TY - JOUR
AU - Zhao,, Yingxi
AB - Abstract Civil wars, political conflicts, ethnic issues and stagnant social development have resulted in fragile health systems in Northeastern Myanmar. The healthcare provision continues to be fragile and inefficient, with prevalent health inequity. Limited service point, poor financial protection mechanism and gender-based inequity restrain the population’s access to healthcare services, not to mention local authority’s lacking participation in the making, implementation and evaluation of health policies. The issuance of the National Health Plan (NHP) 2017–2021 brought huge potential for the ethnic health organizations to strengthen the health system in ethnic regions. The present study aims to audit the local health systems and their performance in Northeastern Myanmar ethnic region through qualitative data collected by 26 semi-structured interviews and seven focus group discussions with key informants including health officials, policymakers, international donors, ethnic authority/government officials, local clinic managers/staff and health workers, non-governmental organizations, private outlets, etc. The findings indicated that challenges exist within each pillar of the health system. To achieve universal health coverage in the ethnic regions, health system alignment and decentralization is needed. Health system strengthening could serve as both an urgent need and also a way of peace building. Health system, ethnic minority, Myanmar, conflict, evaluation Key Messages Fragile health system contributed to poor statistics in post-conflict Myanmar ethnic regions. Challenges exist within each pillar of the health system in Northeastern Myanmar. Health system alignment and decentralization is needed for universal health coverage. Introduction Since the historic Panglong conference in 1947 and the independence of Myanmar from the United Kingdom in 1948, Myanmar has witnessed some of the longest civil wars in modern history. Numerous small militia groups still operate in the border areas, and over 20 ethnic armed organizations (EAOs) control parts of the country, primarily in remote and frontier regions (The Asia Foundation, 2014a). Despite a nationwide ceasefire agreement (NCA) has been drafted and signed by some of the EAOs, frequent conflicts between other EAOs and government forces that occur in Kachin, Karen and Shan States impede with negotiating settlements and reaching regional peace. The ongoing conflict leads to Myanmar’s notably substandard health statistics, and the health statistics in the ethnic conflict areas is even worse. In 2012, the infant mortality rate of Myanmar was recorded as 41 per 1000 live births, more than four times the rate of Thailand. However, the national data did not include data from the conflicted areas, which presumably will result in a higher rate if accounted for. Survey from Myanmar–Thailand border indicated an infant mortality rate and under five mortality rate as high as 94.2 and 141.9 per 1000 live births, and a maternal mortality rate of 721 per 10 000 live births (The Health Information System Working Group, 2015; Wang et al., 2016), two to three times the average rate of Myanmar. The poor-functioning health system in the border area is one of the key reasons for the notoriously poor health indicators. The health system in the special regions experienced complex changes along with continuously turbulent political situations. In the 2008 Constitution, leading bodies of the ‘Self-Administered Zones’ and the ‘Self-Administered Divisions’, according to the Schedule Three, are legislated to be responsible for a series of civil affairs, including urban and rural projects, development affairs, preservation of natural environment, etc. and also public health (Constitute Project, 2008). However, due to relatively weak capacity in public health of the health authorities of EAOs [also refer to as ‘Ethnic Health Organizations (EHOs)’] and extremely limited resources, the healthcare provision continues to be fragile and inefficient, with prevalent health inequity. Limited service point, poor financial protection mechanism and gender-based inequity restrain the population’s access to healthcare services (Tang et al., 2017), not to mention local authority’s lacking participation in the making, implementation and evaluation of health policies. Different health services providers co-exist with limited resources in the ethnic regions, including EHOs, Ministry of Health and Sports (MoHS), international organizations and private sectors. The issuance of the NHP 2017–2021 brought huge potential for the ethnic regions to accelerate health improvement. With ‘universal health coverage by 2030’ as its goal, the NHP aims to extend access to Basic Essential Package of Health Services for the entire population by 2020 while increasing financial protection (Myanmar Ministry of Health and Sports, 2016). The highlight of this NHP is its all-inclusiveness, which is listed as one of its guiding principles. This is also the first time the MoHS mention EHOs as a key stakeholder in its official documents, which indicated the possibility of the Ministry’s willingness to acknowledge ethnic minorities’ health organization as important service provider in hard-to-reach region. According to the NHP, EHOs are planned to be actively involved in not only service provision, but also the planning and monitoring, evaluation process at township level (Myanmar Ministry of Health and Sports, 2016). Another positive sign for ethnic health system strengthening is Myanmar’s increasing effort towards decentralization. The process of decentralization process started since the 2008 Constitution, including but not limited to the new State and local governance structure, transfer of administrative, fiscal and political decision-making into lower level of administration (WHO, 2014; The Asia Foundation, 2015). Within the health sector, decentralization includes decentralization of antiretroviral therapy (ART) services through establishing decentralized testing and ART sites at peripheral levels (UNAIDS, 2015; PEPFAR, 2016); strengthening of basic health staff capacity, the local health workforce at rural areas who are trained at region and states instead of national medical institutions (The Asia Foundation, 2014b); as well as the concept of inclusive township health plan (ITHP) mechanism that aim to ensure public and different stakeholders’ participation in the health planning process. The present