National plans and private support improve Myanmar's health outcomes

 

Health care expenditure has been rising in Myanmar, and the government is implementing three national health plans (NHPs) to lead the country towards the goal of universal health care (UHC) by 2030. Furthermore, private investment has become increasingly welcome and significant growth potential exists in the insurance market. Nonetheless, the sector requires more systematic data collection to better prioritise the geographic and service areas where resources are most needed. Widening access to primary health care and improving the quality of services at all levels will be key to fostering sustainable economic growth.

Oversight & Priorities

The Ministry of Health and Sports (MoHS) oversees the health care sector, with its responsibilities divided among seven departments: public health, medical services, human resources, medical research, food and drug administration, traditional medicine, and sports and physical education. The ultimate goal of the MoHS is to establish a UHC system, which is guided by three, five-year NHPs (see analysis).

The aim of the first of these, the NHP 2017-21, is to grant the entire population access to a basic package of essential health services – which would be expanded upon in the second and third NHPs – and lessen the financial burden on citizens. Four overarching policy areas are being targeted: human resources, infrastructure, service delivery and health financing.

“The NHP is evidence-based and of an international standard. It reflects our basic needs and current problems,” Dr Sitt Paing, general manager of the ICT and innovation department at Pun Hlaing Siloam Hospitals, a network of private health facilities, told OBG. However, he added that the effectiveness of implementation has been held back by a lack of data. In July 2019 U Myint Htwe, the health and sports minister, told local media that the ministry’s priorities for FY 2019/20 will be the “prevention of non-communicable diseases (NCDs), school health, health education, physical exercise, food and drug administration, and market surveillance”.

Public Financing

Health care funding accounted for 4.5% of the national budget in FY 2018/19, down from 5.2% in FY 2017/18, but a substantial increase on the 1% in FY 2011/12. However, Myanmar’s health expenditure ranks as one of the lowest in the region, and the share fell again to 3.8% in FY 2019/20. In absolute values MMK1.13trn ($736.6m) was allocated for health and sport spending in FY 2018/19, and MMK1.07trn ($697.5m) in FY 2019/20. Limited public spending power is a key barrier to improving the health care system, according to a 2019 report by Pun Hlaing Siloam Hospitals. The document details that high user fees and considerable out-of-pocket payments – which have traditionally accounted for around half of total health expenditure – pose considerable financial risk to demographic groups across the population (see analysis). Total health expenditure is expected to account for approximately 3% of GDP in FY 2019/20, at $39 per capita, according to the report.

General Indicators

There has been a substantial increase in life expectancy in Myanmar since the turn of the century, rising from an average of 59.90 years in 2000 to 66.96 years in 2019, an indication of improving public health. The country’s infant mortality rate has also improved considerably in recent years, falling by around 25% from 48.5 per 1000 live births in 2010 to 36.8 in 2018. Despite the improvement, this rate places Myanmar among the worst-performing countries in the region. The maternal mortality rate of 282 per 100,000 births in 2014 was also the second-highest in ASEAN that year, although this improved to 250 in 2017. To identify why the rate was so high, the Maternal Death Surveillance and Response system was launched in 2016 by the Maternal and Reproductive Health Division of the MoHS, with the support of a number of international partners, including the UN Population Fund.

When it comes to infrastructure, the overwhelming majority of hospitals are public, accounting for 1115 of the total 1302 hospitals in the country and hosting 55,895 beds as of late 2019. This supply is insufficient, however, with around 0.9 beds per 1000 of the population, compared to an average of 4.7 among the 34 members of the OECD. Moreover, Myanmar has only 0.6 doctors and 0.9 nurses per 1000 of the population, compared to OECD averages of 2.5 and 9, respectively. On this metric, Myanmar falls short of the World Health Organisation (WHO) recommendation of one doctor per every 1000 people. Access to medical facilities and personnel can be particularly challenging for citizens in remote areas. This poses a considerable obstacle to improving public health, given that these areas are home to around 70% of Myanmar’s population. The situation is exacerbated both by a lack of basic health knowledge among the public and the absence of a reliable electricity supply – which is vital not only for medical equipment, but also for the cold-chain management required for certain medications and vaccines.

