The provision of medical services is set to receive major funding and attention

By most accounts, Myanmar has made significant economic progress in recent years, but general health care quality and access still lag dramatically behind that of its neighbours. Decades of mismanagement and limited funding has diminished the health sector and left it in dire need of reform, leaving the Ministry of Health (MoH) to fight an uphill battle. With life expectancy in the country being among the lowest in the world and region at an average of 64.9 years in 2012, according to the World Bank, both government and foreign donors are ramping up efforts in the fight against HIV, malaria, tuberculosis (TB), and maternal and child mortality.

Increased Spending

In order to address these issues, the government has increased health expenditure to MMK652bn ($652m) for the 2014/15 fiscal year, a staggering 800% jump in a mere five years. In 2011 at the time of political transition, health expenditure stood at a meagre $0.60 per capita. While junta mismanagement and a lack of financial support for nearly half a century may have left the health care segment in peril, the reopening of the nation gives hope for the future. The increase in the budget has been accompanied with donor support across a variety of areas. The World Bank, The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund), Three Development Millennium Goal Fund (3MDG), US International Development Agency (USAID) and others are acting to expand Myanmar’s health care base. While there is room for hope, difficulties remain, such as those faced by Doctors Without Borders, which is the largest HIV/AIDS care provider in the country. The organisation was granted re-entry in July 2014 after being expelled from Rakhine State earlier in the year for allegedly being biased in favour of the minority Muslim community.

Skeleton

Founded in 1943, the MoH is the primary provider of comprehensive health care in Myanmar. By 1953 the country had laid the foundations for a comprehensive primary health care system, which by the mid-1960s had established a network of hospitals and rural health centres throughout the country. Over the next two decades, health expenditure accounted for around 10% of total government spending, which led to increased life expectancy and decreased child mortality by a third. After 1988, the military junta dramatically reduced social spending, which led to a gradual decay of the MoH’s national health framework.

Other Facilities

In addition to the MoH, the ministries in charge of defence, railways, mining, industry, energy and transport also provide health care facilities for their employees and their families. The Ministry of Labour is responsible for three hospitals, two located in Yangon and one in Mandalay, aimed at providing care to those covered by the social security scheme. For the general public, however, there is a lack of health insurance, and existing provision is supplemented by the practice of traditional medicine. There were a total of 16 traditional hospitals run by the state in the country as of 2012/13. This is a small figure in comparison to the 2020 public hospitals nationwide, but they are supported by government, which seeks to make treatment available to rural populations. The University of Traditional Medicine in Mandalay opened its doors in 2002, further showing the government’s commitment to the field, which is often the only source of remedy for villagers in hard to reach border territories.

In the public sector, the country’s primary health care facilities or specialist hospitals are located in Yangon and Mandalay, the two major business hubs. Hospitals in these areas vary in size and have an average capacity of 500 beds. General hospitals also offer specialist services on site. They are located throughout the country, and with 1500 beds Yangon General Hospital is the largest. Rural or township hospitals are scattered throughout the country. The amount of beds in township hospitals is determined by the size of the local population and such facilities offer no specialist services. Station hospitals are located in very remote areas and offer only the most basic of care. Extreme cases can be referred to Yangon and Mandalay. Furthermore, the MoH has no stable presence in conflict territories, and medical attention in these zones is often provided by international aid organisations. Those seeking emergency care often opt for a private hospital or clinic in either Yangon or Mandalay. Offering higher salaries, these facilities are better equipped and staffed than their government counterparts. Accounting for around 80% of the country’s health expenditure, these hospitals generally specialise in ambulatory services, with some offering institutional care.

Accreditaton

First introduced in 1923 at Rangoon College, now Yangon University, medical science is offered at five universities, which together produce around 2000 graduates a year. After the student uprising in 1988, most universities were closed down for much of the 1990s. During this time, the Defence Services Medical Academy (DSMA) became the only avenue for those seeking a medical degree in the country. Considered to be one of the most selective universities in Myanmar, most DSMA cadets are commissioned at the rank of lieutenant in the Myanmar Army Medical Corps. Upon graduation, physicians are required to serve populations in hard-to-reach areas. Founded in 1992, the DSMA was formed to provide the national army with physicians. Prior to its establishment, the military recruited its medical officers from civilian schools.

After six years of study and a year as a resident, graduates can obtain an undergraduate degree in either medicine or surgery from the Myanmar Medical Council. Upon completing two years of state service doctors are eligible for a master’s degree, a qualification that is hard to come by. Only one-sixth of registered doctors in the country are employed in the public sector. This leaves junior doctors to either seek private tuition if they have the means to do so, or alternatively to offer their services to the private sector for a small remuneration due to their junior qualification.

In an effort to bolster medical personnel, various foreign universities, such as the University of Western Australia and Johns Hopkins University, are offering scholarships to study abroad. President U Thein Sein also announced in February 2014 the commencement of a government-funded international scholarship programme, the first of its kind in more than 50 years, which covers full tuitions and living costs for top students who wish to study medicine abroad.