study aims to audit the health systems and their performance of EHOs in selected ethnic-controlled, government-controlled or mixed-controlled area along the Myanmar border area and identify key challenges faced by the ethnic health systems in achieving universal health coverage. Using data from 26 semi-structured in-depth interviews and seven focus group discussions, the result of this study is referential for understanding the status quo and challenges faced by ethnic health system in Myanmar and also other conflict settings. Methods Study settings and participants Data were collected from four special regions on the Myanmar–China border area, as shown in Figure 1 (Kachin State Special Region 1 and 2, Shan State Special Region 2 and Eastern Shan State Special Region 4, Myanmar; Burma News International, 2016). The political context varies for each of the special region. Kachin State Special Region 2, which is governed by the Kachin Independence Organization has experienced continuous armed conflict with the government. There has been displacement of approximately 90 000 people from over 100 villages. Based in the de facto capital Laiza, the organization governs the area through a civilian body called the Kachin Independence Council, with 12 departments under it, including health. The other region in Kachin state, Kachin State Special Region 1 was formerly governed by the New Democratic Army (Kachin) (NDA-K), and later the organization was transformed into Border Guard Forces (BGFs), which currently has stopped providing social services for the local population and primarily focuses on business and trade. As for the two special regions in Shan State, both regions are currently under control of EAOs that are in peace with the government but have not yet signed the NCA. The Wa self-administered region was designated as an autonomous area called Shan State Special Region 2 when it signed its first ceasefire agreement in 1989. The region is now under the control of the United Wa State Party (UWSP), therefore inaccessible to the government. In 2009 and 2010, the UWSP rejected the requests by the government to transform its armed forces into BGFs and for the party to register for the 2010 national elections. Eastern Shan State Special Region 4, which was authorized by the National Democratic Alliance Army, has a similar condition with Shan State Special Region 2 (The Asia Foundation, 2014a; Burma News International, 2016). Study participants were recruited from EHO officials, local health workers, private outlets, community members, non-governmental organizations (NGO), international donors, etc. in the above-mentioned special regions. Since there is a parallel service delivery system in Shan State Special Region 2 and Eastern Shan State Special Region 4, health workers from the central MoHS were also recruited. Data collection This is a descriptive and explanatory qualitative study that used semi-structured in-depth interviews and focus group discussions for data collected. Interviews and discussions were conducted in the local languages, Chinese or English (where applicable) by the research team. A total of 26 semi-structured interviews and 7 focus group discussions were conducted. The fieldwork took place from June 2016 to January 2017. The questions for interviews and focus group discussion are revised from the Health Systems 20/20's Health System Assessment Manual, which covers the six building blocks of the health system (governance, finance, human resource, information, medical products and service delivery; Health Systems 20/20, 2012). The questions also include the current political context and peace-process in relation to the health system strengthening. Data management and analysis Interviews and focus group discussion with the participants typically lasted from 35 to 90 min while discussion with the NGOs lasted from 60 to 150 min. All interviews and focus group discussions were audio-recorded and transcribed and translated into English, and analysed by the lead researcher using the theme analysis and coding approach. Two individual research team members conducted a close reading of each transcript individually and coded them for basic important themes that emerged from the interviews and focus group discussion under the six building blocks. An across-case coding procedure was further conducted to identify shared themes across multiple respondents focusing on key issues mentioned by respondents. A matrix of themes and codes for further comparison and consolidation were created, and respondent quotes were selected together by the two members for presentation that could reflect the key dimensions of each major theme. Results A total of 55 participants took part in the in-depth interviews and focus group discussions, including 15 local health workers, 14 NGO staffs, 3 international donors, 7 ethnic authority/government officials, 1 private outlet and 15 community members. The local health workers include doctors, nurses and community health volunteers recruited by the EHOs (in Kachin State Special Region 2, Shan State Special Region 2, Eastern Shan State Special Region 4), as well as township medical officer (TMO) and nurses recruited by the central MoHS (in Kachin State Special Region 1, Shan State Special Region 2, Eastern Shan State Special Region 4). The NGOs staffs were recruited both from the international and local organizations working on health. The community members include those residing in both villages as well as refugee camps. The distribution of interviews and focus group discussion with respect to the study sites and participants category is shown in Table 1. Table 1. Number of interviews and focus group discussion, by study site and participant category Study site Interviews Focus group discussion Kachin State Special Region 1 One ethnic government official One discussion (with four NGO staffs) Three local health workers Kachin State Special Region 2 Two ethnic government official Two discussions (with three NGO staffs; nine community members) Four local health workers One international donor Shan State Special Region 2 Two ethnic government official Two discussions (with three NGO staffs; three community members) Four local health workers Two international donor Eastern Shan State Special Region 4 Two ethnic government official Two discussions (with four NGO staffs; three community members) Four local health workers One private outlet Total 26 7 Study site Interviews Focus group discussion Kachin State