Dr. Si Thura, Executive Director of Community Partners International, reviews progress towards universal health coverage in Myanmar and identifies the key actions required to build the momentum needed to reach this goal.
In this period of reform, Myanmar has an unprecedented opportunity to achieve historic gains in advancing health for all. On Universal Health Coverage Day, I urge all of us who are involved in this cause to renew our efforts, and push forward progress so that we can reach every person with affordable, quality health care.
When the National League for Democracy (NLD) took office on 30th March 2016, there were high hopes of root-and-branch reforms of Myanmar’s key service sectors, moving away from a highly centralized model to a more agile and responsive public sector. The health sector was no exception.
In the NLD's 2015 Election Manifesto, the party laid out a Program of Health Reform: A Roadmap towards Universal Health Coverage in Myanmar (2016-2030). Universal health coverage (UHC) is defined as ensuring that all people have access to needed health services of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship.
This aspiration to attain UHC by 2030 was developed further in the National Health Plan (2017-2021), or NHP, launched on March 31, 2017. The NHP committed to strengthening the country’s health system and supporting the implementation of UHC. It is considered as the key policy document of the Ministry of Health and Sports (MoHS). The NHP was groundbreaking in its development process, inviting participation from a range of key stakeholders, including representatives of ethnic health organizations (EHOs). It recognized four types of health service providers - public, private, EHOs, civil society organizations (CSOs) and non-government organizations (NGOs).
The NHP focused on three key strategic priorities: expanding access to essential health services, reducing out-of-pocket costs, and the development of an equity-oriented health system. This focus on equity in health represented the first commitment of its kind made by a government in Myanmar for decades.
Attaining UHC in Myanmar is a noble and necessary aspiration. But what does this mean in practice? The World Health Organization (WHO)’s and World Bank’s monitoring framework defines the achievement target for UHC as reaching at least 80% coverage of essential health services, and 100% financial protection from catastrophic and impoverishing health payments. A third, and fundamental, measure of achievement is equity. Countries seeking to achieve UHC must ensure that poorer, less advantaged segments of the population are not left behind.
These targets powerfully illustrate the scale of the challenge facing Myanmar. After decades of under-investment, Myanmar’s health infrastructure and health workforce remain some way behind the levels required to achieve universal health coverage. The budget allocation for health has increased in recent years, rising from 1% of total government expenditure in 2010-2011, to 5.23% in 2017-2018. However, the majority of health expenditure in Myanmar is still covered by out-of-pocket payments (74% in 2016 according to World Bank data) and hundreds of thousands of people in disadvantaged communities have little or no affordable access to government-supported health services.
The MoHS started to roll out the NHP in March 2017 in the form of investment in a basic essential package of health services (EPHS) delivered initially in 78 townships and gradually expanded in 2018. The mid-point of the NHP five-year implementation term has now passed. While no formal mid-term review has been conducted, it is clear that progress has been mixed and that, after a promising start, momentum has slowed.
Reviewing the progress achieved, and the gaps that remain, I consider that the following three elements will be key to the achievement of the NHP (2017-2021) commitments, and will lay strong foundations for the attainment of UHC by 2030:
1. Investment in strengthening community-level health services
The NHP is distinctive because it recognizes the role of township health departments to identify gaps in the health system from the ground up. It emphasized the need to strengthen these township-level health systems as a key component to ensure the delivery of the basic EPHS. The NHP mandated the establishment of Township Health Working Groups (THWGs) with the participation of township health department officers, general practitioners (GPs) and representatives from EHOs and NGOs. These THWGs are responsible for overseeing the implementation of the annual township health plan by identifying needs and requesting resources from the state/regional and national level health authorities. They also play a role in monitoring and evaluating the township health plan and promoting the accountability of stakeholders.
