Challenges Impede Development of Myanmar’s Public Health

By Tin Htet Paing 15 November 2017

YANGON — Myanmar’s de facto leader and State Counselor Daw Aung San Suu Kyi has repeatedly singled out the minister for health and sports as one of the few Cabinet members whose performance she has been consistently satisfied with since taking office nearly two years ago. Despite this praise, however, after decades of institutional neglect of public services by the military junta, the public health sector still regularly faces criticism for being understaffed and providing substandard care.

“The health status of the Myanmar population is poor and compares unfavorably with other countries in the region,” the Health and Sports Ministry acknowledged in its recently launched 2017-2021 National Health Plan.

Human resources constitute a critical input into the health system if it is to ensure access to quality care. For that reason, the plan cites a lack of human resources, skill imbalances, inequitable distribution of services, and difficulties in rural retention of medical personnel as being among the ministry’s main challenges.

Myanmar’s key health care performance indicators — maternal mortality ratio (MMR) and life expectancy at birth — are among the worst in Southeast Asia, according to World Health Organization (WHO) data.

The MMR is the annual number of female deaths per 100,000 live births from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes). It includes deaths during pregnancy, during childbirth, and within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy. The column chart below shows the MMR ratios (2015) of ASEAN countries, with Myanmar’s being the second highest in the region.

Small Budget Allocation  

Health care spending accounts for just 5.23 percent of Myanmar’s total budget for the 2017-18 fiscal year, which is an improvement over past years but still extremely low by global and regional standards. The charts below show the comparison of Asean countries’ health expenditure and the Myanmar government’s budget allocation on health and sport, and defense. 

Uneven Distribution of Health Care Workers

According to the ministry, there were 1.33 health workers (doctors, nurses and midwives) per 1,000 people – well below the WHO’s minimum recommended threshold of 2.3 – as of November 2016. In terms of distribution, health workers were largely concentrated in Yangon, Mandalay and other urban areas.

The map below shows the distribution of health care workers and health facilities throughout the country according to data from the ministry. The darker shade represents a higher population per hospital bed.

The chart below shows the uneven distribution of doctors throughout the country, both in the public and private sectors.

The main reasons most health workers don’t want to work in rural areas are: a lack of incentives, including very low salaries, from the government; lack of health facilities; and the challenge posed by a low ratio of health workers to patients, according to doctors working at public hospitals who talked to The Irrawaddy on condition of anonymity.

Such a challenging work environment allows no study time, they said. Many medical personnel who wish to become specialist physicians must concurrently prepare to apply for graduate programs while completing their required public service, said a 25-year-old assistant surgeon at Yangon’s Insein General Hospital.

“If the government sends me to a rural area, I won’t go until I have completed the process of becoming a specialist with a graduate degree, and no longer need to spend time studying,” she told The Irrawaddy.

The assistant surgeon said her only aim in working at a government hospital was to complete the service needed to qualify for a graduate course and become a specialist.

Shortage of Personnel, Despite Student Intake

Five medical universities across the country admit a total of around 1,500 students per year, while two nursing universities in Yangon and Mandalay admit around 400 students each year. The chart below shows the number of undergraduate students produced by medical schools overseen by the Ministry of Health and Sports.

Low job satisfaction related to the poor working environment and low pay at public hospitals prompts some to join the private sector, said a 28-year-old doctor who recently joined a non-governmental organization that works in public health.

“With such an unbalanced ratio of human resources to workload, doctors can’t provide quality care to patients, which affects their profession’s image,” he told The Irrawaddy.

“As a result, the profession no longer enjoys the trust and respect that it once did from the public. This causes doctors to quit working in the public service and join the non-governmental sector,” he said.

The graph below shows the percentage of physicians who don’t contribute to the public health care sector after graduation for various reasons.

According to the ministry’s Nursing Department, the more than 1,000 public hospitals across the country require a minimum of 35,000 nurses. But about 43 percent of these nursing positions are vacant, with only about 20,000 nurses serving in government facilities.

Public/Private Sector Wage Differential 

Medical students have to invest seven years of their lives studying, including a year of house surgeon training, to obtain an M.B., B.S. degree, while nursing students spend four years studying for their B.N.Sc degrees. A medical graduate can expect to earn a minimum of 1,000,000 kyats (approx. US$800) at non-governmental organizations or UN agencies, but only 250,000 kyats (approx. US$185) at public hospitals. The chart below shows the basic salaries of physicians and nurses working at government facilities.