Myanmar Patients Pay the Price

By Reform, Samantha Michaels 9 August 2013

YANGON — When Myanmar’s former dictator fell ill six years ago, he didn’t waste time looking for help at local hospitals. Instead, Snr-Gen Than Shwe got on an airplane and flew overseas to Singapore General Hospital, where he reportedly received treatment for an intestinal ailment.

It’s a vastly different story for U Haronbi, a 41-year-old laborer from Yangon who makes just 5,000 kyat (US $5.30) a day. He never set foot inside a hospital for the first four decades of his life, opting to treat himself with over-the-counter medicines during times of poor health. “I cannot afford much,” he told The Irrawaddy.

In 2007, the same year the now retired U Than Shwe sought treatment in Singapore, Myanmar’s former military junta spent less than $1 per person on health care, according to statistics from the Health Ministry. Six years later under the country’s new quasi-civilian government, experts are calling for an overhaul of a medical system that many say is broken after decades of underfunding.

The Health Ministry says it aims for universal coverage in the next 20 years—a major goal considering its starved budget—but in the meantime, patients in the government’s public hospitals have been forced to foot the bill. Yangon General Hospital, among Myanmar’s biggest and best known, is notorious in this regard, requiring patients to pay for any equipment used during their treatment. And in a country where the average person earns about $2.50 a day, many are forced to forego care, or seek other options.

“For [Myanmar’s] public hospitals, which are completely under-resourced by the government, patients often have to pay for everything themselves—IVs, medications, dressings, cleaning, food,” said Dr. Vit Suwanvanichkij, a public health researcher who has worked with migrants from Myanmar on the Thai border for more than a decade, and who visited hospitals in Myanmar last year.

“It’s probably the most privatized health system in the world,” he added, noting that due to widespread poverty, particularly in rural areas, this means that the vast majority of Myanmar’s population is effectively deprived of any access to health care.

Official statistics also show that the government plays an almost negligible role in providing health care. According to National Accounts Data from the Ministry of Health in 2008-09, the ministry was responsible for just 10 percent of all health-care spending, while private households accounted for about 85 percent, with additional funding from other ministries and NGOs.

The Lady’s Doc

In Myanmar’s biggest city, there are a few other options for patients with limited income, including the Muslim Free Hospital, where U Haronbi went earlier this year for a hernia operation.

In addition to offering free medical care to the city’s poor, the hospital has another draw: Its head surgeon, Dr. Tin Myo Win, is the personal physician of opposition leader Daw Aung San Suu Kyi.

The hernia operation would cost about $100 at a public hospital, according to the doctor. “Here it’s charity, true charity,” he said of the hospital, which is named for the religion of its founders but is nonsectarian, serving people of all faiths and classes.

Several patients in the hospital’s surgical and outpatient wings said they avoided public hospitals because they could not afford them and had heard stories about poor treatment. “Some of the doctors and nurses are unfriendly,” said 19-year-old Ma Su Hla Phyu, a mother in Yangon seeking prenatal care during her second pregnancy.

U Ne Win, 53, preparing to be discharged after a surgery in May, agreed: “I’ve never been to any other hospital because I only trust this hospital,” he said.

Funding for the Muslim Free Hospital initially came through religious donations from local Muslims in the city, but later, largely thanks to Dr. Tin Myo Win’s relationship to Daw Aung San Suu Kyi, donations also started coming from abroad.

Even so, the hospital has limited resources. The surgical unit offers just 25 beds—at least theoretically. “Sometimes we have to put [patients] in between the beds, so we can accommodate more than 35 or 40 if necessary,” Dr. Tin Myo Win said, adding that he often performs 10 to 15 surgeries in a single day. “You should only perform about five major operations a day as a surgeon. Sometimes I have to stay late into the evening.”

“This is a small hospital. Some cases, like heart operations, brain operations and kidney operations, we cannot afford to do them here,” he said. He needs to refer about two patients a week to other institutions, although they often say they cannot afford to go elsewhere.

Free medical services are also available at the Thukha Charity Clinic, a project of the Free Funeral Service Society, where pro bono care is offered by volunteer doctors and specialists, including orthopedic surgeons, oncologists, dermatologists, radiologists, pediatricians and ophthalmologists.

Relying on Midwives

In rural areas, these services and more are covered by midwives, who are responsible for about 3,000 patients each in some states, according to the Health Ministry.

