Greater public and foreign spending improve quality of the Myanmar health system

Myanmar’s health care sector has grown considerably in recent years as a result of higher public expenditure and increasing foreign direct investment (FDI). Aside from implementing a range of reforms, the Ministry of Health (MoH) has been proactive in delivering programmes aimed at fighting both communicable and non-communicable diseases (NCDs) nationwide, in accordance with the first phase of the three-phase National Health Plan (NHP) running from 2017 to 2021. However, as the country gears up to achieve universal provision by 2030, significant issues still remain, and long-term financial and political commitments will be necessary to improve the country’s overall health care system.

Structure & Oversight

There are two main bodies that oversee health care operations in Myanmar: the MoH, which manages the country’s entire health sector; and the Department of Public Health (DoPH), a subset of the MoH that acts as the regulatory body for providers, pharmaceutical firms and medical device manufacturers. Aside from the DoPH, there are six departments managed by the Mo H: the Departments of Medical Services, Human Resources for Health, Medical Research, Food and Drug Administration, Traditional Medicine, and Sports and Physical Fitness.

The private sector and NGOs also play crucial roles in the administration of the overall health system. To ensure that private institutions are well integrated into the public system, the Myanmar Medical Association (MMA) serves as an intermediary between providers. There are also different agencies that are authorised to provide licences to medical personnel.

Policy

The NHP outlines several programmes to improve the country’s health infrastructure, services, resources and financing. The main goal of the first phase of the NHP 2017-21 is to extend access to a basic essential package of health services to the entire population by 2021 and increase financial protection for those who need it the most. In line with its policy goals, the government implemented basic health care packages in 70 townships in 2017, spending MMK55bn ($3.5m) on medical equipment and facility reconstruction. That same year also saw 800 clinics and health centres renovated nationwide. The free vaccination programme was expanded to cover 14m children between the ages of nine months and 15 years, and the Japanese encephalitis vaccine was added to the list in 2018, making it the 11th vaccine on the immunisation schedule. The MoH expects to further expand its provision of free medical services in various hospitals and health centres by 2020.

The government’s focus on improving the population’s health has translated into a rise in public expenditure, with 4.5% of the FY 2018/19 national budget allocated to health, indicating a drop from 5.2% in FY 2017/18 but a significant increase from 1% in FY 2011/12. According to the World Bank, per capita health expenditure increased dramatically from $15 per person on 2010 to almost $60 in 2015. This has led to upgrades in infrastructure and considerable progress in the fight against communicable diseases, such as HIV/AIDS, tuberculosis (TB) and malaria.

Communicable Diseases

Due to government efforts to combat HIV/AIDS, recent years have seen incidences of new infection decrease sharply, from 35,000 cases in 2000 to 11,000 cases in 2017, and the incidences of HIV/AIDS-related deaths fall from 14,000 in 2010 to 8000 in 2016. To further these efforts and support the National Strategic Plan on HIV/AIDS 2016-20, the government tripled its budget for prevention and treatment from $5m in FY 2016/17 to $15m in FY 2017/18. In 2017, 60% of the 225,000 people living with the disease in Myanmar were undergoing treatment through the programme. The MoH and the Joint UN Programme on HIV/AIDS also launched the $10m National AIDS Programme in October 2017, a two-year initiative aimed at providing treatment to regions with high infection incidence by conducting awareness programmes, testing blood and administering anti-retroviral therapy to key at-risk demographics. Myanmar aims to eradicate the disease as a public health threat by 2030.

The government is also making headway in the fight against TB. According to the World Health Organisation (WHO), there are an estimated 631 new cases of TB and 25 new cases of multidrug-resistant TB (MDR-TB) in Myanmar per year. The National Tuberculosis Programme, which was implemented in 2016 to tackle the disease, treated some 140,000 TB patients and 2700 MDR-TB patients in 2017. Other efforts saw FHI 360, a US NGO, launch a public awareness campaign about MDR-TB in February 2018 using short videos and advertising via billboards and leaflets.

With regard to malaria, the government has made headway in reducing the rate of new infections – likely the result of the combined efforts of state actors, NGOs and the private sector. In 2012 the MoH, in collaboration with the WHO, launched the National Malaria Control Programme to reduce the incidence of malaria to less than one case per 1000 people by 2020. It has been providing medicines to affected populations, spreading awareness, educating health volunteers and distributing mosquito nets in malaria-affected regions. The MMA has also engaged general practitioners from 135 townships, trained 560 health volunteers, and distributed diagnostic test kits and educational materials to increase public awareness. These projects led to a 49% drop in new incidences and a 62% decrease in malaria morbidity rates from 2012 to 2017.

In spite of this success, some challenges remain. There is still a lot of work that needs to be done so that Myanmar can catch up with other Asian countries like Thailand, which spends four times as much per capita on health care. There are also issues with a lack of trained human resources. “The sudden increase in budget has translated to a higher demand for public health services. This has led to overworked personnel and substandard services, especially in the relationship between providers and clients during service provision,” Dr Kyaw Oo, head of research at the MoH, told OBG. “Nevertheless, the MoH is doing its best to ensure that the minimum standards of care are still carefully met.”