Special Region 1 One ethnic government official One discussion (with four NGO staffs) Three local health workers Kachin State Special Region 2 Two ethnic government official Two discussions (with three NGO staffs; nine community members) Four local health workers One international donor Shan State Special Region 2 Two ethnic government official Two discussions (with three NGO staffs; three community members) Four local health workers Two international donor Eastern Shan State Special Region 4 Two ethnic government official Two discussions (with four NGO staffs; three community members) Four local health workers One private outlet Total 26 7 View Large Table 1. Number of interviews and focus group discussion, by study site and participant category Study site Interviews Focus group discussion Kachin State Special Region 1 One ethnic government official One discussion (with four NGO staffs) Three local health workers Kachin State Special Region 2 Two ethnic government official Two discussions (with three NGO staffs; nine community members) Four local health workers One international donor Shan State Special Region 2 Two ethnic government official Two discussions (with three NGO staffs; three community members) Four local health workers Two international donor Eastern Shan State Special Region 4 Two ethnic government official Two discussions (with four NGO staffs; three community members) Four local health workers One private outlet Total 26 7 Study site Interviews Focus group discussion Kachin State Special Region 1 One ethnic government official One discussion (with four NGO staffs) Three local health workers Kachin State Special Region 2 Two ethnic government official Two discussions (with three NGO staffs; nine community members) Four local health workers One international donor Shan State Special Region 2 Two ethnic government official Two discussions (with three NGO staffs; three community members) Four local health workers Two international donor Eastern Shan State Special Region 4 Two ethnic government official Two discussions (with four NGO staffs; three community members) Four local health workers One private outlet Total 26 7 View Large The main themes that emerged from the study were: poor health system planning with poor implementation; health financing highly depend on out-of-pocket payment and international aid; insufficient amount of qualified health workforce; limited capacity in information collecting, reporting and analysing; lack of essential drugs as well as standardized guideline; and low coverage of health services with limited functions. The themes will be further explored in detail in the paragraphs that follow, and are supported by quotes from the interviews and focus group discussions from the different groups of study participants. Description of the themes by health system building blocks and region is shown in Table 2. Table 2. Matrix of health system challenges with high impact and urgency by pillars and governance structure Governance Finance Human resource Information Medical products Service delivery Central Government Dominant (Kachin State Special Region 1) Poor policy implementation The replacement of governance from EHO to central government is slow No special funding allocated to remote communities or in extreme poverty Designated human resource not in place Language barrier and distrust limit the health service of doctors from Myanmar Ministry of Health and Sports Incomplete information system and private sector’s absence in the information system Failure in the planning of drug purchase Inappropriate supply chain and transportation of vaccine Limited resource and huge workload leads makes outreach activities and health education impossible Inadequate quantity of service delivery point EHO Dominant (Kachin State Special Region 2) Lack of management personnel lead to poor policy implementation Health budget flows to short-term medical education, drug purchase and transfer, and neglecting public health expenditure Low retention rate of health workers Conflict leads to poor quality of information Limited analysis towards information Information system depend on NGOs Severe bottleneck in terms of drug procurement and stocking system Low coverage of health services Weak supervision over service delivery of the private sector and in remote area Co-existence model (Wa region and Shan State Special Region 4) Low priority on health in the government’s policy Weak capacity of health management No budget system, existing tiny budget flows to military /officials Commercial operation of hospitals No funding for population in extreme poverty Absolute lack of health worker Community volunteer failed to mobilize the community Poor quality of private sector Sub-qualified training Policymakers failed to conduct quality control and analysis towards information system Use of Chinese drugs without standardized guideline, leading to antibiotic misuse and excessive infusion Lack of anaesthetics Scattered health service delivery system Poor quality of primary healthcare, and no regulation towards service delivery Governance Finance Human resource Information Medical products Service delivery Central Government Dominant (Kachin State Special Region 1) Poor policy implementation The replacement of governance from EHO to central government is slow No special funding allocated to remote communities or in extreme poverty Designated human resource not in place Language barrier and distrust limit the health service of doctors from Myanmar Ministry of Health and Sports Incomplete information system and private sector’s absence in the information system Failure in the planning of drug purchase Inappropriate supply chain and transportation of vaccine Limited resource and huge workload leads makes outreach activities and health education impossible Inadequate quantity of service delivery point EHO Dominant (Kachin State Special Region 2) Lack of management personnel lead to poor policy implementation Health budget flows to short-term medical education, drug purchase and transfer, and neglecting public health expenditure Low retention rate of health workers Conflict leads to poor quality of information Limited analysis towards information Information system depend on NGOs Severe bottleneck in terms of drug procurement and stocking system Low coverage of health services Weak supervision over service delivery of the private sector and in remote area Co-existence model (Wa region and Shan State Special Region 4) Low