Infectious Diseases

Myanmar has the second-highest prevalence of HIV in the region after Thailand, at 0.8% of the population aged between 15 and 49. The MoHS implemented a National Strategic Plan on HIV/AIDS covering the 2016-20 period, which aims to end the AIDS epidemic by 2030 through increased awareness, diagnosis and treatment. As well as government funding, HIV/AIDS prevention and treatment programmes receive financial support from national and international organisations, including the Global Fund to Fight AIDS, Tuberculosis (TB) and Malaria. Progress is being made, with the number of new HIV cases falling from an estimated 35,000 in 2000 to 11,000 in 2016. Moreover, the number of AIDS-related deaths declined by 43% between 2010 and 2016, falling from approximately 14,000 to 8000.

TB and multidrug-resistant TB (MDR TB) remain a public health threat. The MoHS-led National Tuberculosis Programme provides free diagnosis and treatment, and aims to increase public awareness of the disease. The programme treated 140,000 TB and 2700 MDR-TB patients in 2017. Awareness campaigns in the Yangon region have included short videos that illustrate the experiences of patients who recover from the disease, alongside leaflets and billboard posters. A national survey on the prevalence of MDR TB was slated to be conducted in 2019 to update the data on the disease, though no results were available as of December 2019.

Myanmar has one of the highest rates of rabies in the world, with the number of reported dog bites rising from around 180,000 in 2017 to 192,000 in 2018 and 60,000 in the first six months of 2019. Between FY 2016/17 and FY 2018/19, MMK15bn ($9.8m) was spent on rabies vaccines, and the WHO provided Myanmar with 14,000 vials of rabies vaccines in 2019. Accordingly, the number of deaths from rabies has fallen, halving from 145 in 2011 to 71 in 2018. By August 2019 around 40 deaths were recorded for the year.

The country has also made considerable progress in addressing malaria, with the support of international health organisations. Between 2012 and 2019 the number of cases fell by 85%, and the number of deaths by 95%, although some 70,000 cases were still reported in 2018. The current policy focus is on tackling the disease in the regions to eliminate transmission by 2030.

NCDS

As the prevalence of infectious diseases is declining, the government is placing greater focus on NCDs. The primary causes of death in this category are heart attacks, cardiovascular disease, cancer and diabetes. The rate of NCDs often rises in emerging economies as they experience rapid urbanisation, an ageing population, and changing lifestyle factors associated with a growing middle class. NCDs accounted for 59% of all health-related deaths in 2014 and 68% in 2016, according to the latest data from the WHO.

Myanmar has a National Strategic Plan for Prevention and Control of NCDs covering the 2017-21 period, outlining preventive measures as well as strategies to detect and treat NCDs. As part of this effort, 90 townships out of a total of 330 had received a package of essential NCD interventions as of April 2019, with this set to reach 95 by the end of 2019. Services provided under the scheme include screening for hypertension, diabetes and cardiovascular disease, and the treatment of uncomplicated cases, as well as the detection of oral, breast and cervical cancers to enable the early referral of patients. With regard to preventive practices, the MoHS is working to reduce and control tobacco use by establishing smoke-free zones, raising taxes on tobacco products and rolling out campaigns to raise awareness of the dangers of smoking. Other aims are to limit the excessive consumption of alcohol, oil, salt and sweets, minimise the addition of dyes and chemicals in foodstuff and encourage more active lifestyles.

Human Resources

The Department of Human Resources for Health under the MoHS produced a Human Resources for Health (HRH) Strategy for the 2018-21 period. This addresses three broad areas to help the country meet its health care goals: quality, which comprises career development and appraisal, as well as education and training standards; planning, which includes recruitment and distribution of resources; and governance and financing, which covers regulation, budgetary concerns and remuneration. In line with the goal of UHC, there is a focus on improving the quality of basic services and employing additional personnel – particularly in rural areas.

