Executive Summary. xxii

Transcription

1 Executive Summary The total population of Myanmar was estimated at 51.9 million in 2010, with an annual growth rate of about 1%. There was no substantial growth in the country s per-capita gross domestic product (GDP) between 2000 and There are positive indications in Myanmar that the new government is working towards achieving macroeconomic stability. The people of Myanmar comprise over 130 ethnic groups. Life expectancy at birth increased for both males and females between 1980 and The top five causes of disability adjusted life years (DALYs) in 2010 were lower respiratory tract infections, tuberculosis, diarrhoeal diseases, Human immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome (AIDS) and stroke. New among the top 10 causes of DALYs in 2010 were HIV/AIDS, ischaemic heart disease, road injury and cirrhosis of the liver these require effective prevention policy. The top five risk factors are diet, tobacco smoking, household air pollution from solid fuels, high blood pressure, and high blood sugar. Noncommunicable diseases (NCDs) contribute to approximately 40% of deaths in Myanmar. NCDs and injuries generally rose between 1990 and 2010, while communicable, maternal, neonatal and nutritional causes of DALYs generally declined. Improvements in access to safe water and adequate sanitation have been reported. However, diarrhoea remains among the top five causes of death. There has been an increase in the child immunization coverage, a decline in infant mortality rate (IMR), under-five mortality rate (U5MR) and maternal mortality ratio (MMR). Myanmar has made some progress towards achieving its Millennium Development Goals (MDGs), but there is need for improvement to reach the 2015 targets. Nearly seven decades of internal conflict in Myanmar have harmfully affected the lives of hundreds of thousands of civilians. Myanmar is also prone to natural disasters: coastal regions exposed to cyclones and tropical storms, and the whole country at risk from earthquakes. Cyclone Nargis was the largest natural disaster in Myanmar s recent history. The Ministry of Health (MOH) is the major player in the health sector as a governing agency as well as a provider of comprehensive health care. However, many key players played increasing roles with the evolving political and administrative circumstances. Historically, the health system has been shaped by the five distinct periods of administrative regimes and xxii

2 political systems. The government used to be the main source of financing, with provision of services virtually free until user charges were introduced in the form of cost sharing in 1993; since then household out-of-pocket (OOP) payment has become the main source of finance. The health system comprises a pluralistic mix of public and private systems both in financing and provision. The Department of Health (DOH), one of the seven departments of MOH, is the service provider and also takes the regulatory functions of the Ministry in protecting the health of the people. The network of hospitals and health centres (which extends down to village level) provides preventive and curative services ranging from primary to tertiary care. Inadequate managerial capacity and the lack of proactive mind-set among health workers at local level (inherited from the previous political environment) are challenges that need to be overcome to make decentralization smooth and effective. The National Health Plan (NHP) remains an integral part of the comprehensive national development plan. Successive NHPs have been developed taking into consideration health needs and the policy and developmental context of the country, the need to honour various international commitments, the determinants of health, and the need to build a strong health system. The National Health Committee (NHC) is a high-level interministerial policy-making body concerned with health matters. NHC played an instrumental role in providing the mechanism for intersectoral collaboration and coordination. However, there is no formal coordinated social protection mechanism to prevent families from falling into poverty as a result of health payments. Only a small proportion of formal-sector workers are covered by the current formal social-security system. The government has started to take the initiative to introduce formal social protection in the country and MOH is in the process of piloting and introducing some community-based and demand-side approaches as interim measures while the Social Protection System is in the developmental stage. The current Health Information System comprises hospital, public-health, human-resources and logistic information. The Central Epidemiology Unit of the DOH is a national focal point for communicable-disease surveillance and response, responsible for disease surveillance. Health technology assessment is an area in which the health sector needs capacity development. The DOH is the main organization designated to regulate health-care providers, pharmaceuticals, medical devices and aids, and capital investment. Previous political situations and restrictions made patient empowerment more of a concept than practice. xxiii

