Of Health Care and Management Malpractice
By Ye Min Zaw 18 April 2018
A political decision at the top can have huge impact on the ground. There has been a furious response from young medical staff to comments made by Health Minister U Myint Htwe at a peace talk in Myaungmya Township, Irrawaddy Region, earlier this month. The minister said there was plenty of medicine available, even an oversupply, especially if expired stocks were taken into account. Many junior doctors struggling with shortages were among the loudest critics. U Myint Htwe soon issued an apology and clarification via social media, and the ministry acknowledged that there was indeed not enough medicine to go around.
The episode epitomizes a failed system, one that deserves scrutiny. It further exposes a health care system that has deteriorated over the decades and is struggling to rebuild. The National Health Plan (NHP) already laid bare the system’s failures and challenges, including a highly fragmented and complicated supply chain.
It is a wonder the health care system has even survived without logistics staff for many years. The central supply department takes care of all distribution of medicine. But policy and regulation dealing with procurement and distribution are weak. On top of that, the health budget is miniscule and largely dependent on external aid. This has led to limited capacity and inadequate infrastructure. A free essential medicine scheme introduced in 2013 by the previous government was popular but politically motivated.
The situation has hardly improved since the National League for Democracy took control of the government some two years ago. As part of its decentralization efforts, the procurement of medicine was shifted onto the shoulders of state and regional health officials. Although procurement guidelines are in place, little is known about how procurement takes place; the process lacks transparency. By obscuring the source of medicines, most junior staff don’t know where they come from. In addition, requested supplies usually arrive late — sometimes six months late — further exacerbating hospital shortages.
Given the woeful infrastructure and poor application of technology, the medical inventory system is naturally outdated. That makes it difficult to anticipate shortages and to be proactive. The lack of a dedicated logistics unit places the burden on medical officers not trained for such tasks. One of the main complaints from medical officers is that the medicine they receive is often nearly expired, placing pressure on them to dispense it quickly. These problems are rooted in the lack of a reliable data system or standardized management procedures. No one knows how much medicine has gone to waste as a result.
But the problems aren’t just technical.
A system born of politics can only be fixed with political will. When assessing failed states, discussions of political will and government capacity often come up. Capacity means the effectiveness of government systems. And as author Stephen Browne has said, the acid test for a government’s effectiveness is its use of resources. It has become a cliché to say that Myanmar has wasted its resources and failed to adequately fund its health care system, though the NLD has proven its commitment to change.
So the health minister’s recent comments came as a surprise. He was criticized for failing to reflect reality and for living in an echo chamber. He had probably been misinformed, which reinforces the popular perception of a bureaucratic elite standing like a wall between ministers and their frontline staff. It forced the minister to issue a clarification. His performance as a technocrat is not the issue here. But as a politician, he failed to communicate with his own staff, let alone the public. Rather, by proactively discussing the ministry’s challenges, he might attract buy-in from colleagues and at the same time make them more accountable.
Political will is needed not only at the ministerial level, but at all levels. All levels should be made aware of how the procurement system — which remains a politically sensitive topic of discussion — works. That sort of knowledge could empower medical staff to demand adherence to guidelines and further transparency, and inspire officials all along the supply chain to embrace genuine change. Everyone is responsible for making the system better simply by virtue of being a part of that system. We cannot simply expect change to come from above.
The current government talks more about big dreams than about attainable objectives. The NHP is ambitious, but the minister’s goals should be grounded. This episode is a wakeup call to talk openly and honestly about the health care system’s challenges and root problems. It is time to say “I can’t do that” and remove those who say “all is fine.”
Ye Min Zaw studies international development with a focus on peace processes, transitional issues and Rakhine affairs. He is also a medical doctor who has worked for many international organizations including UNICEF.