The number of students enrolled in health-related courses has been increasing. In mid-2016 there were 29,528 students taking such courses, of which 41% were enrolled in general medical training – a dramatic increase on previous years, according to the HRH Strategy – 26% in nursing and midwifery training, and 33% across all other specialties. As the number of students seeking these courses has begun to exceed the capacity of school faculty and classrooms, admission requirements have become more stringent. In addition, while medical training is financed almost exclusively by the public sector, the HRH Strategy suggests that the best way to raise financing for improved medical training would be to share costs through higher student fees.

To help maximise the effectiveness of human resource distribution, the country is developing a Consolidated Human Resources for Health Information and Planning System, although this had not been completed as of November 2019. The HRH Strategy also recognises the need to introduce some form of remuneration package and special allowances since no formal incentives or performance-based pay currently exist. This is one measure to retain talented medical staff who may otherwise relocate with the promise of a higher salary or opportunities for career progression.

Insurance

Social security schemes in Myanmar fall under the remit of the Social Security Board (SSB). The role of the SSB is laid out under the Social Security Law of 2012, which replaced the Social Security Act of 1954. In a proposal submitted to the Ministry of Labour, Immigration and Population in December 2018, the SSB reported that the number of insured persons had been “gradually increasing monthly and yearly” since the introduction of the 2012 law. However, health insurance penetration remains quite low, according to local media, covering approximately 1.3m workers as of March 2019, equal to 2% of the population.

While insurance contributions are mandatory for businesses with at least five workers, registered employees may be unaware of their eligibility to make a claim, or poor perceptions of health services – combined with slow processing of payouts – may discourage participation in the scheme. Indeed, a report published in the International Journal of Health Planning and Management in 2018 suggested that the general public did not perceive health insurance as offering substantial benefits. Nevertheless, the results of the journal’s study highlighted interest in health insurance products. Although less than 40% of respondents to a survey initially reported knowledge of health insurance, 75% of all respondents expressed a willingness to enrol in an insurance scheme. Survey respondents cited a preference to pay a low premium on a monthly basis – made by the beneficiary themselves, rather than collected through taxation – to a fund mediated by a government body with no co-payment. Similarly, the findings of a report by IKBZ Insurance, a key player in the insurance sector, suggest that the market has considerable growth potential. A survey conducted by the insurer found that while financial barriers and a lack of knowledge have limited the segment’s growth, 63% of respondents expressed interest in insuring themselves and their families after the concepts of health and life insurance were explained.

In a step forwards, a health coverage scheme called the Purchaser-Provider Split (PPS) was implemented on a trial basis in March 2019. The PPS is led by the SSB in collaboration with private clinics and covers insured workers who contribute 3% of their salary,with 2% supplemented by their employer. Service providers are employed on a contract basis separate from the third-party payer. The hope is that care delivery will be improved through increased competition among service providers and the contributory scheme will lower financial risk to the insured.

Private Care

The number of private hospitals has grown significantly in the last two decades, rising from 50 in 2000 to 193 in 2015 and an expected 250 in 2020, according to Dr San San Yi, chairman of local medical and laboratory equipment supplier Okkar Thiri. Increased foreign investment has led to improved facilities, equipment and care provision, allowing more people access to a broader range of services in Myanmar. Local stakeholders have been willing to partner with international players and share their expertise of the domestic market. The 2019 sector report by Pun Hlaing Siloam Hospitals puts the number of private hospitals in the country at 187 that year, with a total of 5500 beds, and private clinics at 5500. The hospital group told OBG that their commercial revenue was on the rise over the course of 2019. This was attributed, in part, to a greater share of the population seeking private options, boosted by government awareness campaigns and increasing internet penetration.

