Healthandsustainabledevelopmentinmyanmar 171118091515

What are the challenges facing Myanmar in progressing towards Universal Health Coverage?

Policy Note #1

Myanmar Health Systems in Transition Policy Notes Series

Policy Notes Series No. 1

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WPR/2015/DHS/001 Š World Health Organization (on behalf of the Asia Pacific Observatory on Health Systems and Policies) All rights reserved.

PHOTO: Nicholas Rikker and onetwodream.wordpress.com

What are the challenges facing Myanmar in progressing towards Universal Health Coverage?

Policy Note #1

Myanmar Health Systems in Transition Policy Notes Series

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Policy Notes Series No. 1

Acknowledgements

Authors

The Myanmar Policy Notes draw upon the Myanmar Health Systems in Transition review, published in 2014 (available on the Asia Pacific Observatory’s web site http://www.wpro.who.int/ asia_pacific_observatory/en/). As such, the indirect contribution of the Myanmar HiT authors to the Policy Notes is acknowledged.

The Policy Notes benefited from comments and suggestions provided by Jorge Luna and Alaka Singh (WHO/Myanmar), Hnin Hnin Pyne (World Bank/Myanmar) and Billy Stewart (DFID/ Myanmar). Technical guidance for the Policy Notes was provided

by Viroj Tangcharoensathien (IHPP/Thailand); Dale Huntington (APO Secretariat) was the managing editor of the series. The APO is grateful for the financial support provided by the 3MDG Fund for this series of publications.

Phone Myint, Deputy Director General (Retired), Department of Health Planning, Ministry of Health, Nay Pyi Taw, Republic of the Union of Myanmar Than Tun Sein, Director of Socio-medical Research (Retired), Department of Medical Research (Lower Myanmar), Ministry of Health, Nay Pyi Taw, Part-time Professor, Anthropology Department, Yangon University and Honorary Professor/Faculty Member, University of Public Health, Republic of the Union of Myanmar Andrew Cassels, Senior Fellow, Global Health Programme, Graduate Institute of International and Development Studies, Geneva, Switzerland

Policy Note #1

What are the challenges facing Myanmar in progressing towards Universal Health Coverage?

The Government of the Republic of the Union of Myanmar is committed to achieving universal health coverage (UHC) by 2030.

In practice, this means that over the next 15 years the aim is to progressively ensure that all people in all parts of the country have access to the health-care services they need – both preventive and curative – without suffering financial hardship when paying for them. This ambitious goal is seen as a desirable end in itself, and as a means to achieving people-centred development.

This policy note is the first in a set of four. It provides an overview of the challenges to be overcome in making progress toward UHC and sets out recommendations for how they can be tackled. The other notes look in more detail at three specific issues: how UHC can improve equity, and how strengthening the township health system and expanding financial risk protection contribute to UHC.

1. What are the challenges?

There are two fundamental challenges to be addressed, if the ambitious objectives of UHC are to be achieved.

Health has been a low priority Health has lacked clear leadership. Despite a National Health Policy (1993) and national health development plans for the period 2000–2016, which included UHC as an overarching goal,

political and economic stability has taken precedence over social and human development. Overall levels of funding for health have been insufficient to make the idea of health-for-all and financial protection a reality. The Government has seen health as the sole responsibility of the Ministry of Health and other parts of government with an influence on health outcomes fail to see health as relevant to their mandate. In part because of lack of evidence and in part through active opposition (e.g. from tobacco growers) health is seen neither as a contributor to peace nor to economic growth. The net result is a substantial gap between goals and objectives, the funding needed to achieve them, and the partnerships needed for effective implementation.

Health services function poorly The second set of challenges is related to the first, but concerns the health system itself. Inadequate public financing means that too many people cannot access the services they need. There are several reasons for this, which together create a vicious cycle. Deterioration of health service infrastructure (clinics and hospitals) contributes to a decline in the standard of services.

This is exacerbated by inadequate and unreliable supplies of essential medicine and equipment, and further compounded by inadequate numbers and maldistribution of staff. On top of this, a continuing reliance on out-of-pocket payments for health

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care deters the poor from seeking health care or exposes them to unaffordable payments. The combination of these factors results in a public sector in which people have little faith, and a for-profit private sector that offers low quality care, too often at high prices. Breaking this vicious cycle requires action on several fronts.

2. What do we know?

There is a growing body of evidence that illustrates the magnitude of these challenges.

• Primary care takes second place to hospital services: Despite being one of the first countries in the South-East Asia Region to develop a primary health care approach, training of health workers and development of health facilities have focused more on doctors, nurses and hospitals, as opposed to health workers at primary facility and community level.

Evidence shows that there has been little or no change in the number of primary health care facilities – station hospitals, rural health centres, maternal and child health centres, and school health teams – since the late 1980s. Myanmar national health accounts suggests that government health spending has been directed more towards high-end tertiary

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services located in big cities, which offer limited access to the rural poor.

• Access to services remains highly inequitable: Despite policies to expand services to rural and hard-to-reach areas, monitoring data indicate that disparities still exist in service availability and health outcomes across regions and across socio-economic groups. Coverage of basic services in regions and states with significant hard-to-reach areas is thus considerably lower than in other parts of the country, despite their greater health needs. In some areas non-state actors have established ethnic health authorities and community-based organizations have opposed expansion of government services, seeking instead for recognition of their own work. Shared understanding of this situation is growing but interventions to strengthen alignment are hampered by slow progress in the peace process.

• The poor rely on private providers: Most poor households rely on private health-care providers because of their physical proximity, shorter waiting times, availability of staff and drugs, and perceived quality of care. The use of private health care is made additionally necessary by the scarcity of public health services in peripheral areas of the country. The lack of

adequate private sector regulation means that the poor are vulnerable to overpriced services, which are often of very poor quality.

• User charges discriminate against the poor: Household out-of-pocket payments became a dominant source of health service financing following reforms in the 1990s. As a result, utilization of services depends more on capacity to pay for medical care and transport costs than health needs. Measures taken to protect the poor and support the destitute have been found to be ineffective.

• Deployment and retention of staff are major challenges: A range of factors including, but not limited to, low salaries affect the motivation of all public health staff. However, this is particularly problematic when it comes to placing and retaining health workers in less-secure and hard-to-reach areas. Hardship allowances have had little impact and have been judged to be financially unsustainable. The result is that vacant posts are not filled, making it impossible to ensure adequate services in those areas. Alternative approaches such as contracting local nongovernmental organizations (NGOs) to provide services have yet to be tried on a large scale.

• New graduates cannot find jobs in the health service: Despite a manifest shortage of human resources, it is assumed that budget constraints mean that many new professional graduates cannot find positions in the health service, but more evidence is needed to determine whether this is the main issue. Whatever the reason, many doctors either migrate abroad or work in private practice, usually in the main towns and cities. A similar situation exists for nurses and other health and paramedical professionals.

• Scarce resources are allocated inefficiently: The priority given to hospitals means that the government is not achieving good value for money. Similarly, procurement reform for pharmaceuticals (which is now underway) has the potential to result in significant savings. Reallocation towards primary care, which allows for prevention and promotion as well as treatment, will result in far better health outcomes even at low levels of investment. Of equal concern is the fact that money spent on hospitals is also being used inefficiently.

A study conducted in 2011 showed that 60% of hospitals surveyed performed poorly in terms of bed turnover ratio, bed occupancy rate and average length of stay.

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3. What needs to be done?

This Policy Note makes three closely linked sets of recommendations, namely to: A. Increase financial investment in health as a cornerstone of people-centred development; B. create the partnerships and governance mechanisms needed to ensure that better health is an outcome of policies and programmes in all sectors; and C. strengthen the township health system (THS) with a new focus on equity and efficiency.1 These recommendations are interdependent if UHC is to be achieved. Thus, seeking to strengthen the current health system without a significant increase in resources is likely to achieve little. Relying purely on the health sector to produce a more healthy population, in the absence of addressing the other determinants of ill health, will pay limited dividends. And strengthening the health system as it currently operates, without fundamental reform that focuses on significant and measurable efficiency gains, will result in deepening inequity and continuing waste.

A: Increasing investment in health It is important to note that the Government has taken steps to increase the health budget, but has done so from a very low base.2 Myanmar still spends less as a proportion of gross domestic product, and as a proportion of overall government spending, than its neighbours and other countries in the South-East Asia Region. The key message is that without significant increases it is unlikely that even current plans for staffing, facilities or commodities will be affordable.

The first step is to systematically review opportunities for increasing the fiscal space for health. Here, there are several options to consider. To date, most of the increase in health spending has resulted from overall economic growth. In other words, health has maintained a constant share of a growing pot of resources. The next obvious step therefore is to assess the potential for reallocation to health from other sectors (increasing the share of the overall pot), using the evidence that shows how health can significantly contribute to economic growth as a compelling part of the business case. Reallocation is likely to be more acceptable as overall fiscal space increases through tax reform, more effective tax collection, and new revenue streams (from natural resources, for example).

1 Policy Note #3: How can the township health system be strengthened in Myanmar? provides more details on strengthening township health systems.

2 The 2015/2016 budget of US$602 million is 8.7 times that of 2011/2012.

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A further option to be considered is using so-called “sin taxes” – imposing a levy on items such as tobacco, alcohol or sugary drinks – that can be used in whole or in part to finance health expenditures. Such taxes or levies have a direct public health benefit as well as generating additional resources.

sectors play is now an increasingly important element of UHC, particularly as the proportion of death and disability attributable to road traffic accidents and noncommunicable conditions like cancer, diabetes and cardiovascular and respiratory disease increases.

With the opening up of the country, Myanmar will continue to attract external development assistance, and for many donors health is a priority.3 It is important that external funding does not displace domestic resources, so that external funding is additional to domestic spending.

The health sector must be an advocate for policy change, but real progress will depend on actions in other sectors and will require high-level political support. In this sense, health becomes a governance issue, requiring a careful assessment of how each sector can make a difference. The urgency of the issue is compounded by the evident speed of private sector investment in Myanmar.

In summary, there is a political window of opportunity during the upcoming general election to increase health spending, as a key to achieving UHC.4 B: Health in all policies Better health cannot depend on health services alone. While the case for greater investment in health rests in part on the contribution that health makes to national economic development, health is a significant beneficiary from good policy in other sectors. Moreover, the role that other

In many areas, new investments in sectors such as communications, rural transport, financial services and telecommunications can have a positive impact on health and health systems. At the same time, the increasing availability of fast food, tobacco products and alcohol, combined with risk factors such as more sedentary lifestyles and environmental degradation, are likely to have a negative effect on people’s health.

3 Recent developments suggest that this may no longer be the case as Australia, the European Union and DANIDA plan to discontinue health funding.

4 Policy note #4: How can financial risk protection be expanded in Myanmar? provides additional details on health financing and social protection.

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Policy coherence across government is equally important in relation to health financing. For example, while the Ministry of Social Welfare, Relief and Resettlement is taking the lead on introducing formal social protection, the Ministry of Labour, Employment and Social Security is concurrently expanding social security coverage. Given the importance of financial protection as one component of UHC, it is critical that different arms of government approach social protection in ways that are well aligned and synergistic. Health will also benefit from investment in disaster preparedness, prevention of road traffic accidents and water and sanitation.

The Ministry of Health has a key role in generating the evidence that policy-makers need to weigh the positive and negative impacts of policies in other sectors. It will also require a careful assessment of the governance instruments (legal, regulatory, public communications, target setting and monitoring) that are needed to ensure that health is a beneficiary and not a casualty of developments in other sectors.

