towns, mobile clinics were set up to facilitate access to the greatest number of people. The mobile units based at each of the clinics serve a radius of 60 km, ensuring that the teams cover no more than 120 km in a round trip. At the height of the conflict this was an essential measure to ensure the clinic teams' safety. In addition to clinic staff, community health promoters from the IDP communities are attached to each clinic.

In the initial stages of the project, many clients came mainly for primary health care services, reflecting the poor health status of the IDPs. However, this provided the opportunity to reach a much wider audience for reproductive health, including typically hard-to-reach target groups such as adolescents and men. All the team members were trained with a strong reproductive health focus, which meant that during general health treatments they could identify clients who might be in need of reproductive health services. Services provided through the stationary and mobile units include antenatal and postnatal care, a full range of temporary and permanent family planning methods, and the prevention and management of STIs.

In addition to service delivery, the programme includes extensive health education that covers nutrition, recognising and conserving clean water, disease transmission, gender awareness, family life education, contraception, pregnancy and STIs including HIV. IEC activities are undertaken in a range of settings, including schools around the camps and with a variety of beneficiaries, including female community health volunteers, young people and community leaders. The community health volunteers are supported by the government but PSL also undertakes training and capacity building with them.

Lessons learned

PSL has implemented the programme in line with international best practice, following guiding principles laid out in Reproductive health in refugee situations, a field manual produced by the Inter-Agency Working Group on Reproductive Health in Refugee Situations. These principles include: community participation, quality of care, integrated services and IEC activities.

Community participation underpins the programme and has been essential to its successful development. A number of approaches have enabled PSL to achieve effective community participation. Setting up and training Health Committees in each IDP camp/settlement allowed the committees to become a key voice of the IDP community. The committees enable PSL teams to receive crucial feedback regarding IDP needs, including appropriate operating times for each community (e.g., for Muslim communities Sunday is an appropriate day to access services, while this is not the case for other IDP communities).

A second major feature of the programme is the identification and training of Community Health Promoters (CHPs) from IDP communities. These educators play a major role in raising awareness of reproductive health and acting as co-ordinators for the outreach service teams. The CHPs receive initial training covering basic health and first aid, maternal and child health, and reproductive health information. The modules are prepared in collaboration with the Ministry of Health. Through the initial training programme and regular refresher training sessions conducted by PSL, the CHPs build up a great deal of knowledge on reproductive health care, general primary health care, hygiene and sanitation. They will take this knowledge with them when they are able to move back to their areas of origin, along with any training materials they have used during their attachment to the programme.

Another important facet of the programme is the inclusion of all the affected communities including the local host population. In many settings, agencies are mandated to serve a particular group of people, often to the exclusion of communities in the vicinity. This can cause resentment and lead to an increase in tensions. In addition, excluding sections of the community, particularly in situations of ethnic conflict, can lead to suspicion and repercussions for service providers. Thus, PSL developed its programme to ensure the inclusion of all the communities, including the local host population.

Services are provided in a manner that is appropriate to all clients, whether at stationary clinics or mobile settings. The PSL project teams comprise medical and other staff from host and IDP communities to ensure the linguistic and cultural appropriateness of service delivery. In addition, this contributes to a reduction in ethnic tensions between the communities as well as offering a model of how ethnic differences can be overcome.

Working towards sustainability

In many conflict settings, fighting may continue for decades, making it very difficult for displaced populations to return home. Projects are therefore rarely short-term and consideration should be given from the outset to the longer term impact and sustainability of interventions. PSL has established a financially, socially and culturally sustainable programme through:

• close collaboration and coordination, including provision of training, with both government and NGOs to prevent gaps in services and avoid duplication
• charging locally appropriate service fees with provision of subsidised fees to ensure accessibility to all
• employing staff, particularly CHPs, from the IDP community to ensure the cultural appropriateness of services and to ensure continuation of health provision on eventual return to home
• providing reproductive health services within an integrated health setting to allow clients to seek out reproductive health services in a confidential setting, thereby increasing acceptability.