priority on health in the government’s policy Weak capacity of health management No budget system, existing tiny budget flows to military /officials Commercial operation of hospitals No funding for population in extreme poverty Absolute lack of health worker Community volunteer failed to mobilize the community Poor quality of private sector Sub-qualified training Policymakers failed to conduct quality control and analysis towards information system Use of Chinese drugs without standardized guideline, leading to antibiotic misuse and excessive infusion Lack of anaesthetics Scattered health service delivery system Poor quality of primary healthcare, and no regulation towards service delivery View Large Table 2. Matrix of health system challenges with high impact and urgency by pillars and governance structure Governance Finance Human resource Information Medical products Service delivery Central Government Dominant (Kachin State Special Region 1) Poor policy implementation The replacement of governance from EHO to central government is slow No special funding allocated to remote communities or in extreme poverty Designated human resource not in place Language barrier and distrust limit the health service of doctors from Myanmar Ministry of Health and Sports Incomplete information system and private sector’s absence in the information system Failure in the planning of drug purchase Inappropriate supply chain and transportation of vaccine Limited resource and huge workload leads makes outreach activities and health education impossible Inadequate quantity of service delivery point EHO Dominant (Kachin State Special Region 2) Lack of management personnel lead to poor policy implementation Health budget flows to short-term medical education, drug purchase and transfer, and neglecting public health expenditure Low retention rate of health workers Conflict leads to poor quality of information Limited analysis towards information Information system depend on NGOs Severe bottleneck in terms of drug procurement and stocking system Low coverage of health services Weak supervision over service delivery of the private sector and in remote area Co-existence model (Wa region and Shan State Special Region 4) Low priority on health in the government’s policy Weak capacity of health management No budget system, existing tiny budget flows to military /officials Commercial operation of hospitals No funding for population in extreme poverty Absolute lack of health worker Community volunteer failed to mobilize the community Poor quality of private sector Sub-qualified training Policymakers failed to conduct quality control and analysis towards information system Use of Chinese drugs without standardized guideline, leading to antibiotic misuse and excessive infusion Lack of anaesthetics Scattered health service delivery system Poor quality of primary healthcare, and no regulation towards service delivery Governance Finance Human resource Information Medical products Service delivery Central Government Dominant (Kachin State Special Region 1) Poor policy implementation The replacement of governance from EHO to central government is slow No special funding allocated to remote communities or in extreme poverty Designated human resource not in place Language barrier and distrust limit the health service of doctors from Myanmar Ministry of Health and Sports Incomplete information system and private sector’s absence in the information system Failure in the planning of drug purchase Inappropriate supply chain and transportation of vaccine Limited resource and huge workload leads makes outreach activities and health education impossible Inadequate quantity of service delivery point EHO Dominant (Kachin State Special Region 2) Lack of management personnel lead to poor policy implementation Health budget flows to short-term medical education, drug purchase and transfer, and neglecting public health expenditure Low retention rate of health workers Conflict leads to poor quality of information Limited analysis towards information Information system depend on NGOs Severe bottleneck in terms of drug procurement and stocking system Low coverage of health services Weak supervision over service delivery of the private sector and in remote area Co-existence model (Wa region and Shan State Special Region 4) Low priority on health in the government’s policy Weak capacity of health management No budget system, existing tiny budget flows to military /officials Commercial operation of hospitals No funding for population in extreme poverty Absolute lack of health worker Community volunteer failed to mobilize the community Poor quality of private sector Sub-qualified training Policymakers failed to conduct quality control and analysis towards information system Use of Chinese drugs without standardized guideline, leading to antibiotic misuse and excessive infusion Lack of anaesthetics Scattered health service delivery system Poor quality of primary healthcare, and no regulation towards service delivery View Large Poor health system planning with poor implementation Due to different political scenario, the organization of the health system varies in each special region. In Kachin State Special Region 1, the health system is governed solely by the central MoHS; In Kachin State Special Region 2, the health system is under the governance of ethnic authority; while in Shan State Special Region 2 and Eastern Shan State Special Region 4, the health system is governed in parallel by the ethnic authority and MoHS. Despite the governance difference, participants across the sites strongly perceived that the health system planning and regulation is weak and the poor policy implementation leads to severe health inequity. For the local health workers who work for the MoHS, the TMO is considered as the sole person responsible for the health system within the township. However, since TMOs also serves as the service provider within the special regions, and that there has been political tension between the central government and ethnic authorities, TMOs himself/herself is barely involved in the policymaking and regulation process. Usually the MoHS will send people to negotiate with the ethnic authorities. The Ministry used to send people to meet with the ethnic authority to discuss collaboration, and it happened five to six times in 2015. However, the ministry does not directly support funding for local health plan. The major barrier is the peace talk (R15). While for the ethnic