The private sector is expected to account for around 30% of health care spending in FY 2019/20, equal to $630m, according to the group. Pun Hlaing Siloam Hospitals predicts this share to remain steady through to FY 2028/29, as public expenditure is also slated to rise, but the absolute value of private health care spend is projected to increase to $2.25bn per year. Private investment has been aided by some favourable regulations: health services was one of the sectors promoted under the 2016 Myanmar Investment Law, qualifying investors for a range of tax benefits, while joint ventures with foreign firms for trading health care equipment have been possible since November 2015.

Medical Tourism

Myanmar’s economic development has outpaced progress in the health care sector, which may be a considerable factor in the high rate of outbound medical tourism. Indeed, some 500 patients from Myanmar seek treatment abroad every day. It is not only the higher quality of care that encourages outbound medical flow, but also shorter waiting times due to a higher number of doctors. The 2019 report by Pun Hlaing Siloam Hospitals shows Thailand as the primary destination for residents seeking treatment outside of Myanmar. The country captured 56% of the market in 2016, followed by India (19%), Singapore (11%) and Malaysia (5%). Furthermore, local infrastructure challenges mean that the costs of establishing and operating a mid-level hospital in Myanmar – reflected in the costs passed on to patients – are equivalent to running a top-tier hospital in Thailand. “The quality of health care is improving, but there is reputational damage to repair,” Dr Kyaw Myint Naing, president of Golden Zaneka Public Company, a local health services firm, told OBG. “Increased trust is needed to persuade people not to seek medical services in Thailand.”

Pharmaceuticals

Branded medicines are fairly new to Myanmar and this segment remains relatively small, with generic medicines making up the majority of the pharmaceuticals market.

Currently some 85% of Myanmar’s medications are imported. Regional neighbours India, Bangladesh, China, Indonesia, Pakistan, Thailand and Vietnam supply the majority of Myanmar’s pharmaceutical needs, with India alone supplying 40-45%. While private and foreign players can be found in the warehouse and distribution segments of the industry, local production is dominated by state-owned actors, particularly Myanmar Pharmaceutical Industrial Enterprise. Prior to July 2017 Myanmar was the only ASEAN member country without a private pharmaceutical manufacturer, but this changed when Pacific Medical Industries (PMI) opened a facility in Yangon that month. While Yangon is a popular choice for any type of business, the PMI is keeping production close to one of the country’s primary sales markets: around 60% of all pharmaceutical product sales are made in Yangon and Mandalay. Local manufacturers, as well as importers, will soon be subject to a new regulation that mandates all medication labels include information in both the Myanmar and English language.

Medical Technology

Myanmar has lagged behind regional neighbours such as Thailand and Laos in the uptake of medical technology. However, Myanmar now has the opportunity to leapfrog inefficient systems and make rapid progress to the benefit of its health sector. The digitalisation of medical records is a popular starting point for countries making the shift, as it immediately supports the treatment of patients and enables better long-term planning by government bodies. This latter benefit allows real-time data to be used in budgetary and resource allocation decisions so the country can prioritise and tackle causes of ill health.

In addition to minimising delays, digitalising patient records will reduce the likelihood of lost information. While an operational health management information system is in place, it is not yet of a sufficient standard, according to a 2017 report published by the UN Population Fund. Indirect effects from technological progress elsewhere in the economy are also aiding health care, particularly in areas traditionally underserved by brickand-mortar facilities. “The rapid expansion of internet and phone penetration has made telemedicine viable,” Dr Kyaw Myint Naing told OBG. “Telemedicine will help improve service provision in rural areas.”

Outlook

While the foundations are already in place for Myanmar to make considerable progress towards its health care goals, several steps must be taken in order to build on existing infrastructure and frameworks. Overhauling the social security scheme to make health insurance more inclusive will go a long way towards ensuring people seek the care they need without high personal costs, while the systematic collection of data will help ensure a more effective allocation of resources. Greater support for private operators looking to enter the market coupled with increased public sector investment has the potential to turn the tide of outbound medical tourism back to Myanmar.

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The Report: Myanmar 2020

Education & Health chapter from The Report: Myanmar 2020

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