Limited Resources

According to MoH official statistics from 2012, there are 29,832 registered medical doctors in the country. This equates to around one doctor for every 1700 people. Dr Aye Aye San, CEO of Victoria Hospital in Yangon, told OBG, “One of the biggest challenges in Myanmar is the lack of medical staff, particularly nurses. For every 1000 people there are 0.4 nurses available. Brain drain is also a major issue. Many local doctors emigrate to seek better salaries.”

With a shortage of doctors throughout the country, midwives act as the primary source of medical care, and therefore shoulder much of the responsibility for health care delivery. Dr Win Oo, country programme manager at the AIDS Healthcare Foundation, told OBG, “Midwives play a crucial role in the provision of primary health care in rural areas, from the delivery of babies to the treatment of disease.” There was a little over 20,000 accredited midwives in 2012/13, with 1000 more graduating every 18 months. However, many of these midwives are unable to enter the field for lengthy periods after graduation as they await deployment by the MoH. Dr Win Oo also said, “If we can utilise midwives more effectively, then universal health care will be easier to achieve.” In an effort to capitalise on these extra human resources, reproductive and sexual health organisation Maria Stopes International has formed the Myanmar Nurse and Midwife Association in order to ensure that that all nurses and midwives become actively involved in health care activities.

With new government budget commitments, health sector salaries have also risen 50% and even doubled in some cases. According to a 2013 report by US-based think tank the Centre for Strategic and International Studies (CSIS), these increases also helped to reduce wages’ share of the budget from 75% to 30%. This should contribute to the prevention of medical practitioners seeking better remuneration abroad. However, human resources are not the only shortage. Basic equipment is often hard to come by. Limited funding had restricted the purchasing power of hospitals for decades and, during sanctions, hospitals relied on unofficial routes to bring in equipment. However, since the country opened its borders foreign players have been able to bring in much needed machinery via companies such as General Electric, which has provided imaging systems to both public and private hospitals, and Philips Electronics, which plans to expand its consumer electronics and health care business in Myanmar.

Insurance

The absence of a national health insurance scheme has weighed heavily on the pockets of Myanmar’s mostly rural population. At present, insurance plans cover fire, vehicles and property, but not health. According to the World Bank, in 2012 out-of-pocket payments accounted for 92.7% of total health care expenditure in Myanmar, compared to 55.8% in neighbouring Thailand. However, progress is being made, and U Maung Maung Thein, deputy minister of finance and chairman of the Insurance Business Regulatory Board, told local media in October 2014 that plans were under way to set up a health insurance scheme in 2015. “Currently, there is already a general agreement among stakeholders on the compensation rates as part of the health insurance [plan],” he said.

Looking ahead, the current’s government has plans in place for universal health care coverage by 2030. It is an ambitious goal as it will require overcoming Myanmar’s diverse landscape, as well as taking into account the religious, ethnic and political strife that creates additional restriction for the MoH. However, over the next 15 years the universal health care strategy will focus on the gradual expansion of the delivery of medical services, particularly to those in hard-to-reach areas.

Major Concerns

Maternal mortality is a leading public health concern for the country. Myanmar ranked 83rd out of 187 countries on the Gender Inequality Index in the UN Development Programme’s “Human Development Report 2014”. The country also had an average maternal mortality rate of 200 maternal deaths per 100,000 births. However, according to CSIS, the rate varied widely and the eastern border region’s maternal mortality rate is as high as 721 per 100,000 births.

Communicable disease is another major concern for the health sector, with HIV/AIDS accounting for more than 18,000 deaths every year. According to a report produced by USAID, Myanmar has the highest rate of malaria infection in Asia. Studies by the World Health Organisation show that TB prevalence is three times the global average, and there is a high rate of both artemisinin-resistant malaria and multidrug-resistant TB across the country. Non-communicable diseases (NCDs) account for 40% of the total disease burden in the Myanmar as rapid urbanisation and poor lifestyle choices are leading to a high rate of strokes, diabetes and heart attacks. According to the Institute for Health Metrics and Evaluation’s “Global Burden of Disease” report, the top 10 causes of death in the country were NCDs. Between 1990 and 2010 the amount of strokes leading to death rose from 3.9% to 6.9%; during the same period heart disease-, diabetes- and kidney diseaserelated fatalities also doubled.

Bridging The Gap

After decades of poor governance, limited resources and international sanctions, donor agencies are working to bridge the gap between Myanmar’s ill-equipped public health system and internationally recognised norms. The Global Fund is the largest donor, providing an estimated $340m between 2011 and 2014, in addition to the $40m provided under its Artemisinin Resistance Initiative. The organisation initially entered the country in 2004, but after the government denied it unrestricted access and movement in certain areas in 2005 they exited the country only to re-enter six years later under new conditions after the end of military rule. Between 2005 and 2011, the absence of the Global Fund left a large gap in communicable disease aid. To fill this void, the Three Disease Fund (3DF) was established in 2007 by seven donor nations, which committed $138m over the following five years. Shortly after the re-entry of the Global Fund, 3DF rebranded itself as 3MDG. The $300m 3MDG project aims to uplift health capacity in 42 of the poorest townships across Myanmar, with a primary focus on promoting maternal, newborn and child health.