C: Strengthening township health systems Firstly, the key message is that making health systems more equitable, effective and efficient requires action on many fronts.

Like any system, the different elements are dependent on

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each other: human resources, supplies and logistics, financial management, leadership, health information, planning and budgeting, public engagement and communications, monitoring and evaluation. Any actions to be taken need to be strategic, sustained and consistent. Taking into consideration the many bottlenecks that require urgent attention, both immediate and long-term measures are needed. Secondly, it is vital to recognize that strengthening the system is not an end in itself. It is a means to ensure people have access to quality health care that delivers good health outcomes. With this in mind, a number of actions need to be considered.

• Declaring a decade for township health systems development (2016–2026) sends a powerful message: The THS is the vital strategic front. A declaration focusing on the township will signify strong political leadership and long-term sustainable financial commitment. While greater decentralization of financial authority is a prerequisite, support from regional/state authorities in the form of policy frameworks, technical guidance, monitoring and supervision will be essential5.

• Reducing inequity is of paramount importance for the health sector as a whole:6 However, progress in reducing inequities will require major reforms at township level and

5 Policy note #3: How can the township health system be strengthened in Myanmar? provides more details on these points.

6 See Policy note #2: How can health equity be improved in Myanmar? on health equity provides more details.

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below to ensure health-care services reach the poor and disadvantaged groups. This is particularly so for minority groups and people in conflict-affected areas.

ethnicity and maternal educational level – provides a platform for holding different stakeholders to account. Support will be needed to build the capacity for effective equity monitoring.

• Upgrading close to client services is urgent: Priority should be given to increasing the quality of care provided at rural health centres, sub-rural health centres and station hospitals in rural areas, before upgrading secondary and tertiary urban hospitals.

• The Health Management and Information System (HMIS) needs to be strengthened: While the HMIS should be able to generate adequate indicators of acceptable quality, the system needs to be further strengthened if it is to generate more reliable evidence. The HMIS currently collects data only from public facilities. With the upcoming Demographic and Health Survey now is the time to explore inclusion of the private sector in data sharing.

• Up-to-date service mapping will reveal the current maldistribution of facilities: Service-delivery infrastructures should be equitably distributed across the country. The most needy areas should be prioritized through rapid assessment and adequate supply of essential medicines and basic medical equipment, made available on the basis of level-of-care needs of individual localities. Service delivery mapping should include all providers including the private sector, NGOs, and ethnic health organizations.

• Monitoring equity is key to ensuring accountability: Regular monitoring of how health equity has improved, stagnated or regressed is a priority for sound policy-making. Evidence on all dimensions of health inequity – geographical, socioeconomic,

• The township health system includes all health providers: The purpose of coordination at township level is to ensure that different departments and programmes deliver health services responsively and effectively. The THS (and township health plans) must include all providers of health care: public, private and NGOs. • Station hospitals can become more efficient: Many station hospitals do not perform well and provide poor-quality services. Inadequate staffing, insufficient supplies and outdated equipment exacerbate this situation. Station

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hospitals can save lives; ensuring that they have the means to do so is a priority, given their importance to the rural poor.

• A more systematic approach to the work of Basic Health Staff is needed: Basic health staff are the backbone of the THS: making the best use of their skills and enhancing their motivation is critically important. A systematic review of roles, responsibilities and workloads is required. This review should determine how the tasks should be distributed among rural health team members; what potential tasks should be shifted to others such as auxiliary midwives and community health workers; how the productivity of basic health staff should be assessed; and what skill mix is required to deliver services in line with the health needs of the population. The review should take into account changing patterns of disease, notably the growing prevalence of noncommunicable diseases.

• Interim measures should be introduced prior to an essential package of care: The Ministry of Health is in the process of developing an essential package of health services that will be covered (and also fiscally sustainable) under UHC.

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Reaching consensus on this package will take time. In the interim, it is desirable to agree on a more limited range of cost-effective interventions, based on international experience and evidence, that target selected services such as maternal, newborn and child health care.

• Free access to medicines for all now would demonstrate political commitment to UHC: One immediate action the Government should consider is to ensure free access to essential medicines for the whole population as a signal of its commitment to UHC. This is not only ethically sound, given high levels of poverty, but also politically strategic. The Government has already increased spending on free essential medicine significantly since 2012. There is some evidence, however, that poor supply and logistic systems have meant that medicines have not always reached facility level. An expansion of this programme would therefore benefit from a rapid assessment of progress to date, to ensure that existing measures are effective, equitable and sustainable, and that supply bottlenecks have been overcome.

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Challenges Impede Development of Myanmar’s Public Health

Specials

Challenges Impede Development of Myanmar’s Public Health

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Challenges Impede Development of Myanmar’s Public Health

About 1,000 students from Yangon's University of Nursing protested against the Ministry of Health and Sports’ policy of issuing nurse license certifications to graduate nurses only after three years of working in government hospitals. March 15, 2017. / Myo Min Soe / The Irrawaddy

By TIN HTET PAING

15 November 2017

YANGON — Myanmar’s de facto leader and State Counselor Daw Aung San Suu Kyi has repeatedly singled out the minister for health and sports as one of the few Cabinet members whose performance she has been consistently satisfied with since taking office nearly two years ago. Despite this praise, however, after decades of institutional neglect of public services by the military junta, the public health sector still regularly faces criticism for being understaffed and providing substandard care.

“The health status of the Myanmar population is poor and compares unfavorably with other countries in the region,” the Health and Sports Ministry acknowledged in its recently launched 2017-2021 National Health Plan.

Human resources constitute a critical input into the health system if it is to ensure access to quality care. For that reason, the plan cites a lack of human resources, skill imbalances, inequitable distribution of services, and difficulties in rural retention of medical personnel as being among the ministry’s main challenges.

Myanmar’s key health care performance indicators — maternal mortality ratio (MMR) and life expectancy at birth — are among the worst in Southeast Asia, according to World Health Organization (WHO) data.

The MMR is the annual number of female deaths per 100,000 live births from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes). It includes deaths during pregnancy, during childbirth, and within 42 https://www.irrawaddy.com/specials/challenges-impede-development-of-myanmars-public-health.html

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days of termination of pregnancy, irrespective of the duration and site of the pregnancy.

The column chart below shows the MMR ratios (2015) of ASEAN countries, with Myanmar’s being the second highest in the region.

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Maternal Mortality Ratio In The Region

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(per 100,000 live births) 200 180 160 140 120 100 80 60 40

Vietnam Philippines Indonesia Cambodia Myanmar

197

178

Malaysia

161

Brunei

126

40

Thailand

114

23

Singapore

54

20

0

10

20

Lao

Source: World Health Organization (2015 Data)

Maternal Mortality Ratio In The Region Infogram

Small Budget Allocation Health care spending accounts for just 5.23 percent of Myanmar’s total budget for the 2017-18 fiscal year, which is an improvement over past years but still extremely low by global and regional standards. The charts below show the comparison of Asean countries’ health expenditure and the Myanmar government’s budget allocation on health and sport, and defense.

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Challenges Impede Development of Myanmar’s Public Health Health Expenditure of Regional Countries

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% of Total Government Expenditure

2000

2014

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Source : World Health Organization (2014 Data)

Health Expenditure of Regional Countries Infogram

Budget Allocation Comparison

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Budget (Billion Kyat)

Percentage

Budget (Billion Kyat)

Health

Defense



Other

Source: Ministry of Planning and Finance, Myanmar (Citizen's Budget 2017-18)

Budget Allocations Comparison Infogram

Uneven Distribution of Health Care Workers According to the ministry, there were 1.33 health workers (doctors, nurses and midwives) per 1,000 people – well below the WHO’s minimum recommended threshold of 2.3 – as of November 2016. In terms of distribution, health workers were largely concentrated in Yangon, Mandalay and other urban areas.

The map below shows the distribution of health care workers and health facilities throughout the country according to data from the ministry. The darker shade represents a higher population per hospital bed.

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Population Per Hospital Bed 280

1.5k 957 AVG

?

Map by Tin Htet Paing

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The chart below shows the uneven distribution of doctors throughout the country, both in the public and private sectors.

Number of Doctors In Private and Public Sectors

Public Sector

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Private Sector

Source: Ministry of Health and Sports (2015 Data)

Number of Doctors In Public and Private Sectors Infogram

The main reasons most health workers don’t want to work in rural areas are: a lack of incentives, including very low salaries, from the government; lack of health facilities; and the challenge posed by a low ratio of health workers to patients, according to doctors working at public hospitals who talked to The Irrawaddy on condition of anonymity.

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Challenges Impede Development of Myanmar’s Public Health

Such a challenging work environment allows no study time, they said. Many medical personnel who wish to become specialist physicians must concurrently prepare to apply for graduate programs while completing their required public service, said a 25year-old assistant surgeon at Yangon’s Insein General Hospital.

“If the government sends me to a rural area, I won’t go until I have completed the process of becoming a specialist with a graduate degree, and no longer need to spend time studying,” she told The Irrawaddy.

The assistant surgeon said her only aim in working at a government hospital was to complete the service needed to qualify for a graduate course and become a specialist.

Shortage of Personnel, Despite Student Intake Five medical universities across the country admit a total of around 1,500 students per year, while two nursing universities in Yangon and Mandalay admit around 400 students each year. The chart below shows the number of undergraduate students produced by medical schools overseen by the Ministry of Health and Sports.

Undergraduate Students (Through June 2015)

 Medicine

Nursing

Dental Medicine

Medical Technology

Pharmacy

Community Health

Source: Department of Health Professional, Ministry of Health and Sports

Undergraduate Students Production Infogram

Low job satisfaction related to the poor working environment and low pay at public hospitals prompts some to join the private sector, said a 28-year-old doctor who recently joined a non-governmental organization that works in public health.

“With such an unbalanced ratio of human resources to workload, doctors can’t provide quality care to patients, which affects their profession’s image,” he told The Irrawaddy.

“As a result, the profession no longer enjoys the trust and respect that it once did from the public. This causes doctors to quit working in the public service and join the nongovernmental sector,” he said.

The graph below shows the percentage of physicians who don’t contribute to the public health care sector after graduation for various reasons. https://www.irrawaddy.com/specials/challenges-impede-development-of-myanmars-public-health.html

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Unutilized Trained Doctors

27%

Absconded, Resigned, Pensioned, Death

Source: Ministry of Health and Sports (2011-2015 Data)

Wastage in Trained Health Workforce Infogram

According to the ministry’s Nursing Department, the more than 1,000 public hospitals across the country require a minimum of 35,000 nurses. But about 43 percent of these nursing positions are vacant, with only about 20,000 nurses serving in government facilities.

Public/Private Sector Wage Differential Medical students have to invest seven years of their lives studying, including a year of house surgeon training, to obtain an M.B., B.S. degree, while nursing students spend four years studying for their B.N.Sc degrees. A medical graduate can expect to earn a minimum of 1,000,000 kyats (approx. US$800) at non-governmental organizations or UN agencies, but only 250,000 kyats (approx. US$185) at public hospitals. The chart below shows the basic salaries of physicians and nurses working at government facilities.

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Basic Salaries of Health Workers 380,000 ~ 400,000 MMK Deputy director-general~ Superintendent

250,000 ~ 270,000 MMK Assistant Surgeon ~ Head physician of station hospital

280,000 ~ 300,000 MMK Chief Nurse

150,000 ~ 175,000 MMK Midwife/ Nurse Source: Ministry of Health and Sports (2017 Data)

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Share

Medical Workers’ Salaries Infogram

Topics: Public health

Tin Htet Paing

The Irrawaddy Tin Htet Paing is Reporter at the English edition of The Irrawaddy.