3 Total health expenditure in Myanmar, % of its GDP between 2001 and 2011, is the lowest among countries in the World Health Organization (WHO) South-East Asia and Western Pacific Regions. General government health expenditure (GGHE) as a percentage of general government expenditure (GGE) is low, at 1% between 2003 and GGHE as percentage of GDP amounted to % over the same period. GGHE as a percentage of GDP and of GGE in , increased significantly to 0.76% and 3.14%, respectively; however, this level of health investment is still low compared to the demand for health care. The statutory financing system is very limited: only 1% of population is covered by Social Security Scheme, spending by Social Security was low at 1.3% of GGHE. Inadequate government expenditure on health care over the past decade resulted in high OOP payments by households, which became the dominant source for financing for health care (accounting for 79% of total health expenditure). Expenditure by other ministries on medical care for their employees is small; while donor contributions remain substantial, at 7% of total health expenditure in 2011 (half what the government spends on health). As a result of economic sanctions, official development assistance has been relatively low compared with other developing countries, and was channelled through global partnership programmes; (this is changing rapidly, however). Aid flows increased in the late 1990s and peaked in 2009 and 2010 in response to Cyclone Nargis. Challenges emerged at that time as donor funding was managed by nonstate actors through numerous parallel programmes often not in line with government policy priorities and not sustainable in the long term. Donations by households and communities for health care and support to the poor are often inadequate to meet the high demand. The 2012 Social Security Law providing comprehensive social and health protection for formal-sector employees is an important milestone, yet challenges remain on how the government will introduce financial-risk protection for the majority of the population who are poor and those engaged in the very large informal sector. The provision of universal access to free essential generic medicines is an immediate step in moving closer to universal health coverage. Measures, including tax reforms, are needed to expand the fiscal space and enhance government expenditure on health. All categories of public-sector health workers are government employees. While salaries are low in relation to the cost of living standards, self-motivation and earnings from secondary jobs (clinical or nonclinical) are the main incentives keeping them in government service. There has been an increase in the number of public hospitals since the early 1990s, in total an additional 140. Ayeyawady Region has invested in hospitals the most, followed by Sagaing Region; however, there was no change in the xxiv

4 number of hospitals in Chin State. Coinvestment by the local community contributions in building rural health centres (RHCs) and sub-rural health centres (Sub-RHCs) is widely practised. The number of private hospitals increased within this decade, but at a lower rate than public hospitals. Hospital equipment is usually provided by the government budget and MOH s share of government expenditure was increased four-fold in The recruitment of doctors, nurses and midwives has been increasing since the early 1990s, but has not yet reached the global benchmark of 2.28 doctor, nurse and midwife per 1000 population. There is also underproduction of dental surgeons, pharmacists and technicians as compared to doctors and nurses. In order to improve the health workforce situation in the public sector, a Human Resources for Health Master Plan was prepared in 2012 for the next years. Voluntary health workers from the community have been recruited and trained since the 1980s, using multiple sources of public and non-government funds. Even though there is some attrition, training and assigning community health workers (CHWs) on special jobs by vertical programmes and providing social recognition, moral support and incentives to CHWs and auxiliary midwives have motivated them to remain as voluntary health personnel for the benefit of their own communities. The existing health management information system (HMIS) needs to be strengthened, and an e-health care system developed from primary level to tertiary hospitals. The MOH is determined to deal with communicable diseases, NCDs and the high burden of maternal mortality in the country. The DOH is mainly responsible for the management of public health activities through various national programmes and implementation in collaboration with development partners, civil service organizations and community-based organizations. Public health services in Myanmar are delivered to the communities by RHCs and Sub-RHCs through corresponding township, district, and region and state health departments that provide technical assistance and support. Campaigns and implementation of specific national programmes such as those for tuberculosis, malaria, HIV/AIDS, leprosy, and prevention of blindness are systematically delivered at all levels. Maternal and child health (MCH) services and prevention of vaccinepreventable diseases through the expanded programme on immunization are delivered together with nutrition promotion, health education and environmental sanitation services in the community. While the disease surveillance system is well established in the public sector, there is still room for improvement in getting information from the private sector. International health regulation core capacities have been strengthened at eight points of entry into the country, but there are gaps in human-resource xxv

5 and infrastructure development. There will be more challenges in this area with the development of a new airport, sea ports and cross-border projects. Occupational hazards are managed by the Occupational Health Department. Services provided for NCDs not only cover treatment, but also prevention, control, and reduction of disease, disability and premature deaths due to chronic disease and conditions. Primary ambulatory care is usually provided by all outpatient departments at the hospitals, urban health centres, MCH centres, school health teams, RHCs and Sub-RHCs that handle outpatient care. Emergency, specialized ambulatory and specialized inpatient care are handled by the hospitals at all levels according to their capacity. Specialized inpatient care is conducted in both public tertiary hospitals and private specialist clinics and hospitals. The Central Medical Store Depot procures and distributes medicines to hospitals all over the country, but supplies are insufficient; management of the supply chain needs to be strengthened. Meanwhile, private pharmacies and drug stores are reaching consumers, who then incur OOP expenses. The country has institutional care like homes for long-term care of the aged and also community-based care by volunteers implemented in over 150 townships supported by Help Age Korea, and DOH is implementing an elderly health care project in another 150 townships opening weekly clinic for care the elderly at the RHC level. Though dental care is based on clinical institutional care, it is also concerned with public health where oral health programmes are conducted in schools for schoolchildren. Traditional medicine of Myanmar also has an important agenda as regards service delivery as many rural people still rely on traditional herbal medicines. Expansion of the health system, with the networks of public hospitals, RHCs, Sub-RHCs and urban health centres, was most vibrant between the 1970s and 1990s. The health system can also be judged by its success stories: eradication of smallpox, elimination of leprosy, trachoma, poliomyelitis and iodine-deficiency disorders. The first in the series of reforms implemented since the 1990s was on improved access to essential medicines and the introduction of different financing mechanisms to recover and replenish the costs. Reforms in other health-financing mechanisms were added (e.g. Revolving Drug Fund, hospital trust funds, community cost sharing including exemption for the poor, and community donations) in all public hospitals. Some of these financing mechanisms continue today. Initially, these mechanisms aimed at ensuring continuous replenishment of essential medicines by mobilizing resources from households and communities in the face of insufficient government funding. Later the mechanisms were extended by introducing exemption for the poor and supporting them through other mechanisms like trust funds, xxvi