Lifestyle Diseases

NCDs remain a substantial health issue in Myanmar, accounting for more than 40% of annual deaths, according to the MoH. Cardiovascular disease (CVD) is the leading cause of death, accounting for 87,472 fatalities per year, or 23.4% of the total. Of the top-five leading causes of death overall, CVDs make up the first three. This is exacerbated by high use of tobacco products, which, according to the WHO, kill 65,651 people each year, accounting for 17.6% of all deaths. The WHO estimates that 13.3m people are at an increased risk of CVD due to tobacco use and exposure to second-hand smoke.

To manage this, the government has launched several campaigns to warn its citizens about the dangers of smoking and chewing betel nut through radio and television advertisements. Smoke-free zones have also been set up in different regions, with the hope that banning smoking in public areas will further reduce tobacco use. These efforts are aligned with the WHO’s Framework Convention on Tobacco Control, under which Myanmar was selected as one of 15 countries that will receive dedicated support for tobacco control.

Diabetes is also prevalent in Myanmar, with 10.5% of the population affected by the disease, compared with the global average of 8.8%. To address this issue, the MoH partnered with Danish pharmaceutical firm Novo Nordisk to launch the Myanmar Diabetes Care Programme (MDCP) in 2017. The $1.2bn, four-year programme is designed to provide free services to children with diabetes and capacity training to medical personnel, as well as establish a registry system to monitor cases. In addition to the MDCP, the government’s Prevention and Control of NCDs 2017-21 initiative saw diabetes programmes implemented in 70 townships in 2017, which it expanded to 100 in 2018. The programme aims to distribute 20,000 glucometers to rural and subrural areas while making affordable medications available for the prevention and treatment of stroke, heart attack, cancer and asthma.

Sector Personnel

The most recent MoH data reported the per capita ratio of health workers, including doctors, nurses and midwives, at 1.33 per 1000 people in 2016, below the minimum threshold recommended by the WHO of 2.3 per 1000 people. Attracting and maintaining staff – especially in rural areas – has proven difficult, as there is limited funding to pay health care personnel. Of those that do not move to neighbouring Thailand or Singapore, the majority are located in urban centres, such as Yangon, leading to poorer health outcomes in rural areas.

“Human resources are hard to recruit and retain,” U Soe Myint, CEO of diversified conglomerate Family Mandalar, told OBG. “This is particularly evident in health care, where, for example, only 30 neurologists are available in a country of over 55m people.”

However, the tide may be turning. The number of students taking up health-related courses has increased. In 2014 the MoH reported a total of 25,678 undergraduate and postgraduate students enrolled in medical fields. By 2016 this figure had risen to 29,528 students, with 12,230 of these studying medicine and 7572 pursuing nursing. In recognition of the need to train and retain health care personnel, the MoH announced in February 2018 that the government would upgrade Hlaing Thayar General Hospital and Thanlyin Hospital for the purpose of training postgraduate doctors and surgeons. The expansions will include new buildings, as well as a number of new facilities, including emergency and delivery wards, operating theatres and laboratories.

Public Facilities

Funds are also being allocated to open additional government-run facilities. From 2011 to 2016 the number of public hospitals increased from 924 to 1115, rural health centres grew from 565 to 1778, and school health teams rose from 80 to 330, according to the MoH. Traditional medical centres also increased slightly, from 237 to 260, highlighting the value the government places on these methods.

While such increases mean that more people have access to care, public hospitals continue to face several challenges, including a lack of modern facilities. Consequently, an estimated 150,000 patients from Myanmar spent $6m seeking medical treatment in Thailand and Singapore in 2018. The pressure for the government to boost the public hospital profile comes at a time when demand for and investment in private care is on the rise. In February 2018 the MoH announced upgrades to hospitals in the Yangon Region, including Insein General Hospital, North Okkalapa General Hospital and Thingangyun Sanpya Hospital; however, further details had yet to be made public as of late 2018.

Private Care

The private sector has seen an increase in the number of health facilities and personnel – especially in urban areas. In 2013 there were 164 private hospitals, 4420 doctors and 2533 nurses. By 2016 these figures had increased to 212 private hospitals, 5108 doctors and 3028 nurses. Moreover, many private clinics and hospitals have started to upgrade their medical devices to improve patient diagnosis. Private doctors have also created a range of innovative projects, such as the Doctor on Wheels Programme, in which patients can be visited by medical personnel in their homes.

Attracting Investment

Recognising the importance of the private sector in health care provision, the country is stepping up efforts to attract FDI, especially as foreign players are now able to own up to 70% of hospitals and clinics. According to Myanmar’s Directorate of Investment and Company Administration, FDI across all sectors jumped from $1.4bn in 2013 to $9.5bn in 2016, with the health sector looking to grow its share.