As mentioned earlier, this initiative was developed as a phased approach, focusing first on 78 townships and then expanding, so as to make implementation more manageable. This phased, community-based approach is technically-sound, inclusive, practical and achievable. Firstly, the focus on strengthening service delivery at township level and below is important because the majority of Myanmar’s population lives in rural areas that have traditionally received less priority in terms of investment in health care. Secondly, health facilities and providers at township level and below are the gatekeepers of the health system. Strengthening the quality and availability of primary health care in rural areas is both technically and politically astute. Thirdly, well-equipped, well-resourced and high-functioning township health facilities can play a crucial role in mitigating the overburdening on the secondary and tertiary health sectors.
However, the roll-out of the THWGs and the implementation of the basic EPHS at township level and below has not proceeded as smoothly as planned. There is a need for clear guidance on how to craft township health plans, and how to ensure that THWGs are functioning as envisaged, in a fully inclusive and transparent way. Furthermore, fund allocation levels to help meet minimum standards in township-level health facilities have fallen short of commitments and so need to be increased to ensure that township health plans can be effectively implemented.
To help extend health services to rural communities, it is also necessary to develop a community-based health workers (CBHWs) program as soon as possible. This will require the drafting of standard operating procedures and guidelines for CSOs and NGOs operating under the stewardship of the MoHS. After receiving training, these CBHWs will be able to provide a package of integrated health services which can significantly improve access to primary health care for rural communities across Myanmar. Global evidence shows that these kinds of programs improve access to health care and generate high returns on investment. This program could be implemented swiftly and affordably throughout the country.
2. Improved Financial and Legal Frameworks to Support UHC
The increase in government investment and overseas development assistance alone will not be sufficient to resolve the challenges of low health service coverage, high financial risk, and inequities in access to care in the Myanmar health system. As the NHP acknowledges, Myanmar’s public sector does not have the capacity to reach the entire population of the country with the EPHS. Cooperation and engagement between the government and other health care providers (private, EHO, CSO, NGO) are essential to ensure full and equitable coverage and avoid duplication in service delivery. One major barrier to this engagement is financing. Current financial rules and regulation inhibit financing mechanisms through which the government can purchase health services delivered by other non-public care providers (strategic purchasing) Therefore, a supportive legal framework, or UHC Law, is necessary to allow the government greater flexibility in purchasing health services.
Despite significant increases in the allocation of total government expenditures for health, consistent underspending by the MoHS and other government ministries reveals challenges and bottlenecks in budgeting and expenditure processes. In the 2015-2016 financial year, MoHS expenditure fell 11.89% short of the original budget estimate. This rose to 15.26% in the 2016-2017 financial year (The Ananda, 2018). So, adjustments are needed to the public financial management system to support improved budgeting and the full use of allocated funds.
There is also an urgent need to diversify financing sources for health services in order to attain UHC. In June 2017, Myanmar’s House of Representatives introduced a motion, the Myanmar Health Insurance Bill, to establish a national health insurance system to help fund the health system and reduce households’ out-of-pocket expenditure on health care. However, the progress of this legislation has been slow and the motion has not yet passed into law. It is necessary to renew momentum behind the bill in parliament to enable the government to expand health financing options.
3. Recognition of the Ethnic Health Workforce
Although the NHP clearly articulates the need to recognize the ethnic health workforce, no tangible steps to do so have yet taken place. The NHP specified that the standardization of clinical skills would be one of the first steps towards recognition of EHO health workers. Therefore, standard operating procedures (SOPs) need to be developed in an inclusive way that provide a clear outline of the clinical competencies and skills required for the delivery of the service and interventions included in the basic EPHS. These SOPs need to be developed with clear roles and responsibilities for the different types of service providers, including EHOs. Simultaneously, it is necessary to establish a compatible accreditation mechanism to provide quality assurance of education and training of the ethnic health workforce.
In the context of Myanmar’s turbulent history, and in light of the continuing tensions as communities in Myanmar seek to achieve lasting peace, the recognition of the ethnic health workforce will be a concrete demonstration of the commitment to equity as a cornerstone of Myanmar’s future.