Country Cooperation Strategy

2002 - 2005

NATIONAL  HEALTH  SITUATION

Myanmar is a country of 46.4 million people¹ with natural resources including land, water, natural gas, coal, petroleum, mineral and marine resources. Uplifting of health, fitness and education standards of the entire nation are among the twelve socio-economic development objectives stated by the Government.

The country has undergone considerable changes from a centralized to market oriented system since 1988. Economic changes have lead to a market-oriented economy and the creation of more employment opportunities but also increased population migration (mostly internal) which has health implications due to social and environmental changes. The population pyramid of Myanmar highlights a ‘young population’ where 33% are under 15 years of age.

As the country strives to attain its health objectives, positive trends in various health indicators are found as presented in Table1. The Central Statistical Office (CSO) estimates life expectancy at birth combined for both sexes at 62.6 years in 1997. In the area of child health, progress has been achieved primarily through the strengthening of Basic Health Services for all children with special focus on under-served areas. Major causes of under 5 mortality in Myanmar are diarrhoea, acute respiratory infections, measles, malnutrition, brain infections (non specific & TB), cerebral malaria, premature delivery and birth injuries. Infant mortality rate (IMR) and under 5 mortality rate (U5MR) have shown declining trends. Despite the linear decline in the utilization of institutional services (Statistical Year Book, 1998); there is an increasing trend in the coverage of antenatal and delivery services by trained personnel including treatment of childhood diseases. This may mainly be due to the domiciliary services provided by midwife and nurses, who provide basic services to the poor, free of charge. High maternal mortality ratio and high percentage of low birth weight, however, still remain a serious concern. Evidence suggests a difference in the health status of people living in urban and rural areas. Infant and child mortality rates and malnutrition outcomes are comparatively higher and access to health services generally lower in rural areas.

In the area of infectious diseases, malaria, tuberculosis and HIV/AIDS are of national concern. However, with the epidemiological transition, non-communicable diseases may, in the near future, cause a double burden of disease in Myanmar.  The key issue for further improvement of the national health situation is to strengthen the health system, with  special approaches to urban, rural and border areas.

Table (1)          Trends in Health Outcomes and Indicators over time, 1990-1997

^aPopulation Change and Fertility Survey (1991), Dept. of Population.

^b UNICEF estimates from MICS

^c Multiple Indicator Cluster Survey, 1997, Dept. of Health Planning

^dFertility and Reproductive Health Survey (1997), Dept. of Population

^eFRHS 1997,  The State of World’s Children 2000 (UNICEF),  UNFPA and  MMCWA

^f Revised 1990 estimates of MMR (A new approach by WHO and UNICEF – 1996)

^g Statistical Year Book 1998, Gov’t of the Union of Myanmar, Central Statistical Organization, Yangon

^h National Nutrition Survey, 1991

While the government has set up a fairly widespread system of health care providers, utilization tends to be relatively low. It is interesting to note that while treatment at Traditional Medical Centers has risen more than four fold, the general usage of hospitals and dispensaries in 1996-1997 had fallen to less than 20% of the levels recorded 10 years before (Statistical Year Book, 1998). In depth interview with national experts indicates that this could be due the combined effects of three factors, i.e. the increasing private sector activity, the introduction of user fees in public institutions and inadequate responsiveness of the health system.

National Health System

The last decade has been characterized by a number of political and economic changes, which have contributed to improving the overall health of the population, as shown by the differences in mortality rates of children and infants between 1990 and 1997, and the steady increase of life expectancy.  Since poverty is a major cause of ill- health and reduces productivity of the work force, a major contributor to the economy, the challenge for Myanmar is therefore  to ensure (a) adequate investment in health, especially for the poor and (b) fair distribution of the benefits resulting from economic growth.

A significant program of market-oriented economic reforms was introduced in Myanmar after the State Law and Order Restoration Council (SLORC) assumed power in late 1988 and has resulted in high GDP growth rates in the mid-1990s.  However, in recent years economic activity has slowed down and foreign reserves decreased. To compensate for the decline in tax revenue and reduce the budget deficit, the government has cut down on capital and public expenditures. There has also been an expansion of the private sector. Efforts are being made to develop a supportive and regulatory mechanism for the private sector.