Burma

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Healthcare in Myanmar

Nagoya J Med Sci. 2016 May; 78(2): 123–134.

PMCID: PMC4885812

Healthcare in Myanmar Nyi Nyi Latt,1 Su Myat Cho,1 Nang Mie Mie Htun,1 Yu Mon Saw,2 Myat Noe Htin Aung Myint,1 Fumiko Aoki,1 Joshua A. Reyer,1 Eiko Yamamoto,1 Yoshitoku Yoshida,1 and Nobuyuki Hamajima1 1 Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan 2 Women Leaders Program to Promote Well-being in Asia, School of Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan Corresponding author: Nobuyuki Hamajima, MD, MPH Department of Healthcare Administration, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-ku, Nagoya 466-8550, Japan E-mail address: nhamajim@med.nagoya-u.ac.jp Received 2015 Dec 24; Accepted 2016 Mar 4.

Copyright notice This is an Open Access article distributed under the Creative Commons Attribution-NonCommercialNoDerivatives 4.0 International License. To view the details of this license, please visit (http://creativecommons.org/licenses/by-nc-nd/4.0/).

This article has been cited by other articles in PMC.

ABSTRACT

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Myanmar transitioned to a civilian government in March, 2011. Although the democratic process has accelerated since then, many problems in the field of healthcare still exist. Since there is a limited overview on the healthcare in Myanmar, this article briefly describes the current states surrounding health services in Myanmar. According to the Census 2014, the population in the Republic of the Union of Myanmar was 51,410,000. The crude birth rate in the previous one year was estimated to be 18.9 per 1,000, giving the annual population growth rate of 0.89% between 2003 and 2014. The Ministry of Health reorganized into six departments. National non-governmental organizations and community-based organizations support healthcare, as well as international non-governmental organizations. Since hospital statistics by the https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885812/

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government cover only public facilities, the information on private facilities is limited. Although there were not enough medical doctors (61 per 100,000 population), the number of medical students was reduced from 2,400 to 1,200 in 2012 to ensure the quality of medical education. The information on causes of death in the general population could not be retrieved, but some data was available from hospital statistics. Although the improvement was marked, the figures did not reach the levels set by Millennium Development Goals 4 and 5.

A trial prepaid health insurance system started in July 2015, to be followed by evaluation one year later. There are many international donors, including the Japan International Cooperation Agency, supporting health in Myanmar. With these efforts and support, a marked progress is expected in the field of healthcare.

Key Words: Myanmar, healthcare, manpower, facility, health insurance

INTRODUCTION

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Myanmar is a country with an area of 680,000 km2 (1.8 times of Japan) surrounded by Thailand, Laos, China, India, and Bangladesh. According to the Census 2014, the population in the Union of Myanmar was 51.41 million in September 2014.1) There are 135 different ethnic groups with their own languages and cultures in Nay Pyi Taw Union Territory and 14 states/regions.

In addition, illegal immigration across the border is not rare. In this heterogeneous society, there are many obstacles to the provision of health services to the whole nation.

The election of 2010 led Myanmar to a civilian government in March, 2011.

Since then, the democratic process has accelerated, but there are many problems to be resolved in every field. In the field of healthcare, there are problems in maternal and child health, nutrition, infectious disease controls, tobacco controls, access to healthcare services, and quality of services.2-5) This paper briefly describes the current situations of healthcare in Myanmar, based on sources available in English from the Internet, as well as scientific papers in English and Myanmar language newspapers reporting the recent changes. The main sources are the official website of Ministry of Health (MoH), Myanmar (http://www.moh.gov.mm) and the 2014 Myanmar Population and Housing Census (http://countryoffice.unfpa.org/myanmar/ census/). This article covers general information on population and birth rate, structure and function of MoH, healthcare facilities and professionals, health https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885812/

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insurance, mortality, Millennium Development Goals (MDGs), and support from international donors.

POPULATION AND BIRTH RATE

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Accroding to the Myanmar Population and Housing Census 2014, the population in the Republic of the Union of Myanmar was 51,419,000 (24,821,000 males and 26,598,000 females) as of March 29, 2014, which includes an estimated population of 1,206,000. Yangon was the most populated area (7,355,000, 14.3%), and the capital, Nay Pyi Taw, had 1,158,000 (2.3%).

According to the Union Report, 28.6% were aged under 15 years, 65.6% were aged 15 to 64 years, and 5.8% were aged 65 years.6) At the same time, another source, the World Factbook, reports that the estimated population for July in 2015 is 56,320,000; 26.1% for those aged 0–14 years, 68.6% for those aged 15–64 years, and 5.4% for those aged 65 years or over.7) Based on the Census 2014, the government estimated that the crude birth rate in the previous one year was 18.9 per 1,000 population. The annual population growth rate was estimated to be 0.89% between 2003 and 2014.6) Despite the government historically encouraging population growth and adopting a laissezfaire policy towards fertility in the past,8) fertility has been steadily falling.

Myanmar’s total fertility rate estimated by the Census 2014 was 2.29, which down from 6.1 in 1965.9) Fertility rates in the urban areas were low (1.7 in Yangon Region and 1.9 in Mandalay Region), and those in the surrounding regions were hovering just above replacement fertility (2.1 in Magway Region, 2.1 in Nay Pyi Taw Union Territory, 2.2 in Bago Region, 2.6 in Ayeyarwady Region, and 2.3 in Sagaing Region). Further away from the urban areas, the rates were relatively high (2.4 in Mon State, 2.7 in Shan State, 2.8 in Kachin State, 3.0 in Tanintharyi Region, 3.3 in Kayah State, 3.4 in Kayin State, and 4.4 in Chin State). While providing direct support to family planning in order to improve women’s reproductive health, it has only been in the last 20 years that the government has taken actions with regards to fertility, seeking to maintain replacement-level fertility.10)

ADMINISTRATIVE STRUCTURES

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Myanmar healthcare systems have drastically evolved with recent changes of political and administrative systems. Although the healthcare systems are a mixture of public and private sectors both in the aspects of finance and supply, MoH remains the major provider of healthcare services. As shown in Fig. 1, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885812/

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there are 6 departments in the MoH, which facilitate all aspects of health for the whole population.11) Fig 1 Administrative structures supporting healthcare in Myanmar The Department of Public Health is mainly responsible for primary healthcare and basic health services; nutrition promotion, environmental sanitation, maternal and child health, school health, and health education. The Disease Control Division and Central Epidemiology Unit under this Department cover prevention and control of infectious diseases, disease surveillance, outbreak investigations, and capacity building. The Department of Medical Services provides effective treatments and rehabilitation services. Curative services are provided by various categories of health facilities under the control of the Department. The Department of Health Professional Resource Development and Management is mainly responsible for training and production of all categories of health personnel, except for traditional medicine personnel, to attain equitable healthcare for the whole population. The Department of Medical Research conducts national surveys and research for evidence-based medicine and policy making. The Department of Food and Drug Administration ensures safe food, drugs and medical equipment, and cosmetics. The Department of Traditional Medicine is responsible for the provision of healthcare with traditional medicine, as well as training of traditional medicine personnel. There were 6,963 private traditional practitioners in 2014. Most of them were trained at the Institute of Traditional Medicine until 2001, and at the University of Traditional Medicine from 2002 onwards.

In line with the national health policy, non-governmental organizations such as the Myanmar Maternal and Child Welfare Association and the Myanmar Red Cross Society are taking a share of service provision. Nation-wide nongovernmental origanizations, as well as locally acting community-based organizations and religion-based societies, also support and provide healthcare services.

HEALTHCARE FACILITIES

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Although there are substantial number of private facilities for the wealthy, the English documents concerning these are limited. In 2007 the government https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885812/

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issued “The Law Relating to Private Health Care Services”. Private Health Statistics 2015 by the Department of Medical Services reported that there were 193 private hospitals, 201 private specialist clinics, 3,911 private general clinics, and 776 private dental clinics. In Myanmar, many charity hospitals run by private sectors are operating for the poor. There are private non-profit clinics run by community-based organizations and religion-based societies, which also provide ambulatory care. Among them, some have developed to provide inpatient care in Nay Pyi Taw, Yangon, Mandalay, and other large cities in recent years, although the funding and provision of care were still fragmented. Since Hospital Statistics by the government covers only public facilities,12) the information on private facilities both for the rich and the poor is limited.

Public hospitals are categorized into general hospitals (up to 2,000 beds), specialist hospitals and teaching hospitals (100–1,200 beds), regional/state hospitals and district hospitals (200–500 beds), and township hospitals (25–100 beds). In rural areas, sub-township hospitals and station hospitals (16–25 beds), rural health centers (no beds), and sub-rural health centers (no beds) provide health services, including public health services.

Table 1 shows the number of public healthcare facilities in Myanmar in 2014.13) There were 1,056 public hospitals with 56,748 beds in total. These facilities mainly provide curative and rehabilatitive services. There are 87 primary and secondary health centers, 348 maternal and child health centers, 1,684 rural health centers, and 80 school health teams. These facilities are mainly responsible for preventive services and public health activities. There are 16 traditional medicine hospitals and 243 traditional medicine clinics.13) Table 1 Public health facilities in Myanmar, 2014 The Ministries of Defense, Railways, Mines, Industry, Energy, Home and Transport also provide healthcare for their employees and families with their own medical facilities and budget.11)

HEALTHCARE PROFESSIONALS

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1) Current manpower

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The numbers of healthcare professionals are shown in Table 2.13) Classification of public sector or private sector was available only for medical doctors, dentists, and traditional medical practitioners. Some of the public professionals also work at private facilities, while those categorized as private sector work only in private facilities.

Table 2 Healthcare professionals in Myanmar Almost 70% of the population resides in rural areas. Basic health staff are the main health care providers for them. Generally, one rural health center (RHC) has four sub-centers. The staff is made up of one public health supervisor grade I at the RHC, four public health supervisors grade II (one at each sub-center), five midwives (one at the RHC and one at each sub-center), one lady health visitor at the RHC, and one health assistant at the RHC. The basic health staff is responsible for maternal and child health (clinic or homecare), school health, nutritional promotion, immunization, community health education, environmental sanitation, disease surveillance and control, treatments of common illnesses, referral services, birth and death registration, and training of volunteer health workers (community health workers and auxillary midwives).

These health workers face many challenges in their effort to reach out to the remote villages, with meager resources and support.

According to World Health Organization (WHO) health statistics, in 2013– 2014 the number of doctors, nurses and midwives, and dental surgeons per 100,000 population in Myanmar were 61, 100, and 7, respectively, while in South-East Asia as a whole there were 59, 153, and 10, respectively.14) Despite an increase in health workforce, there is an uneven spread of skillful health workers between urban and rural areas.

2) Education for healthcare professionals The MoH, Ministry of Education, and Ministry of Defence are responsible for the training and production of different categories of health workforce for the whole population. There is no private medical university in Myanmar. Under the MoH and Ministry of Education, health professionals are being produced by 15 universities and 46 nursing and midwifery training schools. There are a medical school and an allied university under the Ministry of Defence.