authorities, only one out of three has made its own health plans and strategies, but a top-down manner that fails to account for wider range of representatives (community groups, private sector, etc.). However, these plans were not used to guide their decisions about resource allocation and performance measurement on health impact, and there is no regulatory system to ensure that the policymaking process is based on scientific evidence. The periodic review of health plans was included in the plan, yet it was not actually implemented. We (as an NGO) assisted the ethnic authorities in making a health plan, but it only lasted from 2011 to 2014 and has not been renewed. The plan is only a general plan, and there is no section for resource distribution. There is also no sufficient funding to support the plan, health is their least concern (FGD03). The local health authorities assume basic health management functions but their capacity is still relatively weak, evident by limited capacity in monitoring drug quality. Besides, the ethnic authority prefers building hospitals and purchasing high-end medical devices as a way of ‘strengthening health system’, neglecting the actual health need of rural communities, which leads to inequitable health services. Health financing highly depend on out-of-pocket payment and international aid Health service depends on out-of-pocket money and the limited health budget from the ethnic authority is directed to the reimbursement of military and government staffs’ visits, leading to severe health inequity. In both MoHS health facilities and EHOs, high fee-for-service may result in exceptionally high healthcare expenditures, making healthcare services essentially unaffordable to patients with lower socio-economic status. Regardless of some attempted mechanism to ensure health equity, health service still mostly rely on out-of-pocket payment and fee-for-service, which cannot be afforded by people living in poverty. We (the EHO) provide ‘matching’ budget to the aid programs by donor agencies, usually at 5%. The budget is used for paying our own workers, and also reimbursement of the military staffs’ visit. All military staff enjoy free healthcare, their family members enjoy 50% discount (R11). We (the EHO) do not have a health budget, it all depends on how the highest leader of our ethnic government think. If there is a need, we will write a proposal to him (R19). Hospitals and health facilities are responsible for their own profits and losses, since there is no financial support from the government for healthcare providers, thus facilities of all level have to assume full responsibility for their profits and losses. The improper economic incentive leads to misconducts like unsafe and unregulated prescription of drugs, resulting in high-economic burden of medical service for the general population. There is no financial subsidy from the government besides that they will reimburse for the military and government officials’ outpatient visits. A common cold will charge 30-40 RMB (around 5 USD). It’s small amount for urban citizens, but quite a burden for rural population (R20). International aid focus more on vertical programmes, such as selective disease control, neglecting other important components like health education. Most donors focus on selected diseases including HIV/AIDS, malaria and tuberculosis. Although they contribute much to the public health service and could effectively decrease cases of specific diseases, basic health education and sector-wide support are largely ignored, which are actually more urgent in the special regions. Insufficient amount of qualified health workforce The number of healthcare workers, especially those working in the community level, is deficient and uneven in terms of geographic distribution. The MoHS usually send one certificated doctor who completed medical education following national standard to each township at the border area. However, with low salary and chance for promotion, it is hard to retain trained medical workers in the conflict regions. The ethnic authorities also have their own medical education programme under the assistance of NGOs. In terms of service quality, the general level of health service provided by those health workers in the special regions is lower than medical workers trained by the MoHS, as a result of lower education level, shorter medical training period and substandard medical education. Also the education highly depends on the Chinese medical training, resulting in the trainees implementing Chinese standards in diagnosis and treatment. Though this may solve the workforce shortage in the short run, it may eventually be problematic for the government and EHO, for the trained doctors also bring many malpractices from China, including but not limited to antibiotic misuse. Medical education is one of our (the EHO’s) key focus and we invested a lot in it. We have a medical school and one international organization provide training for us. We also send twenty to thirty students to China to receive three-year medical education training (R05). The education situation of the ethnic minorities is weak, and is not compatible with the Myanmar standard. So there is no local person that could be qualified for medical education in Myanmar. The service quality is quite weak now (R13). Due to the deficiency of medical workforce in the public sector, community volunteers and private outlets contributed significantly to the health workforce at community level. Largely supported by international aid, there is a great amount of HIV/AIDS, malaria and tuberculosis volunteers. However, the village health committees are barely involved in any policymaking or evaluation process, and has not fully functioned as health promoters to mobilize the community. [This is] the name list for village health committee. This is the head of the village, and these are volunteers for HIV/AIDS and malaria and other disease. The volunteers report to the NGO. Besides, the committee does not have much function, we also sometime gather together to tidy the village (FGD06). Limited capacity in information collecting, reporting and analysing The information system of MoHS health facilities is in accordance with MoHS standard that includes inpatient and outpatient data, along with malaria and tuberculosis prevalence. However, as these data are collected during patients’ visits to the township hospitals, most home-base birth and death are not recorded. As for health information system