Accessible Healthcare Requires Local Participation: Dr. Cynthia Maung
By Nyein Nyein 18 July 2019
The Mae Tao Clinic, known locally as the Student Clinic, in Mae Sot, Thailand, near the Myanmar border, has been providing basic healthcare services for internally displaced persons (IDP) and migrant workers for three decades.
With the changing political landscape in Myanmar and bilateral ceasefire agreements signed between the Myanmar government and ethnic armed organizations in 2012, the clinic has seen a reduction in aid from the international community, forcing it to end some healthcare services. However, the number of patients seeking healthcare at the clinic—from Karen State and elsewhere in the country—has not declined.
Despite facing many challenges in providing basic healthcare services—including maternal and childcare services and providing education to the children of migrant workers in Thailand’s Tak Province, as well as issuing birth certificates to the newborn babies of migrant workers—it continues to operate.
Since Myanmar’s peace process began, a consistent sticking point in talks has been the reintegration of refugees displaced by decades of fighting. Dr. Cynthia Maung, the clinic’s founder, said it is important to include the experiences and perspectives of local health workers when considering future health sector development in ethnic areas as part of interim arrangements outlined in the nationwide ceasefire agreements.
On the occasion of the 30th anniversary of the founding of the Mae Tao Clinic, in June, The Irrawaddy’s Associate Editor Nyein Nyein spoke with Dr. Cynthia Maung about healthcare services and her views on the implementation of the peace process.
Most patients seeking healthcare at the clinic have been from areas affected by armed conflicts along the Myanmar-Thailand border. After the ceasefire, whom are you mainly providing healthcare services to?
Although there are ceasefires, basic healthcare alone is not enough for the IDPs and migrant workers to receive all-accessible healthcare services. It also depends on their incomes, jobs and the stability of local populations.
Without an income, a job and a stable populace, IDPs become migrants. Moreover, not all migrant workers are from the border areas of Kayin State alone. Every year, many people from other parts of the country—including the Bago, Ayeyawady and Yangon regions—come to Thailand. As a result, there are always new people arriving here. The number has never dropped. It can be assumed that the number has increased.
Many migrants’ children are born here. It isn’t yet possible for migrant workers to go back as they have their jobs here, so they send their children to school here. As a result, child rights protection and education have become part of the clinic’s operations.
For healthcare services inside Myanmar there are ethnic group-based healthcare service teams providing basic healthcare in their respective areas. We continue to train health workers and provide technical assistance as much as possible.
Sometimes, patients seeking healthcare at the clinic need to be referred to government hospitals in Thailand. We also encourage programs to refer patients to government hospitals [in Myanmar]. We are cooperating with government hospitals especially in the maternity and childcare sector so that patients can get services there [in Myanmar]. Patients with injuries or chronic diseases are still coming here to Thailand.
Even though there is a ceasefire, we need to give priority to providing accessible healthcare services to all. When it comes to maternity services and childcare, we give priority to vaccination, family planning and taking care of pregnant women.
For vaccination and pregnancy care, some people are still coming to us in Thailand, as we have enough trained healthcare workers and we are in close geographical proximity. They are receiving healthcare services here depending on the type and level of services they need.
Some well-to-do people go to private Thai clinics or to Mae Sot Hospital. Not all of them come to us. Some 30 percent of patients seeking care in private hospitals and township hospitals along Thai-Myanmar border are Myanmar citizens.
What role does the clinic play in providing healthcare services to repatriates?
There are two types of repatriates: refugees who officially lived in refugee camps and those who did not. Most migrants tend to commute repeatedly even after they return home. One or two years after they go back in Myanmar, then they come back again. It is difficult to predict [their movements].
Healthcare service providers along the border continue their assistance to such migrants. When they return from refugee camps to their areas, especially along the border, there are healthcare services provided by ethnic organizations and health workers from civil society organizations. When they return to such places they can continue to receive healthcare services.
However, there are some limits for patients with chronic diseases. If an ethnic healthcare organization cannot provide treatments, for instance, for HIV or TB, we have programs to reconnect them with government healthcare services.
Currently, there are some pilot programs on the national level to combat HIV, TB and malaria. However, it is not accessible to all patients. Therefore the access to treatment for patients with chronic diseases including mental illness, HIV and TB is still limited.
How many patients affected with infectious diseases like HIV does the clinic treat every year?
We currently have some 4,000 HIV patients. We know this from those who took blood tests for pregnancy, blood donation and other tests each year. There are 150 new cases every year.
We refer patients who need treatment to Myawaddy Hospital [in Karen State] since the support program for migrant workers by the Global Fund was stopped in 2017. We currently refer most of the patients to Myanmar, but some patients went back to their own villages; if so, we cannot reach out to them.
How is the clinic surviving amidst shortages of funding assistance?
The international governments and their development programs—which now have direct assistance programs in Myanmar and cooperate directly with the government—have reduced their assistance for healthcare services in Thailand since 2012. This has had a great impact on our organization as well as on hospitals in Thailand. There have been no funds for this [Thai] side of the border.