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Currently, 39 doctorate courses, 12 PhD courses, 47 master courses, and 12 diploma courses are provided in medical and allied universities.13) To produce qualified medical doctors, the 9th Medical Education Seminar agreed to reduce the annual student intake of four medical schools from 2,400 to 1,200 (300 in each university) in 2012 and thereafter. Meanwhile, a new medical school was opened recently in Taung-Gyi, the capital city of Southern Shan State (150 students in 2015). In addition, the study period of medical students was extended from 6 years to 7 years.15) For capacity building, candidates from different disciplines have been selected and sent for oversea training in the courses for PhDs, master’s degrees, and other diplomas, as well as for short term training. Medical doctors, dental surgeons, and nurses must join the civil service in order to pursue postgraduate degrees. In Myanmar, the following examinations have been held with the close collaboration of Royal Colleges of the United Kingdom: Membership of the Royal Colleges of Physicians (MRCP), Membership of the Royal College of Surgeons (MRCS), Membership of the Royal College of Paediatrics and Child Health (MRCPCH), and Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG).15) Under the Department of Traditional Medicine, the University of Traditional Medicine was established in 2001, providing bachelor’s and master’s degrees.

The bachelor’s degree is a five-year course, including one-year internship. The curriculum covers traditional medicine, as well as the basic science of western medicine. The yearly intake is about 100 candidates. The University had already produced 1,139 graduates. In the year 2012, the University opened a Master of Myanmar Traditional Medicine course and Bachelor of Myanmar Traditional Medicine bridge course.16) 3) Employment Previously, the members of the public sector health workforce were hired as civil servants by the central government’s Union Civil Service Board (UCSB).

The employment rules and regulations were applied for all public health facilities. At present, the health workforces are recruited not only by UCSB but also by the state/region governments. In addition, they are hired with the civil servant benefits such as permanent contracts, career advancement, opportunities for postgraduate medical education, and so on. In Myanmar, the MoH is the key player in public sectors for the production, utilization, and governing of the health workforce. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885812/

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Private sectors are more flexible in their employment systems. The recruitment systems and the benefit packages offered to the health workforce are designed at each health facility. Compared to public health facility employment, private health facility employment is more attractive in terms of being located in urban areas, offering a higher salary, and providing better working conditions, although there are disadvantages in terms of postgraduate medical education.

MORTALITY

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Although reporting systems based on ICD 10 exist,17) the mortality data are not completely available. Accordingly, the mortality rate of each cause of death cannot be calculated, but the percentages of causes of death are obtainable from hospitals.12, 13, 18) Table 3 shows the frequent causes of death reported from public hospitals,12) which do not reflect all death, such as death outside of hopitals. In addition, the percentages may change according to the method of disease grouping. The figures should be interpreted carefully. The most frequent diseases in Table 3 are infection and parasitic diseases (22.5%), followed by circulatory diseases (17.1%) and deaths at perinatal period (12.3%). Since the age distribution of the deceased patients in hospitals is not described in the document, comparison of the percentages with those in a general population is not possible. Age-specific mortality by cause is not available.

Table 3 Top 10 grouped causes of mortality in percent by sex from hospital reports, in 2012, Myanmar

MILLENNIAUM DEVELOPMENT GOALS

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The United Nations Millennium Declaration was signed by 189 countries in 2000, which was translated into eight MDGs by 2015 for development and poverty eradication. Myanmar is one of the signatories for the MDGs. MDGs 4, 5, and 6 are on health, and related to each other. However, the achievements of these health-related MDGs are not uniform, based on limited data reported.3) MDG 4 is on the reduction of child mortality by two-thirds between 1990 and 2015, based on three indicators: under-five mortality rate (U5MR), infant mortality rate (IMR), and proportion of 1 year-old children immunized against measles. Myanmar has shown moderate progress in this goal. The U5MR is trending downwards, falling from 106 per 1,000 live births in 1990 to 79 in https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885812/

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2000 and 52 in 2012. The IMR has also fallen in the past ten years from 79 in 1990 to 41 in 2012.19) The coverage of measles immunization among 1-yearold children was 86.0% in 2013.20) MDG 5 on maternal health encompasses two targets: to reduce the maternal mortality ratio (MMR) by three quarters between 1990 and 2015, and to achieve universal access to reproductive health by 2015. Indicators for the latter include the proportion of births attended by skilled health personnel, the contraceptive prevalence rate, the adolescent birth rate, antenatal care coverage, and unmet need for family planning. In Myanmar, the national MMR has declined from 520 per 100,000 live births in 1990, to 200 per 100,000 live births in 2013.21) Overall, a slow upward trend in maternal health indicators was observed from 1990 to 2010 in Myanmar, though information on some indicators was unavailable. The proportion of skilled birth attendance in 2007 was 64.1%, reaching 72.0% in 2013.21) The rate of antenatal care coverage of at least one visit in 2008–2012 was 83.1%. Regarding antenatal care, coverage of at least four visits was 73.4% in 2008–2012.19) The prevalence of married women in Myanmar using any sort of contraceptive method has also been increasing gradually; yet rates of contraception use remain relatively low, lagging behind those observed in many other countries. The percentage of currently married women using any contraceptive method was 16.8% in 1991, 37.0% in 2001, and 41.0% in 2007.22, 23) MDG 6 is the control of the “big three” infectious diseases; HIV/AIDS, malaria, and tuberculosis (TB). Among the health-related MDGs, MDG 6 is the only one for which targets have already been reached or are on track to be achieved by 2015 in Myanmar. HIV prevalence in the general population aged 15–49 years has stabilized at 0.6%.20) Among the most-at-risk groups, such as men who have sex with men, female sex workers, and injecting drug users, HIV prevalence rates have significantly declined. However, HIV prevalence among newly diagnosed TB patients has fluctuated around the 10% level.

Meanwhile, anti-retroviral therapy coverage among people with advanced HIV infection in Myanmar was still inadequate, at only 24.0% in 2010.

Regarding the MDG 6 targets for malaria incidence reduction, reductions in malaria morbidity and mortality have been observed in Myanmar since the introduction of the rapid diagnostic test and artemisinin-based combination therapy. From 1990 to 2010, morbidity fell from 24.4 per 1,000 to 11.7 per 1,000, while mortality declined from 12.6 per 100,000 to 1.3 per 100,000.24) In spite of progress in combating malaria, it remains a major public health https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885812/

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problem in Myanmar because of climate and ecological changes, population migration, development of multi-drug resistant P. falciparum parasite, the rise of insecticide-resistant vectors, and changes in the behaviour of malaria vectors. Two-thirds of the population still live in malaria-endemic area and malaria remains a leading cause of morbidity and mortality.24) As in the other parts of the world, the use of insecticide-treated nets (ITNs) has helped to reduce malaria-related morbidity and mortality in Myanmar, but the total population covered by ITNs was only 4 million in 2011.24) However, data were not available on the percentage of children under 5 years sleeping under ITNs and the percentage of children under 5 years with fever who received treatment with any antimalaria drug.

Regarding TB control, appreciable progress has been made in Myanmar as measured in both case detection and treatment success rates. TB case detection rate increased from 8.0% in 1990 to 71.0% in 2010, and TB treatment success rates rose from 77.0% in 1994 to 85.0% in 2009.24) Deaths due to TB among HIV-negative people has also been reduced from 110 per 100,000 in 1990 to 41 per 100,000 in 2010.24)

HEALTH COST PAYMENT AND INSURANCE

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In Myanmar, health insurance was only provided for government employees by the government, and for employees of international organizations by private health insurance. Government expenditure on healthcare in Myanmar was 3.4% of general government expenditure in 2014–2015. Although financial allocation to the health sector and education sector has been increased, the percentage of out-of-pocket expenditures was still high.25) Very recently, Myanmar government officially announced that the nation-wide health insurance policies would go on sale for the first time under a one-year trial as of July 1, 2015.26) State-owned Myanmar Insurance and 11 private domestic companies will offer identical policies, with customers able to buy between one to five units of coverage (one unit costs approximately 50 USD), with a single unit providing the most basic level of coverage. Myanmar citizens and foreign nationals residing in the country who are aged 6 to 65 years and in good health can buy the insurance. Insurers will pay approximately 15 USD per day of hospitalization per unit. A policy holder may receive 30 days worth of hospitalization costs per year. If a policy holder dies in hospital, their designated beneficiary will receive approximately 1,000 USD per unit of insurance in compensation.26) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885812/

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Outside of the health insurance, Myanmar has a social security system called “the Social Security Scheme”, run by the Social Security Board under the Ministry of Labour, Employment and Social Security.

INTERNATIONAL DONORS’ SUPPORT OF HEALTHCARE

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The main international organizations providing technical and financial assistances to promote the health status of Myanmar people are the WHO, the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), the United Nations Population Fund (UNFPA), the Japan International Cooperation Agency (JICA), the Asia Development Bank (ADB), the World Bank, and the Three Millennium Development Goal (3 MDG) Fund.

The United Nations Office on Drugs and Crime (UNODC), the United States Agency for International Development (USAID), the Australian AID, the United Kingdom Department of International Development (DFID), the Korea International Cooperation Agency (KOICA), and the Thailand International Cooperation Agency (TICA) also play certain roles in the support of healthcare systems in Myanmar.

In addition, 57 international non-governmental organizations working in Myanmar, as well as national non-governmental organizations such as the Myanmar Women’s Affairs Federation (MWAF) and the Myanmar Red Cross Society, are listed in a governmental report.11) The list includes five Japanese organizations; the Japan Heart, the Japanese Organization for International Cooperation in Family Planning (JOICFP), the Japan International Medical Cooperation Organization (JIMCO), the Peoples’ Hope Japan, and the Save the Children Japan.

JICA PROJECTS IN THE FIELD OF HEALTH

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JICA is the executing agency of Japanese Official Development Assistance (ODA). The ODA is broadly divided into two systems. One is bilateral assistance, which is given directly to recipient countries from Japan. The other is multilateral assistance, which is provided through international organization such as the World Bank, the United Nations Development Programme, the WHO, and so on. JICA has the responsibility of bilateral assistance in the form of Technical Cooperation, Japanese ODA Loans and Grand Aid.27) All of JICA’s assistance is carried out in principal under the international agreement between each recipient government and the Japanese government. Japan ODA https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885812/

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began in 1954 as part of post-war reparations, and JICA was established in 1974.27-29) The ODA budget has increased in line with Japanese economic growth. In 1989, Japan became the number one donor by amount of ODA. In 2014, Japan was the fifth largest donor in the world.27, 30) Japan ODA is based on three basic policies, which are “contributing to peace and prosperity through cooperation for non-military purposes”, “promoting human security”, and “cooperation aimed at self-reliant development through assistance for self-help efforts”. Japan considers ODA as “investment in the future”, which secures the development and prosperity of the world as a whole, including Japan.27, 28, 31) In the field of health, the international community, including Japan, has been working together to achieve the health-related MDGs. In 2013, Japan formulated “Japan’s Strategy on Global Health Diplomacy”, which positions global health issues as a priority for Japan’s diplomacy. It also sets policies for the private and public sectors to work together on the purpose of improving global health.

In February 2015, Japan revised the ODA charter, which was decided as the foundation of Japan’s ODA policy in 1992 and revised in 2003. The new charter was named the “Development Cooperation Charter”, and contains a broader sense of cooperation. The world is globalizing politically and economically, which makes development issues more diverse and challenging.28, 29) Japan is trying to expand the scope of traditional ODA and invent synergetic effects with other funds like local authorities or private companies.31) In Myanmar, JICA has been working on promotion of social participation by the deaf community. Through this project, a standard of sign language was decided and sign language teachers were fostered. Today, sign language teachers have become instructors and are teaching others to increase the number of sign language interpreters.28) JICA has been working on a variety of healthcare projects in Myanmar since 2000. The projects include projects related to healthcare system preparation and reinforcement, infection control projects like HIV/AIDS, TB, malaria and others, maternal and children’s healthcare projects and projects related to traditional or alternative medicine.