of ethnic authorities, the system was gradually established with the assistance of NGOs and external donors. The information system consists of both public health information and health management information. The public health information includes donor-requested information (mostly disease statistics), immunization rate, HIV/AIDS, malaria and tuberculosis prevalence, maternal and child health are manually collected by volunteers every month (or every 6 months) and reported level-by-level up to ethnic health department. One NGO will participate in the data collection process, analyse it and eventually report to Myanmar MoHS. Information on health management is mostly paper-based. The private sector is not included in the information system, even though they diagnose many cases of malaria, HIV/AIDS and other diseases. Reporting to the MoHS makes the ethnic authorities feel inferior, thus they refuse to report directly. Some of the information concerning immunization includes population information, which is confidential as it reflects the ‘population density’ of the ethnic minorities. Currently, the NGO collect the data from volunteers and report it to the MoHS (FGD02). Despite the huge effort of international organizations in terms of establishing the information system, we have observed that the capacity of ethnic authorities and health workers in terms of information collecting, reporting and analysing is still weak. Data collection and reporting are largely incentivized by the per diem provided by NGOs. There is few analysis of the information by policymakers themselves, thus the data loses its significant over the process of policymaking. Lack of essential drugs as well as standardized guideline Major pieces of medical equipment are funded by EHOs and NGOs, prioritized according to needs. Vaccines are also provided by the MoHS under the arrangement of international assistance, with sufficient category and capacity. However, there has been huge challenge with essential medicine. Some participants mentioned that drug distribution usually encounters delays and there is mismatch in logistics and maintenance (many in-stock drugs are expired). Besides, it’s noteworthy that there is lack of anaesthetics in all health facilities besides one hospital across all four regions, which leads to constraints in conducting surgeries. We do not have anaesthetics here in the hospital. The Ministry of Health would not provide us since it is sensitive. We also cannot get it officially from China. So we could only conduct small surgeries without anaesthetics. I think it is more of a political issue instead of technical (R20). Some participants also mentioned irrational use of antibiotics in most hospitals. Health workers are more likely to prescribe more drugs to patients than it is necessary for economic benefits. Low coverage of health services with limited functions Due to the above-mentioned challenge in finance, health workforce and essential medicine, the absolute quantity of service delivery is limited. Different levels of hospitals operate by their own standards without connection with different levels of hospitals and clinics. The capacity of primary health care (PHC) is very low, with few basic primary healthcare packages and quality control. The only existing standardized referral system is established and run by international organizations. There are many barriers for service delivery, we do not have ambulance so outreach is very difficult, especially hard-to-reach area…As the largest hospital in the township, we do not have any diagnostic equipment, so most occasions we will ask patients to transfer to other facilities in Myanmar or China (R01). Moreover, some participants emphasized the rooted mistrust between Burmese and ethnic minorities, that leads to poor utilization of health facilities and resources. For example, in some regions, the ethnic minorities refuse to go to the nearest township hospitals supported by the MoHS for they do not trust Burmese doctors. [Between MoHS facilities and ethnic facilities] we usually go to the non-Burmese facility. They are the same ethnicity with us, so we definitely trust them more, even if they charge higher (FGD07). Discussion The present study is one of the few studies of that focus on the health system along Myanmar border area. In the analysis of interviews and discussions with 55 participants, we found that challenges exist within each pillar of the health system (governance, finance, human resource, information, medical products and service delivery). There are several potential limitations of the present study: first, the sample of 55 does not represent all key stakeholders in the national and local health system, and we were unable to recruit more private service provider due to various reason. Another limitation is that the challenges may only exist in the selected regions and cannot be applied to other Myanmar border regions or other conflict settings. The new NHP aimed for universal health coverage by 2030, it also outlined emphasizes the critical role of PHC and the delivery of essential services and interventions at township level and below, starting from the community level. The EHOs could be involved in the activities in the Integrated Township Health Plan planning, enabling policies and regulation revision, and monitoring and evaluation. However, considering the complex political and health system situation, the NHP is currently not yet operational in the ethnic regions due to resource and other constraints. To achieve universal health coverage in the ethnic regions, a roadmap from co-existence to health system alignment, and then decentralized local health systems, and eventually universal health was hereby proposed. Difficulties in health system convergence The national peace-process prompts a re-thinking of the interactions between Myanmar’s national health system and ethnic region’s local health systems led by the EHOs. A ‘convergence model’ has thus been proposed as a roadmap for future integrations in health (The Health Information System Working Group, 2015), with the hope that a positive interaction between Myanmar’s national health system and ethnic health systems will not only narrow the gap between the two, but also promote mutual understanding and trust among peoples, hence a sustainable peace. However, several complex factors that should be taken into consideration: First, the health system development for the central government and EHOs might be very