In 1990, a high level inter-ministerial and policy making body for health and health related matters, the National Health Committee (NHC), was set up by the government.  The Secretary-1 of the State Peace and Development Council (SPDC)^[1] chairs this Committee. It developed the still prevailing National Health Policy, which contains fifteen broad policy directions (Annex 1), some of which call for health sector reforms, especially as regards the reorganization and management of health services (including the private sector, as part of health systems decentralization), as well as health care financing.

Health Systems Performance

Myanmar's health infrastructure system consists of 1,412 rural health centers, 348 maternal and child health centers, 359 dispensaries, 742 hospitals with 30,254 beds and over 14,350 doctors and 12,642 nurses. For every 10,000 people, there are approximately 6 beds in the government hospital, 3 doctors and 3 nurses. There is one government hospital available for approximately 100,000 population. In addition, there are 200 traditional medicine clinics and 8 traditional medicine hospitals. Access to health services is estimated at 80 %. Available data on health financing (Statistical Yearbook, Central Statistical Organization, Myanmar, 1998) suggest that per capita  annual expenditure on medical care is Kyatts 570.- (approximately US$ 2.- in 1998). The World health Report 2000 (WHO Geneva) indicates an annual per capita health expenditure of 78.- international dollars (1997) and a total expenditure on health of 2.6 % of GDP. Insufficient financial and foreign exchange resources have resulted in, among others, an inadequate supply of equipment and essential drugs. The performance of the public sector health system, its organization, management and financing, has been affected by a number of factors. The following issues, which cover the four main functions of the health system, need to be addressed.

(a)        Stewardship 

The government plays several roles within the health sector, which cover the planning and regulation of health care delivery, organizing, coordinating and financing health services as well as producing human resources and consumables. The following aspects need to be addressed: (i) health sector reforms; (ii) centralized health system and the national health planning; (iii) input-based rather than result/performance oriented planning process; (iv) mechanisms regulating private sector activity; and (v) health legislation and management information system.

(b)        Health Financing

Although there has been an increase in GDP, the health sector is not receiving a proportionate share.  The proportion of out of pocket expenditure is 69.9%, although attempts are being made to provide safety net for the poor.  The sustainability of alternative financing schemes, including a Social Security Scheme, need to be  monitored in the light of rising costs due to the introduction of new technologies.

(c)     Resources Development

There is a need to correct the imbalance of skills mix of health personnel characterized

by the low ratio of nurses, midwives and basic health personnel to doctors. While an incentive system has been put in place for health personnel in remote areas, there is a need to ensure availability of equipment and supplies. The development of human resources relating to management needs to be strengthened and measures to assess performance require further development. The insufficient local production of consumables and shortage of essential drugs within the public and private sector need to be addressed. The complexity in drug management due to the multiplicity of providers and financial sources would also benefit from a review.

(d)        Provision of Health Services:

There   is  need  for  coordination  among  health  care  providers  from  the  Ministry  of  Health,  other  sector  Ministries,   Social    Security   and   NGOs.   The  private  sector  services are and will play an increasing role in the future, thus creating the need for  regulatory mechanisms in terms of service provision, costs and quality of care.  