RECOMMENDATIONS

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There seems to be two important views: one for Myanmar government and the other for international donors. The former suggests an increase in fund allocation to public healthcare services, which will not only expand the https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885812/

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services, but also improve the quality of health services. Generally speaking, the larger amount of services causes reduction of the cost per service, improving skills for services.

The latter suggests tighter networks among the donors. Networks may reduce the overlapping functions of the donors, avoiding duplicated donations. The civilian government can allow the donors to discuss the healthcare systems more openly one another.

CONCLUSION

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This paper briefly describes the current situations of various aspects of healthcare in Myanmar, based on the most up-to-date data sources. Although the health conditions in Myanmar have been improving as exemplified by MDGs, there is a serious lack of facilities and healthcare professionals. A new attempt to introduce a health insurance is expected to further improve the conditions. National and international support is needed for successful improvement.

ACKNOWLEDGMENTS

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This manuscript was derived from the presentations at the 1st Healthcare Administration Symposium of Young Leaders’ Program, held on June 19, 2015 at the Nagoya University Graduate School of Medicine.

COMPETING INTERESTS

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The authors have declared that no competing interests exist.

REFERENCES

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1) Ministry of Health. Country profile. In: Health in Myanmar 2014. pp. 2–5, 2014, Ministry of Health, Nay Pyi Taw, Myanmar.

2) Parmar PK, Barina CC, Low S, Tun KT, Otterness C, Mhote PP, et al.

Health and human rights in eastern Myanmar after the political transition: a population-based assessment using multistaged household cluster sampling.

PLoS One, 2015; 10: e0121212. [PMC free article] [PubMed] 3) Saw YM, Win KL, Shiao LW, Thandar MM, Amiya RM, Shibanuma A, et al. Takingstock of Myanmar’s progress toward the health-related Millennium Development Goals: current roadblocks, paths ahead Int J Equity Health, 2013; 12: 78. [PMC free article] [PubMed] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885812/

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4) Syaburn A. Myanmar ministers and opposition leaders agree plan to eliminate malaria by 2030. Br Med J, 2015; 351: h4268. [PubMed] 5) Kyaing NN, Sein T, Sein AA, Than Htike MM, Tun A, Shein NN. Smokeless tobacco use in Myanmar. Indian J Cancer, 2012; 49: 347–351.

[PubMed] 6) Department of Population, Ministry of Immigration and Population.

Summary of the main results. In: The 2014 Myanmar Population and Housing Census, The Union Report: Sensus Report Volume 2. pp.12–42. 2015. Ministry of Immigration and Population. Nay Pyi Taw. 7) Central Intelligence Agency. The World Factbook, Burma at https://www.cia.gov/library/publications/the-world-factbook/geos/bm.html.

8) Nyan M. Recent levels and trends of fertility and mortality in Myanmar.

Asia Pac Popul J, 1991; 6: 3–20. [PubMed] 9) The World Bank. World Development Indicators at http://datatopics.worldbank.org/hnp/popestimates.

10) United Nations Department of Economic and Social Affairs/Population Division. World Population Policies 2013 at http://www.un.org/en/development/desa/population/publications/policy/worldpopulation-policies-2013.shtml.

11) Ministry of Health. Myanmar Health Care System. In: Health in Myanmar 2014. pp. 6–8, 2014, Ministry of Health, Nay Pyi Taw, Myanmar.

12) Department of Health Planning in collaboration with Department of Health. Annual Hospital Statistics Report 2012, 2014, Ministry of Health, The Republic of the Union of Myanmar, Nay Pyi Taw, Myanmar.

13) Ministry of Health. Health Statistics In: Health in Myanmar 2014. pp. 142– 151, 2014, Ministry of Health, Nay Pyi Taw, Myanmar.

14) WHO Global Health Observatory (GHO) data: Health System (Myanmar).WHO Health Statistics 2014. Available at: http://www.who.int/gho/publications/world_health_statistics/2014/en/.

15) Ministry of Health. Managing Health Workforces. In: Myanmar Health Statistics 2014. pp.126–130, 2014, Ministry of Health, Nay Pyi Taw, Myanmar.

16) Ministry of Health. Managing Health Workforces. In: Myanmar Health Statistics 2014. pp.131, 2014, Ministry of Health, Nay Pyi Taw, Myanmar. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885812/

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17) Department of Health Planning in collaboration with Department of Health. Public Health Statistics 2012, 2014, Ministry of Health, The Republic of the Union of Myanmar, Nay Pyi Taw, Myanmar.

18) Ministry of Health. Morbidity and mortality. In: Myanmar Health Statistics 2010. pp.36–71, 2010, Ministry of Health, Nay Pyi Taw, Myanmar.

19) UNICEF, the State of the World’s Children Report 2015 Statistical; 2015.

Available at: http://www.data.unicef.org/resources/the-state-of-the-world-schildren-report-2015-statistical-tables.

20) WHO: Global Health Observatory Data Repository: Country Statistics (Myanmar). World Health Organization; 2015. Available at: https://www.quandl.com/data/WHO/62_MMR-Measles-MCV-immunizationcoverage-among-1-year-olds-Myanmar.

21) Ministry of Health. Maternal and child health. In: Health in Myanmar 2014. pp. 52–55, 2014, Ministry of Health, Nay Pyi Taw, Myanmar.

22) Department of Population and UNFPA. Country Report on 2001 Fertility and Reproductive Health Survey. 2001, Nay Pyi Taw and UNFPA Myanmar: Department of Population.

23) Department of Population and UNFPA. Country Report on 2007 Fertility and Reproductive Health Survey. 2007, Nay Pyi Taw and UNFPA Myanmar: Department of Population.

24) Ministry of Health. Diseases of National Concern. In: Health in Myanmar 2014. pp. 84–103, 2014, Ministry of Health, Nay Pyi Taw, Myanmar.

25) Khaing IK, Malik A, Oo M, Hamajima N. Health care expenditure of households in Magway, Myanmar. Nagoya J Med Sci, 2015; 77: 203–212.

[PMC free article] [PubMed] 26) The Global New Light of Myanmar Newspaper, Vol. II, Number 56, 16, Tuesday, June 2015.

27) Ministry of Foreign Affairs of Japan. Japan’s Official Development Assistance White Paper. pp.2–19, pp.26–31, pp.35–41, pp.110–114, pp.143– 144, pp.148–153, 2014, Ministry of Foreign Affairs, Tokyo.

28) Ministry of Foreign Affairs of Japan, Japan’s Official Development Assistance White Paper. pp.44–48, pp.110–114, 2013, Ministry of Foreign Affairs, Tokyo. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885812/

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29) Public Relations Office, Government of Japan, Highlighting Japan, Sixty Years of Japanese ODA, 2014; 78: 6–7.

30) Organization for Economic Cooperation and Development (OECD), Development Cooperation Directorate (DCD-DAC), Aid Statistics, 2014.

Available at: http://www.oecd.org/dac/stats/.

31) Ministry of Foreign Affairs of Japan, Cabinet Decision of the Development Cooperation Charter, pp.1–15, 2015, Ministry of Foreign Affairs, Tokyo.

Articles from Nagoya Journal of Medical Science are provided here courtesy of Nagoya University School of Medicine/Graduate School of Medicine

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Myanmar Public Expenditure Review: Realigning Budgets to Development Priorities

(http://www.worldbank.org/) Where We Work (/en/where-we-work) Myanmar (/en/country/myanmar) PUBLICATION

Myanmar Public Expenditure Review: Realigning Budgets to Development Priorities

 (mailto:?body=http%3A%2F%2Fwww.worldbank.org%2Fen%2Fcountry%2Fmyanmar%2Fpublication%2Fmyanmar-public-expenditure-review-realigning-budgets-to-d   

Key Findings Myanmar’s budget policies have undergone fundamental shifts since 2011 to accelerate delivery of essential public services.

Economic recovery, one-o measures, and reforms to expand the revenue base have improved general government revenue from 6% to 11% of GDP between 2009 and 2014 While public debt has declined from 77% of GDP in 2007/2008 to 47% in 2013/2014, its debt portfolio of non-concessional external loans and domestic short-term nancing instruments remains vulnerable Fiscal risks that warrant closer attention and more active management include the decentralization of debt management; the impact of commodity price volatility on government revenue; and the scal oversight of State Economic Enterprises (SEEs) There were big changes in budget spending between 2009 and 2015 mainly in public services (falling from 45% to 11%), social services (increasing from 10% to 33%), defense (increasing from 21% to 32%), and capital (falling from 63% to 38%) Prior to 2012, decades of government underspending led to slips in education and health outcomes.

Low school enrolment and completion rate: one third of 1.2 million students enrolled in grade 1 made it to grade 11 9% of grade 3 classes in Yangon cannot read a single word Net primary enrolment rate as low as 69% in poorer areas compared to 85% average nationally Government spending on public health was only $1.6 per capita in 2012 Out-of-pocket payments by households made up 80% of total health spending

http://www.worldbank.org/en/country/myanmar/publication/myanmar-public-expenditure-review-realigning-budgets-to-development-priorities

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Several policy reforms since 2012/2013 helped improve education and health outcomes.

Education reforms are starting to show results. Spending has quadrupled with the elimination of primary and secondary education school fees, compulsory primary education, hiring of 79,000 more teachers, expansion of the stipend program for poor students, and block grants to schools Health policies have improved access to and a ordability of healthcare services. More medical personnel have been hired. Free drugs and selected healthcare services are available for children, pregnant mothers and patients needing emergency support Myanmar is transitioning from a centralized to a decentralized system of government based on the 2008 Constitution.

Initial steps have been taken to establish legislative and executive bodies at State and Region levels Tensions between newly established sub-national institutions and traditional arrangements of central control could lead to confusion over management and accountability of public services Clarifying lines of authority, improving accountability for service delivery, adopting a policy on expenditure assignments can strengthen the decentralized system

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Myanmar’s Public Health system and policy: Improving but inequality still looms large – Tea Circle

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Myanmar’s Public Health system and policy: Improving but inequality still looms large

BY TEACIRCLEOXFORD | AUGUST 30, 2017

Elliot Brennan examines Myanmar’s health system, its successes and challenges.

In late July, panic swept Yangon and parts of Myanmar as news of an “outbreak” of H1N1 erupted on social media. This followed a press conference where Myanmar’s Ministry of Health announced that two people had died from H1N1, commonly known as swine u. A further 13 had been diagnosed with the illness in Yangon. Five hospitals were preparing to receive new patients. Other cases were detected in remote areas of Myanmar, including 10 cases in Matupi in Chin State, and others reported in Bago region, Ayeyarwady Region and Naypyidaw. Hitherto far from being an outbreak by the World Health Organisation’s de nition of such, what the H1N1 cases really highlighted was how far Myanmar has come in health communication and cooperation.

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Indeed, Myanmar’s entire health system has come a long way since the country’s democratic transition began in 2011. Yet much more still needs to be done. A core area of focus needs to be on addressing inequalities in access to health services across the country. In particular, bridging gaps in service delivery between urban and rural communities and for minority ethnic groups. For the government, the pay-off for improving these services will be signi cant. Broadly speaking, increased con dence in government will have positive impacts on continuing cease re negotiations and political dialogue with ethnic armed groups. Indeed, addressing these issues will need to be both cooperative and to a certain degree centrallydirected, thereby demanding that ethnic minorities and the NLD government work together. For international donors, supporting the improvement of the health system in one of the world’s most disaster-prone countries, lying between the world’s two most populous countries, is investing in a more resilient region. This post aims to be a primer addressing some of the most pressing problems in the overall structure of Myanmar’s health system today.

