Guest Column

Health Help on Its Way to the People of Myanmar?

By Myat Htoo Razak 29 January 2014

This week, the World Bank announced a US$2 billion pledge to Myanmar (Burma) to improve access to energy and health care. As a health worker, I am particularly excited about the $200 million pledge to help Myanmar achieve universal health coverage by 2030. If used strategically, $200 million can fill major gaps in access to quality health services for the majority of the people, especially those in states and regions with limited infrastructure.

Just a few days before this announcement, World Bank President Jim Yong Kim laid out his vision for universal health coverage at a conference in Washington, DC. Five fundamental lessons he shared on universal health care from 27 case studies will be very useful in developing a practical strategy to improve access to quality health care in Myanmar.

While commending the World Bank for taking this important step to provide an opportunity to improve two essential areas in Myanmar, I would like to share my thoughts and reflections on strengthening the health system in Myanmar as a member of the diaspora with deep roots there.

Health service delivery must include preventive, promotive and rehabilitative services in addition to treatment and care services. For example, access to quality care must not be limited to neurological and orthopedic services for patients who suffer road traffic injuries, but must address how to prevent road traffic injuries (e.g., vehicle safety, road construction, alcohol and drug intoxication among drivers, seat belt use) as well as rehabilitative services for those who are injured. The Myanmar Consumer Network, formed in December 2013, is trying to address food safety for consumers in collaboration with consumer activists, food industry entrepreneurs, technical experts and government agencies, as a part of efforts to promote health and prevent diseases. Safe water supply, proper sanitation, environmental protection, and appropriate regulation of tobacco, narcotics and alcohol use should be helpful actions for better health services in Myanmar. Access to quality health services must not be limited to the people in big cities and resource-rich divisions and regions but to the majority of people in all states and regions, in both rural and urban areas. Existing local, community-supported health service centers (for example, the Mudon Free Clinic in Mon State) must be taken into consideration as a part of efforts to improve health service delivery in the country.

The health care workforce must be developed and supported based on the needs of the country. As Jim Yong Kim mentioned in one of his fundamental lessons, it is essential to strengthen community and mid-level professionals that constitute the backbone of primary health care services, not just highly skilled professionals. The health workforce is made up of doctors, nurses, laboratory technicians, paramedics, administrators and others from governmental, multi-lateral institutions, INGOs, NNGOs and foundations.

Myanmar’s medical education system is based on the British model, similar to other countries once colonized by Britain such as India, Bangladesh, Sri Lanka, Singapore, Malaysia, Australia and many African countries including South Africa. Lessons learned from those countries in improving their health workforce through strengthening medical education and training programs will be very useful for Myanmar. Some African countries have been strengthening their medical education systems to improve quality, quantity and retention of health workers in Africa through support from the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the National Institutes of Health (NIH). African leadership is the main driver of the program, with collaboration from US universities. Myanmar can incorporate effective strategies and lessons learned from African partners in its plan to strengthen the health workforce.

The Department for International Development (DFID) from the United Kingdom and the Australian Agency for International Development (AusAID) can also be partners and co-funders in improving the health workforce in Myanmar. Japan has been a major supporter in providing advanced education and technical training for university faculty and health officials from Myanmar over the last few decades. Strengthening collaboration with Japan on technical and infrastructure enhancement for the health workforce will be an important strategy for Myanmar.

The participation and ownership of communities and civil society in strengthening health systems is one of the most important approaches to improve health services in a country. Jim Yong Kim’s example of the role of the AIDS Coalition to Unleash Power (ACT UP), an international direct action advocacy group, in revolutionizing HIV/AIDS prevention and care services including discovery and distribution of HIV/AIDS medications globally is one of the best examples that empowered civil societies and communities can and will make a difference in health and development of a country. Myanmar has many civil society and community groups that are capable and willing to participate and guide the country’s future in health and development. It will be important for them to have necessary support and independence for them to articulate perspectives and desires from their communities effectively to the government and decision makers without fear of retaliation, suppression or loss of funding.

Health information systems have to be strengthened for health workers, patients, administrators and policy makers in Myanmar. Information related to health must be accurate, current, relevant, and understandable. Myanmar also needs to strengthen its health legislation to improve all aspects of health protection and promotion, disease prevention and delivery of health care.