“They’re expected to do everything—primary health care, ante and postnatal care, pediatrics, delivering babies, collecting health data. Rural health-care providers joke that the midwife does everything except have the baby,” said Dr. Suwanvanichkij.

“They are so incredibly busy, underappreciated and underpaid for the essential services they are tasked with providing,” he added.

The reason for this overreliance on midwives is that doctors are in extremely short supply. Availability varies from about six doctors per 100,000 people in Mon State to about 60 doctors for the same population in Chin State, according to Health Ministry statistics from 2009, the latest publicly available.

The lack of health infrastructure in rural regions has had devastating results. Malaria is a leading cause of death in Myanmar, while the country’s tuberculosis prevalence is more than 500 cases per 100,000 people, compared to about 270 cases on average regionally, according to 2010 data from the World Health Organization. For HIV, the prevalence is 455 cases per 100,000 people, compared to the regional average of 189.

Want Treatment, Will Travel

The game is completely different for the limited strata of Myanmar’s population with wealth—including President U Thein Sein, who reportedly underwent a health examination at Singapore’s Mount Elizabeth Hospital last year.

Increasingly, Myanmar’s affluent are flocking to Bangkok, which is home to one of Southeast Asia’s most acclaimed hospitals, Bumrungrad International. More than 1,000 Myanmar patients travel to the hospital every month, including government officials and high-profile public figures, according to Helen Hla Kae Khine Aye, senior manager of the hospital’s referral office in Yangon. That’s up from about 50-60 Myanmar patients monthly when she started working for Bumrungrad a decade ago.

“In Myanmar, at our hospitals and medical care centers, maybe they couldn’t get the correct diagnosis,” she said. “A lot of people go abroad to get the correct diagnosis.”

Bumrungrad International Hospital has 14 Myanmar-language interpreters, and the referral office in Yangon helps patients arrange Thai visas and buy plane tickets in advance.

“There are two types of patients,” Helen Hla Kae Khine Aye said. The first, “the very wealthy ones,” visit regularly for checkups and minor ailments. “The other type of patient, they can’t afford much but they would like to get the correct treatment. They sell their houses and property just to go there.”

The Rubik’s Cube

As Myanmar transitions from nearly half a century of military rule, health experts are calling for an overhaul of the country’s health system, though they admit the challenges will be immense.

Daw Aung San Suu Kyi, who has made health and education reform two of her major platforms since winning a seat in Parliament last year, is spearheading a project to upgrade Yangon General Hospital.

Dr. Tin Myo Win, a member of the project’s fund-raising committee, said Parliament had already allocated 5 billion kyat ($5.3 million) to upgrade the century-old 1,500-bed hospital, including plans to build a new 1,000-bed facility to accommodate patients during the renovation.

The surgeon is also developing a national health policy for Daw Aung San Suu Kyi’s National League for Democracy party, with a National Health Network that he formed this year. In addition to meeting health experts from Myanmar and overseas, the network plans to create a mobile clinic with surgeons, specialists and emergency medical technicians traveling to remote areas.

Starting this year, some public hospitals have also begun offering limited financial aid—but they’re not advertising it.

Yangon’s North Okkalapa General Hospital began offering financial aid in January for patients who could not afford to pay for their medicine or IVs, according to an assistant medical officer at the Muslim Free Hospital who completed a yearlong internship at North Okkalapa General last year.

“But the patients don’t know about it,” said the medical officer, 23-year-old Sandy, who studied at the University of Medicine (2) in Yangon. “The public hospital in Insein Township also started offering financial aid, but patients from Insein still come here [to the Muslim Free Hospital] because they do not know.”

Meanwhile, the Health Ministry’s goal of achieving universal health coverage within 20 years will be very difficult to achieve with a health budget that Dr. Tin Myo Win calls “very insufficient.”

“For the Ministry of Health, we can understand. With the amount they have in their hands, they are doing quite a good job for the people,” said the doctor. “But how can you [fix everything] with this limited budget?”

According to the latest figures, health-care spending still accounts for only about 3 percent of the total national budget.

Other experts say it is important to keep a broad focus, with attention paid to building reliable data systems and ensuring that investment reaches rural areas.

“There are so many moving parts that are broken,” said Dr. Suwanvanichkij. “I think when it comes to public health, you need to work on all these places to fix up this messed up Rubik’s Cube.”

This story first appeared in the August 2013 print issue of The Irrawaddy magazine.