Myanmar’s Health System As the world moves to adopt strategies to establish universal health coverage by 2030, as part of the Sustainable Development Goals, Myanmar remains languishing behind in all components of the World Health Organisation’s (WHO) health system building blocks. In order to achieve Universal Health Care (UHC) goals, as well as other outcomes set out by the WHO’s health system framework, Myanmar must signi cantly improve across all components, and in particular on three core building blocks – health services, health workforce and health information. This is assuming that other building blocks of leadership and governance, and health care https://teacircleoxford.com/2017/08/30/myanmars-public-health-system-and-policy-improving-but-inequality-still-looms-large-2/

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nancing will be achieved as capacity continues to be built within the system.

Table 1. HEALTH STATISTICS MYANMAR; SOURCE: WHO Total population (2015)

53,897,000

Life expectancy at birth m/f (years; 2015)

65/68

Probability of dying between 15 and 60 years m/f (per 1

240/183

000 population; 2013) Total expenditure on health per capita (USD$; 2014)

103

Total expenditure on health as % of GDP (2014)

2.3

The previous quasi-military government raised public spending on health from a dismal 0.2% of GDP in 2009 to over 1% in 2014. Recognition of the importance of population health and investment in health continue to improve. Since coming to power in 2016, the National League for Democracy (NLD) has established Universal Health Care and access to a Basic Essential Package of Health Services (EPHS) as central policy objectives of the government, prioritizing health policy in its rst 12 months of government.

Myanmar’s health policy has since 1991 been instituted in four-year plans released by the Ministry of Health and Sport (MoHS). The Myanmar National Health Plan 2017-2021 was released in December 2016 and states as its main goal to “extend access to a Basic Essential Package of Health Services https://teacircleoxford.com/2017/08/30/myanmars-public-health-system-and-policy-improving-but-inequality-still-looms-large-2/

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to the entire population by 2020 while increasing nancial protection.”

The latter part of this objective, increasing nancial protection, is important. Indeed, signi cant improvements in health care nancing must be achieved. There is no reliable health insurance system and a poor overall national health system. In 2014, 81% of Myanmar’s total health expenditure came from out-of-pocket nancing. This gure decreased to 65% in 2015, demonstrating government attention to the issue. Out-of-pocket payments in Myanmar far exceed the global average of 32% of a country’s total health expenditure.

Recent NLD health policy has set an aim of reducing out-ofpocket expenses to 25% of overall health expenditure.

As capacity remains low within the MoHS and the wider health sector in Myanmar, there are numerous NGO’s supporting capacity building programs. One signi cant project is the World Bank’s Essential Health Services Access Project, a $100 million USD project running between 2014 and 2019 which aims to increase coverage of essential health services with a focus on maternal, newborn and child health.

As in most developing and many developed countries, discrepancies in delivery of health services between urban and rural populations also exist. Approximately 70% of the population in Myanmar live in rural environments, and are largely engaged in subsistence farming. Many of Myanmar’s ethnic groups still adhere to cultural practices and traditional remedies. Seeking out astrologers, witches and healers to administer health care is common. Such health-seeking behaviour can cause complications in modern health care

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provision where less effective treatments or mysticism supplants modern medicine.

While eight ethnic armed groups signed a cease re with the Tatmadaw, the Myanmar military, in October 2015, a dozen other groups remain in varying degrees of con ict. The deep and decades long grievances between ethnic minorities and the Tatmadaw have created sub-national governance structures, including sub-national health services. Without the emergence of a federal system that can incorporate these structures, there is widespread inequality in the delivery of services across the country.

Re ecting the problems within Myanmar’s health system, the country’s success at achieving health related Millennium Development Goals (MDGs) were mixed. Indeed, one of the core problems cited was a weak health system. One area of relative success was the improvement in immunization rates.

For example, measles immunization coverage increased from 68% to 88% between 1990 and 2010. However, as evidenced in 2016 by a deadly outbreak in remote north-western Myanmar in Naga areas, disparities remain in ethnic areas. In that instance, more than 80 people, mainly children, died from a preventable disease.

As indicated by the failures in the MDGs, the single biggest problem for Naypyidaw continues to be the implementation of a health system in ethnic minority areas where decades-long con ict with the central government has created deep mistrust. In dozens of townships around Myanmar, the government has little access and ghting between ethnic armed groups and the Tatmadaw continues. In these areas, working with local ethnic health organisations (EHOs) and https://teacircleoxford.com/2017/08/30/myanmars-public-health-system-and-policy-improving-but-inequality-still-looms-large-2/

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local NGOs will be crucial if MoHS wants to ful l its SDG pledge to provide universal access to healthcare to all people in Myanmar.

Among other social determinants of health impacting Myanmar’s health services are poverty, ongoing con ict, endemic and institutional inequality, weak institutions and poor governance, poor infrastructure, seasonal natural disaster and poor access to adequate health care. As detailed in the following critical analysis, three components of Myanmar’s health system will be important in addressing these challenges: Health Services, Health Workforce and Health Information System. Others, such as medical products and technology, will remain crucial but should improve following progress in the stated three components.

Table 2. TRENDS IN HEALTH-RELATED MDG INDICATORS IN MYANMAR, 1990-2010

SOURCE: Saw, Y. M., Win, K. L., Shiao, L. W., Thandar, M. M., Amiya, R. M., Shibanuma, A., Tun, S., Jimba, M. (2013). Taking stock of Myanmar’s progress toward the health-related millennium development goals: Current roadblocks, paths ahead. https://teacircleoxford.com/2017/08/30/myanmars-public-health-system-and-policy-improving-but-inequality-still-looms-large-2/

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International Journal for Equity in Health, 12(1), 78. doi: http://dx.doi.org.ezproxy1.library.usyd.edu.au/10.1186/1475-927612-78 Key Challenges in Reforming Myanmar’s Health System Health Workforce “A well-performing health workforce is one which works in ways that are responsive, fair and ef cient to achieve the best health outcomes possible, given available resources and circumstances.

I.e. There are suf cient numbers and mix of staff, fairly distributed; they are competent, responsive and productive.” WHO Health Systems Framework In 2014, according to the MoHS, it operated 988 hospitals and 1,684 rural health centres. This included, 348 maternal and child health centres. The Ministry cited 13,000 doctors, 30,000 nurses, 22,000 midwives and 11,000 health workers across the country. The number of health professionals was far less than the recommended WHO target per 1,000 people. Auxiliary or volunteer health care workers continue to play core roles in service delivery, particularly in ethnic minority and rural areas and they are often required to perform above and beyond their basic training.

According to World Bank data, some indicators of health service capability indicate that services worsened over the course of military rule in the country. For example, in the 1970s and 1980s it was reported that there were 0.85 hospital beds per 1,000 people, this declined to 0.6 in 2006. Similarly, during the military government, half of health workers worked in urban areas, despite the vast majority of the population https://teacircleoxford.com/2017/08/30/myanmars-public-health-system-and-policy-improving-but-inequality-still-looms-large-2/

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living in rural areas. Under the previous junta government, those living in rural and ethnic minority areas relied largely on traditional healthcare practices, rudimentary local health care or the services of international health professionals working with NGOs. There has long been a desire to improve the health workforce. This was explicitly stated in 2000 by the military government in a policy paper entitled Myanmar Health Vision 2030. The document also highlighted a desire for universal health care. Since the 2011 democratic transition began, efforts to improve the health system, including improvements to the health workforce, have been renewed.

The NLD government has outlined a desire to decentralize health services, previously highly centralised. Today, Myanmar’s 330 townships are overseen by a township medical of cer. At every main township hospital, there is a chief doctor, 1-2 station hospitals, 4-7 rural health centres (RHCs), as well as varying numbers of rural sub-RHCs. RHCs are run by a health assistant and have a catchment population of 20,000.

Sub-RHCs often are run by a midwife or health assistants, staffed by volunteers, and have a catchment population of 5,000. This latter, most basic component of the formal health infrastructure, conducts immunizations and other health programs. While this structure works in theory, on the ground, with various health providers and ongoing ethnic tensions and violence, the reality in many of these townships is far different.

In one example of this, Aung et al (2016) looking at rural and urban disparities in health-seeking for fever, found that “rural populations need improved access to trained providers” and increased knowledge of malaria prevention and treatment.

That study recommended more trained health workers and health centres were needed in rural areas, and that they https://teacircleoxford.com/2017/08/30/myanmars-public-health-system-and-policy-improving-but-inequality-still-looms-large-2/

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should be easily accessible and affordable to the population.

However, poor education standards in rural areas in recent decades has resulted in fewer people of rural background having suf cient education for entry into tertiary education. As such, fewer rural people train to become health professionals, also leading to lower numbers of ethnic minority people becoming quali ed health professionals in the country.

Overall, at a national level, Myanmar has an insuf cient number of health professionals that are representative of the diversity in the population, in ethnicity, gender and language capability. Those that exist are unfairly distributed with varying degrees of competence. These shortfalls signi cantly disadvantage ethnic minorities.

Health Services “Good health services are those which deliver effective, safe, quality personal and non-personal health interventions to those who need them, when and where needed, with minimum waste of resources.” WHO Health Systems Framework Between 2011 and 2015, government expenditure for health increased 8.7 times. The NLD government has continued this trend and set out their own plan: A Roadmap Towards Universal Health Coverage in Myanmar. A broad and ambitious document in scope, it aims to address social determinants of health and looks to reinforce the previous military government’s ambitions toward universal health coverage. There are similarly greater ambitions to reach rural communities and ethnic minorities than previously outlined. The core component of the Myanmar National Health Plan drafted by the NLD government sets out access to a Basic Essential https://teacircleoxford.com/2017/08/30/myanmars-public-health-system-and-policy-improving-but-inequality-still-looms-large-2/

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Package of Health Services for all by 2020 as its core goal.

Furthermore, it looks to improve nancial protections and “alignment” of health services – (also known as “convergence”) – in rural and ethnic minority areas. In general, and disproportionately in urban areas, health services will increasingly have to tackle both communicable and noncommunicable diseases. One study found that currently 59% of deaths in Myanmar are caused by non-communicable diseases, a gure that will rise as wealth increases. In the immediate term, the core problem is equal access to services, particularly between ethnic groups. That is not to say that service delivery in ethnic minority areas is necessarily worse, on the contrary, in many ethnic areas, service delivery is highly effective, often supported by the long-term commitment of faith-based NGOs. In some cases, such as in Wa State which is supported by strong Chinese ties, ethnic minority health care is superior to Myanmar government health services.

In general, resource allocation needs to more closely align with reducing disparities in health services. The centralisation of the health system increases these disparities. However, decentralisation of the health sector is limited by the 2008 military drafted Constitution which enshrines central or national level control, not state or subnational control, over health expenditure.

Such are the disparities between ethnic groups that a gap of 11 years separates the highest and lowest averages of life expectancy in Myanmar. Even so, the average life expectancy of the general population at birth in 2015 remained low – 65 for men and 68 for women, the lowest in ASEAN, as demonstrated by the region in the https://teacircleoxford.com/2017/08/30/myanmars-public-health-system-and-policy-improving-but-inequality-still-looms-large-2/

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health output scoring index (HOSI) in gure 1. Health services are well below acceptable levels across all regions.