For emergency childbirth, we refer patients to Mae Sot Hospital. This is because of the differences in staff and medical equipment between the Mae Sot and Myawaddy hospitals. We refer those who do not need emergency operations to Myawaddy Hospital. Because it is cheaper to get treatment in Myanmar than in Thailand, we send them to Myawaddy and continue to help them with social assistance.
There are some patients, including those with chronic diseases, we cannot refer to Mae Sot Hospital. If the patients can afford the costs, we refer them to Mae Sot Hospital, but as we cannot take responsibility for the costs, we cannot help all patients’ referrals.
Besides, we cooperate with some organizations for patient referrals as we alone could not provide such services anymore.
This is also true for some programs at home [inside Myanmar]. Because the clinics or hospitals in Myanmar can get access to funding to provide direct services, we do refer patients to them, but we try to manage to provide for our staff’s needs, including their salaries and necessary technical support (skills development). However, we cannot afford to pay their wages fully and have had to reduce their pay to 80-85 percent of their previous salary, depending on our funds. [Comparatively], we received as much as 70 percent of our funds from [international] governments in the past, but their funding support is now at some 30 percent.
We try to secure the rest of the funding by applying for funds from foreign embassies in Thailand in cooperation with our partner organizations. There are some Thai individuals and organizations that help fundraising for us among Thai communities too.
Then our international partner organizations also organize fundraising campaigns for us in their respective countries, including the U.S. and the U.K. We also organize fundraising campaigns here. However, we still do not have a strong financial source at the moment. We are trying to sustain ourselves with income programs for the future.
Another source we raise some funds from is the public and parents. For example, we collect 10 or 25 percent of healthcare costs or school admission fees from migrants with their consent. Those who cannot afford this contribution will not have to pay it.
If a patient seeking surgery can contribute only 10 percent of the cost, although we’ve set the fee at 25 percent for such patients, we will accept only 10 percent. Some of them can’t afford anything. Although we expect to get 25 percent of healthcare cost from patients, we may actually receive only 5 to 10 percent of it. We also cannot use that method for all patients. We cannot do this for emergency patients. Patients who do not need emergency treatment and those with chronic diseases can contribute money for blood test fees. There are also programs to collect financial contributions from patients for their costs if they need to be referred to Mae Sot Hospital. Another way is accepting donations of medicine and medical equipment. There are some people in Mae Sot who regularly donate food or medicine.
How is the clinic cooperating with governments or ethnic armed organizations to provide healthcare services to people in border areas?
We are not working alone. We cooperate as part of a group called the Health System Strengthening Working Group, which was reorganized as the Health Convergent Core Group in 2012. The group focuses in areas not just in the eastern part of the country but on all other states, including Shan, Kachin, Rakhine, and Chin.
We are working toward having a better healthcare system among ethnic healthcare organizations, and we also have programs in cooperation with the government.
We have some negotiations with the government for our health workers, including midwives, to become the government-recognized health workers in their villages.
The purpose is [for us and the government] to mutually recognize each other and to make the best use of local health organizations and their strengths. It is a way to exploit human resources for local development.
Mae Tao clinic has trained many refugees and members of ethnic organizations to become health workers, but there is no arrangement that officially recognizes them as health workers or provides them licenses to treat patients [especially in remote ethnic areas where access to healthcare is challenging]. This is a challenge for us.
When it comes to the peace process, it is necessary to coordinate with the government for health systems, social work and other systems for local people, and it is also important to recognize them and make improvements. Only then will we be able to create an accessible healthcare system for all.
It is difficult to create a good healthcare system without the participation of the local people and local health workers.
This is because if we want to build trust politically, geographically, [across different] languages and traditions, we need to find out ways to foster cooperation between health workers and organizations as well as between government health organizations and ethnic-led health organizations.
All this is related to the health sector. How about education and the issuance of birth certificates—what are the challenges in cooperating with the current or with previous governments on these issues?
The first challenge is the need to create programs to make local healthcare systems and ethnic education systems acceptable to all in terms of government policies.
However, there is no program to thoroughly discuss healthcare and education policy. Although they were discussed to some extent [during the political dialogues], it can generally be said that there is no discussion on topics like healthcare and education systems that are in line with federalism.
In regard to the issuance of birth certificates, in ethnic areas, the ethnic health workers deliver newborn babies. A birth certificate includes correct data such as place of birth, parents’ names, origin and ethnicity. Whether it is in education or birth certificates or healthcare, statistics and information that are documented need to be correct. It is one of the topics we need to discuss further.
This is because sometimes there are problems such as misspelled names due to different dialects, or not having the real name, or discrepancies between names written on birth certificates and on the family’s household registration documents issued by civil servants [in governmental departments]. As some people are moving from place to place and do not have household registration documents, their places of birth sometimes cannot be determined. These are challenges we have experienced.
To address all these issues, it is very important [that the government] cooperate with local civil society organizations and local health organizations.
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