different. Although the two have agreed to broad collaboration around health systems strengthening, they disagree about how this should be accomplished, e.g. whether the service provider should be from the EHOs. In addition, the health system convergence model hypothesized a linear process in which the reconstruction of the health systems in ethnic regions progresses with the national peace-process. However, the airstrike near Muse and Kutkai townships in Shan State happened in 2016, which resulted in 10 deaths and over 3000 people fled across the border into China, has suggested the contrary (Thu Thu Aung, 2016). Health system reconstruction is rarely linear and often relapses into conflict (USAID, 2008). The convergence is therefore hardly achievable in a turbulent political situation, as the health system reconstruction is highly dependent on the ability of both sides to re-establish security and reconciliation; rebuild trust in state institutions and promote unity. A potential roadmap from co-existence model to universal health coverage From co-existence model to health system alignment As a more realist approach, a model with both national health system and ethnic health systems co-existing and complementing each other, which has been observed in Eastern Shan State Special Region 4 and Wa Region, seems promising. Extending the national health system to these ethnic regions has helped to shore up weaknesses in the ethnic health systems and achieved wider health coverage is in a relatively short period of time. It has also channelled much-needed essential medicines and health human resource to the ethnic regions and opened-up the possibilities of inter-talk between the two health systems. A key focus at this stage is the alignment of local healthcare services with national standards and clinical guidelines—an essential step to improve the overall quality of care of the ethnic regions. While the national health facilities are reasonably well-equipped by national standards, services provided by EHOs and private practitioners are often substandard. Such an inter-talk between the two health systems under the co-existence model could help introduce national standards and clinical guidelines to EHOs, through which, the quality of local healthcare could be improved. The alignment could also improve the development and retention of ethnic health workforce, especially in the ethnic regions where physicians of the national health system are rarely positioned to Low et al. (2014). Despite MoHS’s interest in recognizing non-government health workers in ethnic areas, there is not yet agreement on the core clinical competency. Therefore, efforts should be made to ensure training opportunities of the national health system, including school-based formal medical education, continued medical education and short-term professional trainings, etc. are readily available to ethnic and private health professionals. It may also be worthwhile for Myanmar health administration to conduct accreditation to EHOs/training institutions (MIMU, 2013; The Asia Foundation, 2016), and offer certification exam for individual practitioners in the ethnic areas to qualify as health professionals. The alignment of standards, clinical guidelines and trainings also creates the foundation for essential medicines, information, services and capacities to flow freely between the two health systems. For example, in spite Myanmar’s commitments to improve access and availability of essential medicines and PHC services, actual realization in ethnic regions remains low (3MDG Fund, 2016) and structural bottlenecks have not been systematically tackled. One of the major reasons is that health professionals of the EHOs we observed were largely trained locally or in China, where the medical practice and guidelines are not completely compatible to the Myanmar’s national standards. The alignment of medical guidelines will improve local physicians’ knowledge of proper drug use; hence facilitate the flow and use of government’s free essential medicines in ethnic healthcare facilities. To ensure that health services and medicine are available to ethnic people, co-ordinated efforts among government health system, the EHOs and international agencies should be made to harmonize the differences in quality of care between national health system and local health systems. The alignment of technical aspects of health systems is hence a feasible first step to revive local health service and a cornerstone for any future reconstruction of local health systems. From alignment to decentralized local health systems Nonetheless, the co-existence-to-achieve-alignment model is only a transitional scenario; the goal should be set for a decentralized local health system in ethnic regions (Tara, 2015). Prior to the issue of the NHP, Myanmar’s health system is highly centralized, with infrastructures, staffing and medicines delivered through a central planning process. Such a health system is not constructed to meet the varying needs of ethnic regions, in terms of different health status, disease patterns and diverse cultures. The idea of a decentralized health system for ethnic regions is in fact in line with the NHP, which emphasizes on an ITHP to identify service delivery gaps, needs of infrastructure, human resource, training and finance (Myanmar Ministry of Health and Sports, 2016). Health system decentralization could significantly improve the quality and efficiency of local health systems by bringing decision-making closer to the field service providers, generating greater potential for multi-sectoral and multi-agency collaboration at lower service delivery levels and improving allocation efficiency. Several ground works should be laid to achieve a functional decentralized local health system in ethnic regions. As a first step, more focus should be given to health system strengthening efforts. During the immediate post-conflict phase, NGOs are best placed for rapid intervention and relief work, providing logistics, emergency services and relief for basic health needs (Bell, 2017). After the emergency phase, continued provision of goods and services, however, can hinder the development of local health and governance system. Therefore, international NGOs should gradually shift its focus to service provision to structural development of health system and governance (USAID, 2008). A key for health system development is to build local health system capacities, in which international donors