Private sector to drive growth and improve health care in Myanmar

Driven by demand for better services from the country’s expanding middle class and bolstered by higher levels of public expenditure, growth in Myanmar’s health care sector is expected to accelerate. This comes during a time of regulatory relaxation, with the government drafting reforms intended to streamline the processes through which local and foreign companies are able to able to invest, incentivising private investment and stoking competition. The government has affirmed its commitment to achieving universal health care coverage by 2030, an objective that will require increased expenditure on the public side. However, there are still numerous obstacles that will need to be overcome before universal health care is made a reality. Notably, these include the need to upgrade existing health facilities and construct new ones, as well as train and retrain health professionals.

Structure 

On the public side, the Ministry of Health (MoH) implements the National Comprehensive Development Plan (NCDP), while the Department of Health acts as the main regulatory body within the ministry, overseeing health care providers, medical devices, pharmaceuticals providers and capital investment.

The Myanmar Medical Association integrates private practitioners with the public system and supports activities among different private health care providers. As of October 2016, regional agencies have been granted authority to approve foreign investments outright, eliminating the previous requirement that they first gain approval from the primary investment oversight entity, the Myanmar Investment Commission. The decentralisation of the investment approval process is expected to provide a much-needed infusion of investment, both financial and technical, from service providers and suppliers in rural areas.

Budget 

The government has been increasing budget allocations for the health and education sectors since 2011. In FY 2016/17 the MoH spent an estimated MMK881bn ($672.9m). However, the amount allocated to health increased by almost 25% in FY 2017/18 to reach MMK1.1trn ($840.2m). A large portion of these funds has been reserved for training medical professionals, purchasing advanced medical equipment and providing free medical treatment for government employees. Even though health received significantly more funding in FY 2017/18, its allocation still represented only 5.2% of the total budget, a relatively low percentage by regional and global standards.

According to Gershu Paul, CEO of Pun Hlaing Siloam Hospital, this boost in public spending and the growing demand for private health care services will help the sector attract new investors. “In 10 years the total health care spend will be in the region of $145 per capita per annum: multiply that by a population of 56m people and you can start to understand the tremendous investment potential of the sector,” Paul told OBG.

However, the development of the sector will be dependent on infrastructure improvements, with sporadic electricity supply one of the main obstacles. Most hospitals have their own generators to manage power cuts and shortages, but a longer-term solution is needed. In addition, the generally poor state of infrastructure nationwide has hindered industrial development and is one reason for the lack of medical devices and pharmaceuticals manufacturers.

Public Vs Private

As of late 2016, around 1120 public hospitals provided 56,700 beds. The public sector also comprised 87 primary and secondary health centres, 348 maternal and child health centres, 1700 rural health centres, 80 school health teams, 16 traditional medicine hospitals and 243 traditional medicine clinics. Overall, the public sector accounts for 86% of the total health facilities in the country.

Meanwhile, the private sector is cautiously expanding, but there are a number of factors hindering its growth, such as the deficit of skilled staff, poor financing and limited liberalisation in the insurance market. There were 193 private hospitals, 201 private specialist clinics, 3910 private general clinics and 776 private dental clinics as of 2015, according to a report by the Department of Medical Services. Private hospitals tend to be smaller than public facilities in terms of the number of beds. The largest private hospital in Yangon has 220 beds, for instance, but about 90% of private hospitals have fewer than 100 beds, and are mainly concentrated in the urban areas of Yangon and Mandalay. The recent growth of the private sector has been spurred by the loosening of foreign investment regulations, with 70% foreign ownership allowed in clinics and hospitals as of 2014. These changes enticed private hospitals like Bumrungrad and Bangkok Hospital to set up representative offices in the country, while Samitivej Hospital partnered with Parami Hospital to establish an international clinic in 2014.

Disease Profile

In 2015 life expectancy was 64.6 years for men and 68.5 for women, according to the World Health Organisation (WHO). The neonatal mortality rate was 26.4 per 1000 live births, while the under-five mortality rate was 50 per 1000 live births. The proportion of births attended by skilled health personnel averaged at 60% over 2005-16. Myanmar’s health figures are below some other ASEAN countries, but are often comparable to those of Laos and Cambodia. For example, Myanmar’s maternal mortality ratio per 100,000 live births was 178, while Thailand’s was 20, Vietnam at 54, Cambodia at 161 and Laos at 197.

Non-communicable diseases are a growing problem in the country, accounting for 68% of all deaths in 2015, according to the Word Bank. The WHO, meanwhile, placed the probability of dying from a non-communicable disease in Myanmar for those between the ages of 30 and 70 at 24.5%, which is roughly in line with the country’s regional neighbours. The main causes of non-communicable deaths in 2016 were cerebrovascular disease and Ischemic heart disease.