Medical products, vaccines and technology are essential parts of any health system. Domestic and international pharmaceutical companies play a major role in Myanmar’s health care services. Affordable quality medicine and health products, including diagnostic products, are much needed in Myanmar for the majority of the people. While trying to meet the demand for quality medicine and health products from private companies, the country will need to strengthen its own industry for affordable and quality products with help from other partners. Thailand, South Africa and Brazil could share their experience and lessons learned in producing generic medicines for people living with HIV/AIDS under major challenges. The newly established Food and Drug Administration in Myanmar needs support in establishing an independent and skilled regulatory workforce to register safe, quality and effective medical products and to monitor products on the market.

Historically in Myanmar, health financing has not been restricted to the government’s health budget. Most of the health care spending in Myanmar has been out of pocket spending. The people of Myanmar are very generous in donating to good causes. There are many private foundations and groups such as the Sitagu Sayadaw’s foundation, Free Funeral Services Society and the Muslim Free Hospital, which provide free medical and social services for those in need with a substantial amount of funds from private donations.

Donor coordination is one of the most important fundamentals in development assistance to emerging countries. The need to coordinate donor assistance appears frequently as a recommendation in donor reports; however, true and comprehensive donor coordination is rare. Rwanda recently demonstrated that effective donor coordination under a country-led approach can yield impressive results in improving health services. Effective implementation of a practical donor coordination strategy in Myanmar among several international partners/implementers is important in improving universal health coverage in Myanmar. Myanmar has seen increasing number of partners/donors in the last few years. For example, the European Union announced €150 million (US$205 million) in new assistance for 2012 and 2013, including the areas of health and education. Other European and Scandinavian countries, Asian partners, the United States, Israel and Australia are on the list of donors in Myanmar. Many of them have health as a main area of focus in their donor profile. It will be important for Myanmar and the donors to work together to enhance complementary approaches among donors.

Leadership/governance has always been a key cornerstone in improving health services. Leadership and governance is not just for the Ministry of Health or governmental agencies. Strong and effective leadership and governance applies to every organization and community including international and multilateral agencies such as the World Bank. One of Jim Yong Kim’s fundamental lessons was that “strong national political leadership and long-term commitment are required to achieve and sustain universal health coverage.” Myanmar has been going through a major transition recently in political leadership and governance in recent years. Despite optimistic expectations from the international community and the people in Myanmar, nobody knows the outcomes and consequences of the upcoming 2015 general election. The holders of the executive, legislative and judicial bodies will set the course of leadership and governance in Myanmar, and in turn will have a major impact on access to quality health services for the people of Myanmar. Access to quality health services will be a major determinant for the economic and social development of the country. Therefore, it is essential for future governments of Myanmar to make access to quality health services for everyone in Myanmar their top priority.

There is an emphasis on “science of delivery” that refers to the focused study of the processes, contexts and general determinants of the delivery of public services and goods. It can be simplified as “how to deliver” but not “what to deliver.” Jim Yong Kim mentioned it as essential global knowledge needed to solve local problems.

How is the World Bank planning to incorporate and rely on experience and lessons learned from the people and health workers of Myanmar who have local “know-how,” experience and ideas to solve the problems, while also trying to bring in technical expertise from the international community?

Jim Yong Kim mentioned that Thailand successfully improved rural health services through providing incentives to attract and retain doctors in remote areas despite the loud objection of the World Bank Group. We hope that the universal health care approach in Myanmar will not fail in 2030 because Myanmar follows the World Bank’s advice. Instead, we would like to hear that Myanmar successfully implements and sustains universal health care for the whole country while maintaining full ownership of the country, in collaboration with different regional and global partners including the World Bank.

The people of Myanmar have articulated that they want assistance that will help them to help themselves. They are smart, brave, proud and practical. Although they know that they need to learn from others to catch up, and to become a contributing member of the global community, they are ready and willing to bring their experience, skills and know-how to make it work in their own communities.

Let’s hope that the World Bank’s pledge will contribute effectively in improving access to quality health care for everyone in Myanmar. Let’s hope that this journey will lead to a mutually beneficial experience for communities, health workers, governmental and international agencies, and everyone involved in the process—and especially for the people of Myanmar.

Myat Htoo Razak participated in the 1988 pro-democracy movement in Burma as a young medical doctor. He left Burma in 1989 and received training in health policy, epidemiology, and HIV/AIDS research and implementation in the United States. He has worked in Asia and Africa on HIV/AIDS research and program implementation as well as health systems strengthening and capacity building of health workers. He now lives and works in the United States on global health research capacity building and health systems strengthening. This article is his own opinion and does not represent any organization he has associated with.