must be prepared to invest in long term. Efforts should be made to both strategic capacity building, such as health policy and planning, vision and long-term prioritization, resource generation and accountability; as well as operational capacity building, such as the management process, communications, regulation, human resource system, financial management, information system, etc. (Waters et al., 2007). Internalizing these capacities for health planners and policymakers of the ethnic regions will ensure a sustainable development of local health systems, long after the departure of donors and international NGOs. To formulate a decentralized local health system, national government, EHOs, civil society should all participate in the planning process. The process must also ensure ethnic people’s full participation in decision-making. Of course, such a proposal relies heavily on political situation between national government and EHOs. A strong commitment to strive for improvement in health, along with open-mindedness and a degree of flexibility of both sides, is important to build trust and co-operation for health system strengthening (The Asia Foundation, 2016). Donors and international organizations should play active roles in the process as supporter, convener and advocate for health system decentralization, as ways to address ethnic disparities and in equitable access to healthcare services. From decentralized local health systems to universal health coverage The goal of the health system strengthening should be set for universal health coverage in ethnic regions of Northeastern Myanmar by 2030, and a decentralized local health system is the means to this goal. For universal health coverage, some fundamental pillars of a sustainable health system need to be addressed. Immediate after conflict, the Basic Package of Health Services (BPHS) was prioritized in the ethnic regions, characterized by collapse health system, inadequate resources, local capacity and poor governance. International NGOs working in Northeastern Myanmar have provided maternal and child health, nutrition, tuberculosis, malaria, HIV/AIDS and supply of essential drugs, etc. for decades in these areas. Such vertical programmes showed effective and significant results of a reduced infant and maternal mortality, decreasing tuberculosis and malaria incidence in a relatively short timeframe. Nonetheless, in the phase of post-conflict health system rehabilitation and reconstruction, resources and policy should be geared towards a comprehensive PHC-oriented health system strengthening (Back Pack Health Worker Team, 2017). While there are similarities between PHC and BPHS, PHC focuses more on systematic approach to address promotive, preventive, curative and rehabilitative care needs of the community, supported by an effective referral system. International NGOs, in collaboration with local governments have already taken rudimental steps to establish PHC system in Eastern Shan State Special Region 4, Wa Region, Kachin Special Region 1 and 2. However, there remain great demands in expanding equitable access to community-based PHC services to remote areas. To achieve universal health coverage, extraordinary financial resource is required to strengthen local health system, particularly when the health sector has been chronically under-funded because of the ethnic conflict. So far, local health expenditures rely heavily on international donors, while only a small proportion of health investment comes from national, local governments or the EHOs (The Asia Foundation, 2016). Inevitably, the initial investment in health system reconstruction and recurrent expenditures exceeds the capacity of ethnic health authorities, and limited resource is available to sustain even basic health services to the entire population of the ethnic regions. In these regions where situation allows, some initial consideration and planning for a sustainable health financing mechanism is needed. Besides supply side investment, ‘…risk pooling mechanisms (on the demand side) will need to be developed to health improve affordability of care and address the substantial barriers to seek care, especially among the poor and vulnerable…’, which has been clearly outlined in the NHP (2017–2021). In fact, establishing health protection mechanism of some sort in the ethnic regions in the key component of a functional and sustainable health system. Strengthening the health system in post-conflict ethnic regions is no doubt an important step to reduce health disparities that are led by prolonged armed conflicts and a lack of economic development. It should also be emphasized that promoting health development in these regions is not only a goal in its own right, but also could be considered as a powerful bridge for peace, as health is an area that political influence is minimal. ‘Health as a bridge to peace’ is not a new concept, but was considered difficult to operationalize considering the dramatically different country scenarios (Sondorp and Scheewe, 2012). We do believe that the NHP poses a great opportunity for the national and ethnic health systems to actively interact and contribute to negotiations on state-building. However, while emphasizing this health for peace concept in fragile and conflict settings like Myanmar, it should be emphasized that the activities aiming at improving health status should focus on health system interventions proposed using a decentralized and community-based approach (Sondorp and Scheewe, 2012), instead of only enlarging technical service delivery by NGOs (Gordon, 2013). Meanwhile, the activities should not overly politicizing health by ‘combining defence, diplomacy and development’ or ‘using health to win hearts and minds’ (Goodhand and Sedra, 2010). With additional support from donors and international organizations, different stakeholders including central government and ethnic organizations should be brought together and initiate discussion on the development of health and peace infrastructure, and working towards improving the health status of ethnic population. 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TI - Health system strengthening in post-conflict ethnic regions of Northeastern Myanmar: a qualitative study
JO - Health Policy and Planning
DO - 10.1093/heapol/czz016
DA - 2019-03-01
UR - https://www.deepdyve.com/lp/oxford-university-press/health-system-strengthening-in-post-conflict-ethnic-regions-of-EjnuW8Dxvv
SP - 151
VL - 34
IS - 2
DP - DeepDyve
ER -