Insurance

yanmar’s private health insurance segment is in its infancy. In FY 2016/17 private health insurance premiums totalled just over MMK98m ($74,900), according to the Central Bank of Myanmar. This low health insurance penetration rate acts as a significant barrier to health care access. As a result, Myanmar has one of the region’s highest out-of-pocket health care expenditure rates: close to 70% in 2015.

The state-owned Myanma Insurance held a monopoly on the insurance industry until 2013, but health coverage was not part of its portfolio. In 2015 the first such scheme was introduced, but take-up has remained low. Although there are 12 private insurers in the market, only nine offer health lines. By law they offer the same product, which guarantees partial payment of hospitalisation costs and covers accidental deaths. Foreign insurance companies have long been prohibited from operating in Myanmar beyond the opening of representative offices, but the Thilawa Special Economic Zone was opened to foreign insurers in 2017 and the government has indicated to a willingness to liberalise the market further (see Insurance chapter).

Universal Care 

The NCDP 2011-30 was formulated by authorities in response to ongoing changes and emerging health challenges. One of the main goals of this long-term strategy is achieving universal health care, which is defined as all Myanmar people having access to quality health services without causing financial hardship. To achieve this objective, the MoH has developed the three-phase National Health Plan (NHP), which was unveiled in December 2016.

The NHP aims to strengthen the health system, creating the necessary structures to provide universal care, while benefitting citizens living in poverty. The plan outlines seven key programmes: disease control, public health, health system strengthening, human resources for health development, promotion of health research, curative services and development of traditional medicine. 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. For the 2021-26 phase the NHP aims to provide intermediate health services, while for 2026-31 a more comprehensive set of services will ultimately deliver universal health care. Although the finalised cost of the plan has not yet been announced, it is expected that extending the first phase to the entire population will likely require substantial investment from private and non-profit health care providers and investors, in addition to the government.

SKILLS SHORTAGE

The system suffers from a major skills and staffing gap, with a particular shortage of trained nurses. According to the latest WHO statistics, Myanmar had 61 doctors, 100 nurses and midwives, and seven dental surgeons per 100,000 people in FY 2013/14. Moreover, the spread of skilled health workers is uneven, with less personnel in rural areas.

A number of different factors are contributing to this skills shortage. Around 1200 medical students graduate from Myanmar’s tertiary institutions each year, but only 400 of these are nurses. After graduation, almost all of the nurses are employed in public hospitals, while private hospitals struggle to employ adequate numbers. Many private hospitals would like to set up their own nursing schools, and it is expected that the government will begin to grant operating licences for this to happen in the near future.

Private nursing programmes would help to relieve staffing shortages, but in the interim some private hospitals have turned to training health care assistants to supplement nursing staff. Other strategies being employed include hiring foreign nurses to train local nurses and recruiting staff who are then trained in the Philippines. In September 2016 the Philippines-based PHINMA – a private network of schools – opened a training centre in partnership with the private Victoria Hospital in Yangon. This venture seeks to provide education in child, elderly and special assistance care, while also easing the wider shortage of health care professionals in Myanmar and creating new jobs.

On Call

Private hospitals and clinics are also faced with a shortage of doctors. Myanmar has no private medical university, so all doctors attend public medical colleges and are contractually bound to serve in public hospitals for at least five years upon graduation. The MoH, Ministry of Education and Ministry of Defence are collectively responsible for the training of the country’s health care workforce. Health professionals are educated at 15 universities and 46 nursing and midwifery training schools. Medical and allied universities offer 39 doctorate courses, 12 PhD courses, 47 master’s degree courses and 12 diploma courses. Furthermore, to keep the public hospitals staffed, doctors, dental surgeons and nurses must join the civil service in order to pursue postgraduate degrees. Private hospitals therefore find it difficult to hire specialists. A common strategy is to offer consultants working in public hospitals positions at private facilities. This, however, presents a problem with physician fatigue and overscheduling.

The brain drain trend is worsening the issue as well. Many health care sector graduates have migrated to neighbouring countries such as Singapore or Thailand to gain better remuneration. However, increasing opportunities in Myanmar’s private sector mean that some emigrant health care specialists are starting to return. In the long run, the solution to enhancing the quality of the health care sector is staff retention.

This outward flow of medical human resources could be slowed by the expected introduction of regulations that will allow for an expanded and diversified private health care segment. Such regulations would likely also reduce the number of outbound medical tourists, generating a greater amount of revenue locally.