Discussions in the rst-year both at national and subnational levels revolved around suggestions that health care systems in sub-national areas could “converge” under one central government-directed and administered health system.

However, while many challenges towards any convergence of subnational and national health systems remain, many more remain for the improvement of the national health system itself.

Internal migration in Vietnam and South Korea has shown that such movement helps to reduce overall poverty and bolster long-term development. However, in the short term, migration can create more vulnerable individuals and families as incomes and assets are more at risk. As a result, and lacking support networks, recent migrants – many of which are from ethnic minority backgrounds – may be more at risk from health problems. In particular, rural-urban migrants are at risk for sexually transmitted diseases, drug and alcohol consumption as well as mental health problems among the largely young, single, and rural men migrating to urban environments. They are also likely to be among the most impacted by high out-of-pocket health cost. One study found that from two (non-ethnic) regions in Myanmar, men were twice as likely to migrate than women. Internal migration will continue to put pressure on the access to health services, and other areas, and must be addressed by the government.

Health Information system

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“A well-functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health systems performance and health status.” WHO Health Systems Framework Much of the current and most of the past research and data collected by the government in Myanmar has been in majority ethnic Burman areas. As such, policy has focused on the majority ethnic group. Increasingly, since the 2011 democratic transition began, this is improving, albeit slowly. The sensitivities around the collection of data were realised by the government when it commissioned a nationwide census in 2014. Sections of this data that pertain to ethnicity and religion, and was deemed too sensitive, was not immediately or fully released. This demonstrates the dif culties that data collection and thus data-derived policy continues to have in the country. Moreover, political interference in data collection and continued high levels of fear among the general population in expressing negative views of government, hamper accurate data collection. One example is an analysis of the 2014 census data that revealed that maternal and child mortality rates were in fact twice as bad as previously reported.

As noted by Khan et al (2016), disparities are exacerbated by the unequal allocation of scarce resources. They note that studies by researchers in certain regions are restricted or discouraged by authorities, including the monitoring of the collection of data at health facilities Indeed, others note that much of collected data and allocated funding only reaches Burman and Buddhist areas and not other ethnic groups, or is unequally collected in these areas. Often international NGOs support ethnic minority groups almost exclusively, at times straining relations with the Burman-majority authorities and https://teacircleoxford.com/2017/08/30/myanmars-public-health-system-and-policy-improving-but-inequality-still-looms-large-2/

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local communities. Such has been the case in troubled Rakhine state, which has witnessed riots against international NGOs or UN agencies seen as supporting the Muslim population and not the wider Rakhine population.

Myanmar’s health information system is highly centralised, discriminating against poorly represented ethnic minorities.

Since the transition, there has been more leniency allowed in letting townships devise and institute their health plans along a framework of goals established by the MoHS. Numerous INGOs support the development and implementation of comprehensive township health plans.

The lack of infrastructure in Myanmar, including insuf cient electricity and until very recently the lack of internet, meant that many remote townships, particularly those in ethnic minority areas, worked to some degree almost independently along government-decreed overarching goals.

Lastly, a key remaining problem is that health information is not shared between health providers in ethnic minority areas, in particular, due to a lack of trust, between ethnic health organizations and the government. Responding to these concerns is a $100 million, four-year pilot program in Myanmar and other low resource countries led by Bloomberg and Australia’s Department of Foreign Affairs and Trade to improve the quality of health information collection.

Looking Ahead A 2014 study based on interviews of representatives from international agencies working in Myanmar explored views of how to strengthen the health care system. Among the https://teacircleoxford.com/2017/08/30/myanmars-public-health-system-and-policy-improving-but-inequality-still-looms-large-2/

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problems cited were impediments to service delivery as a result of health system weaknesses and bureaucracy, including human resource problems, data and logistical problems and not surprisingly insuf cient or inadequate medical equipment, infrastructure and resources.

As Davis and Joliffe (2016) note, given the reality of continued con ict, “convergence activities should be viewed primarily in terms of the need to increase coordination and cooperation between multiple providers to improve health equity through complementarity.”

Looking ahead, Hernandez and Myint (2017) suggest that “older people should be targeted as an approach to tackle the high burden of NCDs and create a strong health system.” They note that 85% of aged people live with family, more than half in this circumstance contribute to household income but also provide free childcare to grandchildren, allowing parents greater freedom to work and move. The economic bene ts of this are obvious; this should similarly bene t growth in ethnic minority areas, many still ravaged by con ict-related illnesses.

Similar attention should be extended to all vulnerable people but ultimately all of Myanmar’s people are best served by an overall improvement of the health system and universal access to healthcare. A special focus on the three building blocks highlighted in this post would help give a much needed shot in the arm to healthcare in Myanmar.

Myanmar has a long way to go to improve its health system and ensure accessibility for all, needing improvements for ethnic minority access in particular. If it is to reach SDG 3 goal “to ensure healthy lives and promote well-being for all at all ages” this will take continued effort by all in government and https://teacircleoxford.com/2017/08/30/myanmars-public-health-system-and-policy-improving-but-inequality-still-looms-large-2/

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require the support of the international community, donors and all ethnic groups in Myanmar.

Elliot Brennan is an independent researcher. He previously worked with the Joint Cease re Monitoring Committee and the Myanmar Peace Centre in Yangon. He has held positions as a research fellow with think tanks in Europe and the USA as well as working with the Lowy Institute’s Interpreter and IHS Jane’s.

Image credit: Re ectedSerendipity on Flickr

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The opinions expressed on this website belong to the authors alone, and do not re ect the views of the editors, the Programme on Modern Burmese Studies, St Antony's College, or the University of Oxford. https://teacircleoxford.com/2017/08/30/myanmars-public-health-system-and-policy-improving-but-inequality-still-looms-large-2/

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Myanmar

Myanmar Norwegian development assistance to Myanmar has increased signi cantly over the past ten years. Emergency relief and humanitarian assistance have been important keywords, but more long-term development cooperation is now taking over

Facts about Myanmar Population

Life expectancy

GNI pr capita

Percentage poor people (below 1.25$)

HDI 150

93820

53.3 82

65

5.2

Millions

Years

USD

0

1

%

Ranking

Source: UNDP (https://data.undp.org/) World Bank (http://data.worldbank.org/indicator)

Bilateral assistance 2016: 252.1 million kroner Emergency assistance

Good governance

Environment and energy

Health and social services Education

Economic development and trade

Bilateral assistance 2016: 252.1 million kroner

https://www.norad.no/en/front/countries/asia-and-oceania/myanmar/

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Myanmar

Unspecified Multilateral organisations

Private sector Public sector in recipient country

Public sector in Norway/other donors

International and local non-governmental organisations

Norwegian non-governmental organisations

Bilateral assistance 2011-2016: 1 161.6 million kroner 250

Million NOK

200

150

100

50

0

2011

2012

2013

2014

2015

2016

Myanmar is undergoing change. In the transition from authoritarian rule to democracy, political culture is evolving.

The government devotes much e ort to the reform and peace processes. The opposition remains unconvinced and complains that too little is happening, and too late. Three processes are unfolding in parallel: economic reform and liberalization, transition from a military regime to a democratic state, and the peace process.

The reform process and liberalization have led to a considerable increase in international investment. Economic growth continued in 2014 for the fourth consecutive year, reaching more than seven per cent.

This growth bene ts a large proportion of the population, but is unevenly distributed. A considerable step forward for many is the access to far cheaper and better telecommunications, made possible by actors including Telenor.

Negotiations on a national cease re have been underway since 2013, and progress has been made in a number of areas. Spring 2015 was marked by combat between military forces and ethnic insurgent groups in North-Eastern Myanmar. Time is running out with regard to the opportunities for a national cease re agreement and political dialogue before the upcoming parliamentary elections to be held in the autumn of 2015.

The humanitarian and human rights situation of the Muslim minority remains precarious, as evidenced by the boat-refugee crisis in the Indian Ocean that attracted international attention in May 2015.

Many forces that oppose reform can be expected to exploit inter-ethnic tension. The Rakhine/Rohingya issue remains highly sensitive and is considered to be an ‘election-losing issue’ for the political actors, which may explain the international criticism of the opposition’s silence regarding this topic.

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The transition from strict censorship to a major degree of freedom of speech has proceeded rapidly, even though some setbacks were recorded in 2014, when journalists were sentenced to long prison terms. Myanmar is currently ranked as no. 151 (of 179) on the World Press Freedom Index published by Reporters Without Borders.

Norwegian development cooperation with Myanmar Myanmar is one of the priority countries for Norwegian aid. Main priorities for development cooperation include natural resource management, energy and environment/climate, in addition to a strong emphasis on peace and reconciliation and the political and economic reform process. In 2014, total Norwegian bilateral aid to Myanmar amounted to approximately NOK 230 million.

A Memorandum of Understanding for development cooperation was signed during the o cial state visit in 2014. E orts to establish Oil for Development, institutional collaboration related to sustainable hydropower development and bilateral environmental collaboration between Norway and Myanmar are well underway.

Political and economic reform Support for the political and economic reform process is a key component of development cooperation between Norway and Myanmar, amounting to NOK 8,3 million in 2014 distributed among six organizations.

This support assists in capacity-building and con dence-building between the central authorities, the ethnic insurgent groups and the local population. Norwegian support has also helped establish the Center for Diversity and National Harmony, a key initiative in building arenas for interfaith dialogue. The operation of 30 di erent o ces has established opportunities for contact and dialogue between the armed ethnic insurgents and the authorities/the army.

Since 2012, Norway has supported the implementation of the government’s economic reform programme through capacity-building and expert advice to the Ministry of Planning and the President’s O ce.

In cooperation with the International Labour Organization (ILO), Norwegian aid promotes better understanding of workers’ rights and facilitates social dialogue between employers and employees in line with the Trade Union Act that was adopted in 2012.

Norway also grants support to the ILO programme Entrepreneurship Development and SME Support in Myanmar, which is intended to strengthen small and medium-sized enterprises to create more and better job opportunities.

In cooperation with UNIDO, Norwegian aid also helps boost Myanmar’s food exports, thus helping promote economic growth and integration into regional and international economies.

Norway grants support to the Myanmar Centre for Responsible Business (MCRB), which assists enterprises and authorities in upholding social responsibilities and human rights.

As part of the preparations for the parliamentary elections in 2015, Norway grants support to International IDEA and the Asian Network for Free Elections (ANFREL) for capacity-building in the election commission, the media and civil society. Norway was also a major contributor to the census that was held in 2014, in cooperation with UNFPA and other donors.

Renewable energy Myanmar is a country with enormous natural resources and a huge potential for future energy production from hydropower and natural gas, as well as renewable energy from solar, wind and bioenergy. Exploitation of this potential and better access to energy are key elements of the government’s plans for economic development. Only one-quarter of the population has access to electricity.

Cooperation between Norway and Myanmar in the eld of natural resource management and energy came fully underway in 2013, and is so far limited to capacity-building in the apparatus of government and support for revision of legislation. Capacity-building is given high priority by the authorities, and Norway plays an important role in this context. This cooperation is expected to expand considerably in the years to come.

The Norwegian Water Resources and Energy Directorate (NVE) has entered into long-term collaboration with Myanmar’s Ministry of Electric Power on capacity-building related to hydropower. NVE will assist the authorities in their e orts associated with hydropower development, legislation, hydropower standards and hydrology, and provide capacity-building in the form of training courses (through the Norwegian International Centre for Hydropower) as well as opportunities for Master’s degree studies at the Norwegian University of Science and Technology (NTNU).