Funding is also coming from multiple bilateral donors, such as Japan’s JPY330m ($3.14m) donated to UNICEF to boost Myanmar’s maternal and child health regiment. The US has also committed $20m annually through its President’s Emergency Plan For AIDS Relief and other USAID programmes aimed at reducing maternal and infancy death rates. The UK remains the biggest donor with £60m ($91.95m). While the diversity of health care providers may hinder the MoH’s decision-making power and expansion plans, the role of donors to help build capacity is vital to the extension of medical care, especially to those in no-go zones where the MoH has limited reach. The MoH is also seeking approval from parliament to secure a $200m loan from the World Bank, half of which would be dedicated to the Myanmar Essential Health Services Access Project, which is aimed at increasing the quality of essential health services.

Medical Tourism

Due to limited options for specialist care, many middle and high-income families opt to fly to Thailand, Singapore, Hong Kong or Malaysia to receive medical treatment. The Bangkok Hospital Group (BHG) handled 22,200 patients from Myanmar in 2012, while Malaysian hospitals attended to 7242 Myanmar patients in 2013, with the majority of visits being for cardiac procedures, cancer treatment, orthopaedics procedures and fertility treatment.

To assist in the growing trend towards medical tourism, various foreign hospitals in the region have opened representative offices in Myanmar that facilitate medical travel requirements. BHG, the most popular choice for citizens, has 13 representative offices across Myanmar. The group reported in mid-2013 that the average amount spent by Myanmar patients on major surgery was BT330,000 ($10,131), with general health checkup costs averaging BT24,000 ($737).

Apart from outbound medical tourism, foreign hospitals are also playing a pivotal role in the evolution of the country’s medical facilities. Bumrungrad Hospital International, the biggest private hospital in Southeast Asia, has an agreement with local entrepreneur Serge Pun to manage Pun Hlaing Hospital, a 100-bed facility in Yangon. Dusit Medical Services, also based in Bangkok, has announced it is planning to acquire land in Myanmar to build a hospital that will cater to high-income local families and expatriates. Malaysia's IHH Healthcare, the world's second-largest hospital operator by market value, has also announced that it is looking at potential sites in both Yangon and Mandalay.

Pharmaceuticals

The practice of traditional medicine is not only supported and regulated by the government but in many cases is the preferred choice for many rural families. Dr Winn Maw Phyoe, managing director of Vital Pharmaceutical, told OBG, “The education level of the rural population is rather low and they have little understanding of the benefits of modern medicine. The price range for over-the-counter medications varies significantly in Myanmar from as little as MMK8 ($0.008) to MMK100 ($0.10) per tablet for the same medicine. The majority of our population is poor and they opt for the inferior, cheaper product.”

However, with a growing awareness of health issues and rising purchasing power the demand for modern medicine is increasing. Although traditional medicine is still widely used, the pharmaceuticals import market was estimated at $100-120m in 2013, with Indian companies accounting for 35-40% of the market, followed by Bangladesh and China. Leading the demand is Yangon and Mandalay, accounting for 60% of all pharmaceutical sales. Local medicine factories account for the remaining 40% of supply, with the largest factory run by the Ministry of Industry and located in Pyin Oo Lwin producing 162 different medications.

It is no wonder that foreign companies have an eye on the once isolated nation, but some believe the country is not quite ready for local production. Girish Wadhwa, the managing director for Myanmar at MEGA Life-sciences, told OBG, “Manufacturing pharmaceuticals is not labour intensive, but requires skilled technicians and infrastructure which needs to be developed. At the same time, the pharmaceuticals industry in Myanmar has good potential for growth. Currently, per capita consumption is about one-third of Vietnam’s and one-ninth of Thailand’s.”

Outlook

Myanmar’s health care sector has a long way to go before it reaches international standards, but the journey to universal care has begun. Both private and public sector players are taking significant steps to adjust to the evolving landscape of the country in an effort to improve the provision of medical care. With the support of global donors, Myanmar’s fight against the prevention and treatment of disease is moving in the right direction. According to the Human Development Index, life expectancy increased by 10.2 years between 1980 and 2013 from 55 to 65.2 years of age, but the country remains on the lower end of the index, ranking 150 out of 187. However, if attended to carefully, health care is an area that government can use to leverage international integration.

After decades of isolation, the sector is now open to foreign investment, allowing 70% ownership in clinics and hospitals. With the rise in the number of people seeking medical care abroad and the rapid growth in tourist arrivals acting as a double incentive for foreign medical companies to set up shop in Myanmar, the future for private health care is bright. With historic visits from major international leaders becoming a regular occurrence, the government is under the watchful eye of the global community, which is eager to see the extension of health services to those who need it most. By most accounts, Myanmar has made significant economic progress in recent years, but general health care quality and access still lag dramatically behind that of its neighbours. Decades of mismanagement and limited funding has diminished the health sector and left it in dire need of reform, leaving the Ministry of Health (MoH) to fight an uphill battle. With life expectancy in the country being among the lowest in the world and region at an average of 64.9 years in 2012, according to the World Bank, both government and foreign donors are ramping up efforts in the fight against HIV, malaria, tuberculosis (TB), and maternal and child mortality.