Partnerships

External assistance is one of the major sources of financing in the health sector. Historically, the support of various partners, especially the UN agencies on health development activities in Myanmar started in the late 1940s. In the last decade of the 20^th century, the pattern and mechanism of assistance from various partners changed. Major bilateral donors decided to scale down their assistance but a number of international NGOs came onto the scene.In 1996, external assistance had increased to US$ 17.16 million, as a result of assistance from the international NGO partners. In addition, some UN agencies have developed new modalities for their assistance in the area of health development. Among the multilateral donors, WHO, UNICEF and UNDP are the major contributors. As one of the countries of the Association of South-East Asia Nations (ASEAN), Myanmar has adopted the activities of the ASEAN Medium Term Plan of Collaboration in Health and Nutrition 1998-2002, which constitutes a basis for partnerships in health between ASEAN countries. The main areas in which both international and national partners contribute are the following: (i) infectious diseases control (emphasis on malaria, vaccine preventable diseases, HIV/AIDS/STDs, tuberculosis, leprosy), (ii) reproductive health, (iii) health sector reform, (iv) anemia & malnutrition, (v) water & sanitation, (vi) health system development including quality of care and health manpower development, (vii) safe blood, (viii) accidents/disabilities, (ix) snake bite, (x) Information Education Communication, (xi) life style/tobacco, and (xii) health of the elderly. Collaboration and assistance from international NGOs has increased in the areas of maternal and child health, primary health care, environmental sanitation, rehabilitation of the disabled and handicapped and prevention and control of communicable diseases.

The government, especially the Ministry of Health, recognizes WHO as the main technical lead agency in health. WHO’s support to the government comprises support to national health development efforts at the country level; inter-country cooperation at the regional level; and inter-regional cooperation at the global level. WHO provides regular budget resources and extra budgetary funds for the above-mentioned support. A joint Government / WHO Collaborative Programme Co-ordinating Committee headed by the Deputy Minister of Health is responsible for planning, coordinating and evaluating WHO collaborative programmes. The results of the analysis of WHO’s country programme during the past three biennia is presented in Chapter 2. The MoH and WHO jointly conducted an Aid Coordination Workshop in Myanmar in January 1998 and recommended regular coordination mechanism among the partners. While the MoH leads the role in co-ordination, WHO provides technical backstopping for this process. During the CCS seminar (June 2000), the possibility of holding once a year aid coordination seminar involving all present and potential partners was discussed as well as the introduction of monitoring meetings (at least twice a year). The joint Government / WHO Collaborative Programme Co-ordinating Committee, responsible for planning, coordinating and evaluating WHO collaborative programmes, is scheduled to meet every six months to monitor and evaluate progress. In the case of collaboration with NGOs, after completing administrative formalities within the Government structure, a Memorandum of Understanding (MOU) may be signed between the concerned health department and respective NGO.

The Co-ordination Division of the Department of Health Planning, Ministry of Health, is responsible for aid co-ordination among partners for health development in Myanmar. The co-ordination of the work of local NGOs is handled by this division and by the International Health Division (MOH) for the INGOs and bi-laterals. Partners involved in the field of health are listed in Annex 2. The International Health Division (IHD) of the Ministry of Health is the central coordinating body between donor agencies and various departments providing health care under the Ministry. In the case of external assistance from UN agencies, the IHD, the respective UN agency and the Foreign Economic Relations Department (FERD) or Ministry of Foreign Affairs (MOFA) communicate among them for co-ordination purposes.

External assistance represents 85.8 % of government health expenditure. There is a need to maximise the utilisation of existing resources. In principle, the Government has the basic responsibility to co-ordinate partners’ assistance. Linkages between the partners include joint planning and joint budgeting exercises. As international assistance is one of the major sources of health care financing, it needs to be strengthened to mobilize more resources, ensure proper allocation according to national priority needs and monitor the effective and timely utilization of these resources.