This cooperation also includes a budding collaboration with the authorities and the Karen National Union (KNU) on hydropower development in regions controlled by the KNU. This is a key element of the peace process and a speci c example of how technical advice in areas in which Norway has a comparative advantage can contribute constructively to the dialogue between the authorities and ethnic groups.

Norway has also assisted the Ministry of Electric Power through a collaboration with the Asian Development Bank linked to capacity-building and a revision of the Electricity Act. Revised legislation on electricity was adopted in October 2014.

For many years, Norway has granted support to the local organization Proximity Designs, which o ers innovative renewable energy solutions to rural farmers. Proximity Designs is also partnered with Norfund for cooperation on micro nance. Cooperation with the local organization Green Economy Green Growth has resulted in the establishment of an ASEAN Institute for Green Economy.

Natural resource management The preparations for an Oil for Development programme are well underway. Since February, a Norwegian consultant has been based in the Ministry of Finance to assist the authorities in matters associated with management of income from the petroleum sector, with a view to establishing a natural resources fund.

Advice linked to revision of the petroleum legislation and establishment of environmental guidelines and social impact analyses in the oil/gas sector are examples of other ongoing activities.

The authorities have expressed great interest in an Oil for Development programme in Myanmar. https://www.norad.no/en/front/countries/asia-and-oceania/myanmar/

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Norwegian support through the Bay of Bengal Large Marine Ecosystem Project (BOBLME) helped launch a voyage with the research vessel ‘Dr Fridtjof Nansen’ in the autumn of 2013 to map and estimate sh stocks and marine biodiversity. The investigations showed that the sh stocks in the seas o Myanmar have declined considerably over a period of thirty years.

A new survey will be conducted in 2015. A long-term collaboration between Norway and Myanmar for sheries management is being considered.

Environment and climate Norway is considered one of the key development actors in the environmental sector. Preparations for bilateral cooperation between the Norwegian Ministry of Environment and Climate (KLD) and the Myanmar Ministry of Environment and Forests are underway, and an agreement is expected to be signed in the autumn of 2015. This cooperation will focus on capacity-building related to biodiversity, water management and hazardous waste. The main actors on the Norwegian side are the Norwegian Environment Agency and the Norwegian Institute for Water Research (NIVA).

Since 2012, Norway has collaborated with the United Nations Development Programme (UNDP) on preservation of Inle Lake, one of Myanmar’s foremost natural treasures and tourist attractions. Partly as a result of this collaboration, UNESCO declared Inle Lake a Man and Biosphere Reserve in June 2015.

Norway also contributes to a wider collaboration with UNESCO for nomination of natural areas in Myanmar as World Heritage Sites.

Climate and forests are increasingly important to the Norwegian development cooperation with Myanmar. Norway has contributed to the preparations for a national programme for the UN forest initiative REDD+ and funds the rst phase of the programme.

Education In cooperation with other donors, Norway has supported UNICEF’s e orts in the area of basic education and development of primary schools in Myanmar. This support includes political reforms, capacity-building at the local and national level and service provision in 34 especially vulnerable townships. Since 2012, more than 185.000 children have been reached through the programmes for early childhood development, informal basic education and training in life skills. Of these, approximately 5000 live in camps for internally displaced persons. Altogether 900.000 children have been supplied with necessary school equipment.

Health Norway has granted support to the Global Fund to Fight Tuberculosis, AIDS and Malaria since its inception, and contributes NOK 1,7 billion for the period 2014–2016.

This global fund has provided support to Myanmar since 2012. Total support amounts to USD 451 million (47 per cent for HIV, 29 per cent for tuberculosis and 24 per cent for malaria).

Results: The results are updated twice annually: http://portfolio.theglobalfund.org/en/Country/Index/MMR (http://portfolio.theglobalfund.org/en/Country/Index/MMR)

Read more about development cooperation through

NGOs Recent reforms in Myanmar have provided a considerably wider latitude for civil society. The number of international and local organizations has grown rapidly, including in rural areas.

The support provided by Norad is spent as much as possible in line with the priorities for other Norwegian aid to the country. The support increased to NOK 20 million in 2014, and a further increase is planned for 2015. This is mainly due to Save the Children’s new cooperation agreement with Norad, according to which Myanmar is one of several priority countries. Other Norwegian NGOs with partners in Myanmar include ADRA (Adventist Development and Relief Agency), the Rainforest Foundation, Norwegian Church Aid, CARE and Digni.

Main sectors include education, minority rights, forest management and preservation of biological diversity, as well as raising awareness on responsible resource management. Save the Children emphasizes children’s rst years at school, children’s rights and their need for protection.

ADRA is active in education, with emphasis on minority rights.

Humanitarian assistance There are major humanitarian needs in the Rakhine state of Myanmar, and the UN estimates that 80–90.000 persons are internally displaced. In the period May‒July 2015, Norway has pledged NOK 20 million in humanitarian assistance to the population of this region. The support will bene t both Buddhists and Muslims, and will be earmarked for various programmes for education, protection and prevention of human tra cking, return of internally displaced persons and contribution to coverage of basic needs.

There is a signi cant need for support to preventive measures in this part of Myanmar to protect more people from falling victim to human tra cking and to help facilitate better interaction between the various ethnic groups.

Published 28.08.2014 Last updated 02.10.2015 https://www.norad.no/en/front/countries/asia-and-oceania/myanmar/

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Related links 

The Myanmar Peace Support Initiative (http://www.embnorway.or.th/News_and_events/Norway-and-Myanmar/MPSI/)

Agreements  Memorandum of Understanding between Norway and Myanmar (MOU).pdf  Nay Pyi Taw Accord for E ective Development Cooperation (NPTA).pdf  Guide to International Assistance in Myanmar (GAD).pdf

Related publications Integrated Community Livelihood Development Program 2013-2016  (/en/toolspublications/publications/2016/integrated-community-livelihooddevelopment-program-2013-20162/) Chin Human Rights Organisation: Project Kaladan Movement External Evaluation  Report (/en/toolspublications/publications/ngo-evaluations/2015/chin-humanrights-organisation-project-kaladan-movement-external-evaluation-report/) Equality Myanmar Human Rights Education Programme External Evaluation  (/en/toolspublications/publications/ngo-evaluations/2015/equality-myanmarhuman-rights-education-programme-external-evaluation/) A Baseline Study of Norwegian Development Cooperation within the areas of Environment and Natural Resources Management in Myanmar  (/en/toolspublications/publications/2015/a-baseline-study-of-norwegiandevelopment-cooperation-within-the-areas-of-environment-and-natural-resourcesmanagement-in-myanmar/) Final Evaluation Report of the Project "Support for Education in Post Con ict Southeastern Myanmar" (SEE NORAD) (/en/toolspublications/publications/ngo evaluations/2014/ nal-evaluation-report-of-the-project-support-for-education-inpost-con ict-south-eastern-myanmar-see-norad/) See all (/en/toolspublications/publications/#&country=12754)

(https://maps.google.com/maps?ll=21.916221,95.955974&z=7&t=m&hl=en&gl=US&mapclient=apiv3) Map data ©2017 Google

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Dr. Soe Myint Public Health Adviser University of Public Health-HelpAge International

Myanmar situated in SE Asia Region with total population of 51.4 M (2014 Census) ! 70 % of population resides in rural areas ! Young female Literacy rate 88% (MICS 2010) ! GDP Per capita US$ 825 (Current) 1135 (PPP) as of 2011 ! 1 in 4 citizen is considered poor (IHLCA, 2010) ! In 2015 election, NLD wins 80% of seats in the parliament and form a civilian gov. !

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Health status

◦ Life expectancy – Male = 63 yrs. Female = 67 yrs. ◦ IMR – 42 per 1000 LB ◦ U5 MR – 62 per 1000 LB ◦ High morbidity and mortality from TB, Malaria and HIV/ AIDS ◦ 59% of total deaths attributed to NCDs

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Resources for health

◦ Density of physicians= 0.5 per 1000 pop. ◦ Density of nurse/ MW= 1 per 1000 pop. ◦ Availability of hosp. beds = .6 per 1000 pop.

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Health financing ◦ Health expenditure contributed by government (3.8% of GDP, 2015) ◦ 7% of total health expenditure contributed by donors ◦ >85% of total health expenditure contributed by OOP payment ◦ Social security scheme covers < 1% of total population ◦ No health insurance system

Myanmar is undergoing prominent political, social and demographic change and is now facing the burden of disease transition ! NCDs are rising very quickly with some challenges on CDs and MCH care still remains ! Weak health infrastructure with insufficient human resource ! Inadequate HIS with limited capacity to develop and implement evidence-based health policies !

NCD burden is on the rise ! National STEP Survey (2014) shows : !

◦ Raised blood glucose: 10.5% ◦ Raised blood pressure: 26.4% ◦ Raised blood cholesterol: 36.7% ◦ Obesity: 5.5% ◦ Smoking: 26.1% ◦ Betel nut chewing: 43.2% ◦ Alcohol drinking: 19.8% ◦ Low fruit and vegetable consumption: 86.6%

Current mortality pattern in Myanmar

Weak public health care and low accessibility in the rural and border areas of the country ! High spending on hospital care with very limited investment on PHC- Almost 70% of health budget went to hospital care ! Severe shortage of human resources at primary health care (PHC) level and preventive aspects ! PHC workers esp. MWs are overloaded with a wide range of duties !

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Reforms introduced as one of the third wave national reform processes aimed at raised social and economic development President of previous gov. give guidelines to introduce health reforms to uplift the health standard of the entire nation Urge to expand current health infrastructure and to promote hospitals as a reliable source of medical care for the poor people To upgrade skills and performance of health staff To introduce health insurance system

MOH DOH RHD Dist. H Dept.

Tsp. H Dept.

Other Dept.

MOH

DPH

DMC

Reg. PHD

Reg. MCD

Dist.

PHD

Dist.

MCD

Tsp. PHD

Tsp. MCD

Other Depts .

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There is a huge expansion of PH infrastructure at the regional and township levels As the plan is very ambitious, actual implementation may be difficult due to several resource constraints Priority given to quantity rather than quality Equal emphasis should be given to quantity as well as quality Little emphasis on accountability and efficiency in service delivery No evaluation or impact studies carried out for previous reforms and no lessons learned

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Myanmar should respond its disease transition by putting more investment in PH Public health care should be strengthened at the PHC level by addressing problems of human resource development and capacity building MOH should support PH institutions to have more experience and skills on evidence-based health policy analysis and policy making processes In order to obtain robust data and timely information for development of public policies and services, MOH should put new emphasis on evidence gathering

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Taking advantage to the change of political situation, it needs to maximize the opportunities to built strong financial, administrative, project management and evaluation skills Aid management should be strengthened with adherence to Paris Declaration on Aid Effectiveness Taskforce or expert groups should be formed to carry out evaluation research or impact studies for health reforms introduced As an attempt to strengthen PH capacity, a four year SPHIP was introduced in 2015

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By doing capacity building of UPH staff, project can support policy analysis of NCDs and inform policy makers to respond to NCD burden in Myanmar It can also promote UPH staff to deliver better research and training in the MOH UPH can also involve in training of health authorities and care workers to have greater knowledge of NCD The project can also enhance program or project operational capacity of UPH By disseminating STEP survey (2014) results to policy makers, project can enhance to scale up NCD control programs UPH can also make active professional linkages with international organizations and universities