In September 2017 the governments of India and Myanmar signed a memorandum of understanding to cooperate in health care provision. India has promised to provide training to local medical professionals, and help draft regulations for equipment and pharmaceutical trading. In February 2018 Myanmar hosted India’s first outreach programme launched by Export-Import Bank of India to create value addition for Indian investors in the Myanmar health care sector.

In June 2018 Ar Yu International Hospital began operations in Tamwe Township in Yangon. The 200-bed facility is a joint venture between Thailand’s Thonburi Healthcare Group and Myanmar company Gamone Pwint. The development will provide job opportunities for over 250 employees. In September 2018 Yoma Siloam Hospitals Pun Hlaing, a joint venture between Yangon-listed First Myanmar Investment and Indonesian conglomerate Lippo Group, acquired a 70% stake in Sein General Hospital in Taunggyi for $4m. The 100-bed facility will be rebranded as Pun Hlaing Siloam Hospital and serve as the group’s first hospital in Shan State.

Foreign Aid

Foreign governments and NGOs also play a crucial role in health funding in the form of aid. The MoH estimates that the country received about $400m in aid for its health sector over 2016-18. Since 2011 the UN Office for Project Services has managed some of the largest development funds in Myanmar. The Three Millennium Development Goal Fund is financed by the UK, the US, Sweden and Switzerland, and seeks to extend quality health services to low-income areas. In 2018 the fund pledged $5.13m to support nutrition and sexual health in the country. Meanwhile, the Global Fund to Fight AIDS, TB and Malaria currently has four active grants providing between $33.7m and $158.7m of committed funds for the improved diagnosis and treatment of communicable diseases.

Pharmaceuticals

The pharmaceuticals industry, for its part, is benefitting in particular from private sector interest. In June 2018 Thailand-based pharmaceutical company Mega Lifesciences, which has been active in Myanmar for over 20 years, opened a new distribution centre in Yangon, through its distribution arm Maxxcare. The MMK18.8bn ($13.3m) facility stretches over 44,500 sq metres with 11,140 sq metres of air-conditioned warehousing space. Maxxcar also recently obtained a licence to set up a new manufacturing facility in the Thilawa Special Economic Zone, where it intends to manufacture medicines for the local market as soon as 2021.

Girish Wadhwa, president of Mega Lifesciences, told OBG that the government decision to open up wholesale and retail trade to foreign investors in mid-2018 will have a significant positive impact on the pharmaceuticals sector (see Industry & Retail chapter). “A more open economy will reduce the overall cost in the value chain, and eventually it will nurture sustainable growth and lead to a more competitive environment.”

Meanwhile, the state-owned Myanmar Pharmaceutical Industrial Enterprise, which currently produces 10% of the country’s medicines, has upgraded its Insein Pharmaceutical Factory, adding eight new medicines to its manufacturing schedule. As a result, the value of medicine it produces reached an estimated MMK50bn ($35.4m) in 2018, up from MMK30bn ($21.2m) in 2017.

The government has also focused on improving its testing and regulation of traditional medicine, with the aim of ensuring the quality of products. A test of 442 traditional medicines conducted in FY 2016/17 found that almost 15% were substandard, prompting officials to tighten manufacturing regulations and licensing. By end-2017 the Department of Traditional Medicine had issued over 2962 medical manufacturing licences and registered more than 13,000 traditional drugs.

Tech Focus

Myanmar has achieved notable progress in using digitalisation to enhance health services. The Safe Delivery mobile app for midwives was launched in February 2018, for example, as the result of a partnership between the MoH, the Denmark-based Maternity Foundation, the University of Copenhagen and the University of Southern Denmark. The app provides easy-to-follow videos to aid midwives and help ensure safe delivery. In mid-2018 officials launched a comprehensive cancer registry system for the country. This registry will use demographic and hospital data to create an inventory of cancer patients, which can then be compared and analysed against global data.

Insurance Schemes

Because Myanmar’s health insurance industry is still in its infancy, the sector offers many opportunities for investors. There are currently 12 private insurers in the country, nine of which offer health insurance at a rate of MMK50,000 ($35) per policy. The application and payment process is similar for all insurers. Policyholders are entitled to claim between MMK15,000 ($11) and MMK20,000 ($14) per day for hospital costs, and MMK1m ($707) for accidental death. Due to the shortage of coverage, however, especially among the middle class and private employees, the World Bank estimates that almost 74% of health-related expenses are currently borne out of pocket, averaging almost $200 per person per year.

Outlook

The prospects for Myanmar’s health system remain encouraging nonetheless. The government’s proactive role in improving the health system, together with the relaxation of investment laws, will be instrumental in helping the country achieve its NHP objectives, with 2017 and 2018 witnessing key gains in the fight against disease. As Myanmar continues to grapple with rising demand for better health care from consumers with more spending power, private health care players are expected to fill some gaps in provision. FDI is anticipated to grow, and this will have positive implications for the quality of the system overall.