Major Health Challenges and Key Issues for Health

Analysis of the overall health situation suggests that communicable diseases remain major health problems that constitute excess burden on the people, health services and on the economy of the country. These indicate the need for interventions that aim at modifying life style and environment. Common       childhood       diseasesparticularly diarrhoea and acute respiratory infection are other areas of public health concern which require an integrated response. Malaria is a major concern for almost 60% of people of the country who live in high and moderate risk areas  (National Malaria Programme, MOH, 1999). In 1998 alone malaria morbidity rate was 12 per 1000 and mortality rate was 6.7 per 1000; the proportion of malaria cases among out-patients was 9.4% and 16.2% of in-patients were attributable to malaria. Dengue/DHF is also becoming an increasing problem, a major epidemic occurred in 1998 with 13,000 cases (Report on Technical Implementation of WHO Collaborative Programme, Myanmar, 1998-1999). TB compounded by HIV/AIDS has reemerged as a major health problem particularly in the border areas. 5% of TB cases were HIV positive and 60-80% of AIDS patients had TB. With an estimated 1.6% of the population infected every year, about 100,000 people progress to develop tuberculosis. Over 29,000 new TB cases were reported and an estimated number of people infected with HIV was over 530,000 in 1999. To cope with the TB problem, Myanmar adopted DOTS in 1997. As of June 2000, 71 % of townships and 85 % of the population are covered by DOTS strategy.The polio eradication programme has made significant progress and is on track to meet the target. Leprosy eliminationhas become an achievable goal by the end of 2003 after intensified social mobilization efforts discovered more hidden cases and put them under complete MDT coverage.  With longer life expectancy, major NCDs (cardiovascular diseases, cancer, diabetes, chronic respiratory diseases etc.) are emerging problems.

Maternal health is another area of health concern. The maternal mortality ratio in rural areas is significantly higher than in urban areas (CSO, 1998). Pregnancy-related deaths constitute the leading cause of loss of healthy lives among women of reproductive age. According to the on-going study on maternal mortality by MOH and UNFPA, 57% of maternal deaths occur at home and 4% on the way to the hospital; around 37% of deaths occur in public hospitals. Unsafe abortion, haemorrhage, sepsis and eclampsia constitute major causes of maternal deaths (Table 2).

Recognizing the pivotal role of health for sustainable development of the country, the MOH is committed to strengthening the health system to meet the needs of the people. Making “health” a crucial element to human development and ensuring equitable access to essential primary health services especially in the remote and border areas and for the poor are considered as key areas of concern.

Extensive research in health has been conducted by the Department of Medical Research, MOH. The key issue to be addressed is greater need in utilization of the research results to improve programme and health systems performance.

Table (2): Distribution of maternal deaths by cause in selected countries of the Region

^a   Represents deaths due to malposition of the baby.

^b  Includes rupture of the uterus following obstructed labour.

^c  Includes 13% from infectious and parasitic diseases and 3% from suicide.

(source: Women of South-East Asia – A Health Profile. WHO SEARO, 2000)

To address poverty and health, the Ministry of  Progress of Border Areas and National Races and Development Affairs has taken responsibility for health care of ethnic minority groups residing in border areas of the country since 1989. 

Nutrition is an area that needs greater attention. Evidence drawn from the National Nutrition Center (NNC) surveys suggest that PEM under three years of age is 30.6%; IDD-visible goiter rate among 5-11 years is 33.1%; iron deficiency anaemia in pregnant women is 58%; vit A deficiency-Bitot’s spot prevalence among under five is 0.4% and low birth weight in new born babies is 24%.

Traditional medicineis formally recognized and practiced as an integral part of the health services at different level. Training and research projects are carried out on various diseases. However, evaluation of cost-effectiveness of traditional medicine interventions would be required.

Water supply and sanitationare improving and current figures show rural water supply to be 42.2% and urban 70.1%. 43% have access to sanitation in rural and 70.5% in urban areas. The challenges to the provision of safe drinking water include the coverage, water quality and the further promotion of inter-sector co-ordination and collaboration.

Considering that communities’ contributions in the spirit of voluntarism provided over 66% of the inputs in the form of funding, labor and transport, the community ownership should be encouraged through their involvement in programme decision-making and monitoring at local level. The key issue here includes decentralization and fairer distribution of services in marginalized area.

With the increasing trend towards privatization and market-oriented mechanisms, the poor are at a greater disadvantage. Evidence of inequities in health is clearly shown in the difference in health status between populations living in urban and rural areas (National Nutrition Survey, 1991, FRH survey, 1997 and Statistical Year Book, 1998). The key issue is the need for public sector to protect the interest of the poor.

1 Central Statistical Office, Yangon, Myanmar (1997)

1 The State Law and Order Restoration Council (SLORC) was re-organized and replaced by the SPDC in 1998.