6 health equity funds, to offer protection from financial burden. However, these interventions are not able to raise sufficient revenues to replenish the medicines, or to reduce the OOP expenses and financial burden of the poor. The work of the RHCs since the early 1970s has been focused on externally assisted programmes, concentrated in selected townships and only for specific programme priorities, such as tuberculosis, malaria and HIV, and reproductive health. Thus, those townships without any donorsupported programmes had to concentrate on their routine activities with little technical, financial or material support. With the low salary paid to health workers, the staff in these areas started dual-practice in their offhours as private practitioners. Major improvements in the health status of the population are crucial for inclusive growth. Public budget allocation for health has increased considerably in the last few years. However, no relevant data are available on how much of this increase has resulted in significant improvement in equity and access to health services. Donorcoordination and fund-support mechanisms have evolved into integrated programme management with the principle of Oneness in line with the Paris Declaration on Aid Effectiveness, but more effort is needed. The challenges of Myanmar are to overcome the limitations of the past (e.g. low investment in rural health services), inadequate funding for expansion of universal health coverage, and possible use for health of the funds generated from revenue on extracting natural resources. New opportunities should also be explored for filling the fiscal spaces in the national budget, and for increasing investment in rural health facilities. In the context of the aspirations to improve the health status and prolong the lives of the people, the National Health Policy and National Health Development Plans ( ) have the achievement of universal health coverage as an overarching objective, with building an effective and equitable health system and addressing determinants of health as important and ambitious objectives. However, emphasis on political stability and economic growth over social development has made the health-forall policy merely a concept. Following the changes in the political and economic environment and the introduction of health-financing reforms in the form of introducing user charges, household OOP spending on health care (and the imperfect nature of the healthcare market) became a dominant part of health service provision, hampering access by the poor who cannot afford to pay. Measures taken to protect the poor were also not effective. With the market becoming a dominant mode of health service provision, some health professionals are more oriented towards making profit. Change in the behaviour of these health professionals, especially doctors, has eroded a once harmonious relationship with patients that xxvii

7 nurtured in the traditional cultural context. Despite the policy to expand services to the rural and border areas, available evidence indicates the existence of disparities in access to and utilization of health services. Utilization of services depends on capacity to pay for medical care and transport cost rather than health need. Both communicable diseases and NCDs were identified as major causes of mortality, with tuberculosis and cardiovascular diseases as the most common causes of deaths. In the face of formidable social and economic challenges, gains in combating major communicable diseases are noteworthy and attributable to the health system. The expansion of health care facilities and adequate staffing with appropriate skill mix to address population health needs require further strengthening. Evidence indicates that the allocative and technical efficiencies of resource allocation are still inadequate. Transparency and accountability are needed in the context of the previous overwhelming domination of socialist ideology, while the historical autocracy and lack of consumer sovereignty are challenges in the current market economy. There had been a substantial gap between policy objective, effective implementation and outcomes. Reform measures initiated by the elected civilian government and recent increase in government spending on health foster new hope for the health system to become well functioning and fair, though it is a long journey to reach that goal. Formation of Regional and State Legislatures and Governments under the new 2008 Constitution raises expectations and a prospect for more decentralization. The central authority at MOH in the future will have to assume the functions of setting rules and standards. Regional/State and local health departments could then take on monitoring and enforcement roles as well as service provision and management of health workforce. Such decentralization would require massive capacity development at local levels. Addressing health inequities is of paramount importance for Myanmar, needing a major reform that will ensure health care services reach the poor and the disadvantaged groups, in particular minority groups and in conflict-affected and hard-to-reach areas, through the effective functioning of township health system. From an equity perspective, the move towards primary health care concepts and practices is a step in the right direction: strengthening RHCs, Sub-RHCs and station hospitals in rural areas rather than upgrading secondary and tertiary urban hospitals is a correct route to improve equity in health care, as these primary health care close-to-client services are better accessed by the vast majority poor rural people. xxviii