Pharma

A shortage of medical technology has remained a roadblock for the sector, but at the same time it presents large-scale opportunities for foreign suppliers, as the government is gradually reducing regulations over the importation of medical devices from international companies. In 2014 Myanmar’s pharmaceuticals market was worth approximately $390m, reaching $440m in 2015, much of which was composed of generic medications imported from India, Thailand, Bangladesh or China. The country’s total pharmaceuticals expenditure has been growing at roughly 11-12% per year, according to market research agencies. Analysts expect that the market’s value will reach $1.1bn by 2023. Nevertheless, there are only a handful of established pharmacies in Myanmar. Instead, clinics and hospitals provide medicines, with each procuring their own supply from a network of preferred distributors. More than 60% of pharmaceuticals sales take place in Yangon and Mandalay. In addition, about 75% of Myanmar’s population utilises traditional medicines for healing and wellness, according to the WHO.

The domestic pharmaceuticals industry is still in the early stages of development. Domestically produced supplies account for only 20% of demand and are mainly made by the state-owned Myanmar Pharmaceutical Factory, which operates under the purview of the Ministry of Industry.“The local pharmaceuticals industry can only produce relatively simple drugs,” Rajeev Rawal, executive director of pharmaceuticals company ABC International, told OBG. “However, the opening of new pharmaceuticals manufacturing units is a step in the right direction, because the country has previously relied on imports to supply local demand. Domestic production can bring costs down and increase the supply of drugs in the market. In the long run, competition will improve the overall quality of domestically produced drugs.” The country’s first privately operated pharmaceuticals producer, Pacific Medical Industries, commenced operations at its Yangon-based factory in July 2017.

More than 100 pharmaceuticals distributors operate in Myanmar, including Thailand’s Maxxcare and Swiss-owned DKSH. The latter has a network of some 60 sub-distributors, reaching 19,000 retail outlets with products from multinational players such as Bayer, Roche and Sanofi. For its part, Maxxcare sells products from the likes of Novartis, Pfizer, Lupin, GSK, MSD and Kalbe – with a sales force that extends to the most remote parts of the country. As the first distributors on the ground, it is expected many more will follow.

Importing Devices 

The only legislation relating to medical goods is the 1992 National Drug Law, which is limited in scope and does not cover medical devices. The Food and Drug Administration (FDA) is in the process of drafting legislation for medical devices, which will adhere to the ASEAN Medical Device Directive. Imported medical devices must obtain an import recommendation from the FDA as well as a trade permit from the Ministry of Trade and Commerce. The medical devices legislation, which is expected to comprise one of the country’s first major updated technical regulations, was drafted in collaboration with the US Agency for International Development and a number of other NGOs. When the drafting process is complete, implementing regulations and a Medical Device Registration list will be issued publicly.

The health authorities have, however, recently published a list of medical devices – including CT scanners, MRI machines and X-ray machines – that are exempt from obtaining an import recommendation prior to importation. This exemption list is expected to simplify the procedures for the importation of foreign-owned medical products and ultimately help to promote the growth of the medical device market. The new laws should facilitate both the trade and import of medical equipment, while also reducing the cost of technology by introducing more competition. “The quality of Myanmar’s medical care is below Thailand and other neighbouring countries, but we will catch up with the help of technology,” U Kyaw Htin Latt, CEO of local business group Seezar Soesan, told OBG. “Health care is a good segment to invest in because there will always be a demand for a quality service in this area.”

Outbound Tourism 

The supply of health services falls short of demand at present. It is common for Myanmar people, especially those in the growing middle and upper classes, to travel abroad for medical care. Indeed, around $250m is spent annually on outbound medical tourism, with Thailand, Singapore and India the most popular destinations. When better quality health care options become more widely available, Myanmar could stand to benefit from an increased amount of this expenditure. “Improving the quality of local health care services will be crucial to retaining more of the Myanmar citizens that currently travel overseas for medical treatment within our local system,” Paul told OBG. “The challenge that local hospitals have is how to enhance their reputations and align their practices and infrastructure with international standards.”

Outlook

As Myanmar’s citizens become wealthier and more urbanised, the demand for high-quality medical resources and facilities in the domestic context will become more pronounced. In the meantime, basic medical care and essential facilities – notably including pharmaceuticals and medical devices – are needed across the country, particularly as the state forges ahead with its bold drive towards universal health care.

As regulations are relaxed and decentralisation gives more power to local authorities, opportunities for investment should grow. Private education and training facilities are expected to gradually become part of the mainstream education system, which would place the country in a better position to staff its medical facilities with locals. Until then, the sector will be dependent on outside assistance and its neighbours to supply it not only with human resources, but also with a wide spectrum of devices and medications that are necessary to provide modern health care to a growing country.

As such, there is a multitude of opportunities for investors in the sector, and those who establish a presence on the ground early should be well placed to expand operations and capture significant market share as development in care provision continues.