Universal Health Coverage in Myanmar: The Way Forward

Community Partners International’s Chief Executive Officer, Dr. Si Thura, 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 reform period, Myanmar has an unprecedented opportunity to achieve historic gains in advancing health for all. On Universal Health Coverage Day, I urge all of us involved in this cause to renew our efforts and push progress forward 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 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 and that using these services does not expose the user to financial hardship.
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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 is committed to strengthening the country’s health system and supporting the implementation of UHC. It is considered the key policy document of the Ministry of Health and Sports (MoHS). The NHP was groundbreaking in its development process, inviting participation from various key stakeholders, including representatives of ethnic health organizations (EHOs). It recognizes 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 developing 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) 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 population segments 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 workforce remain far behind the levels required to achieve universal health coverage. The budget allocation for health has increased recently, from 1% of total government expenditure in 2010-2011 to 5.23% in 2017-2018. However, most 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 rolling out the NHP in March 2017 by investing in a basic essential package of health services (EPHS) delivered initially in 78 townships and gradually expanded in 2018. The midpoint of the NHP five-year implementation term has now passed. While no formal mid-term review has been conducted, progress has been mixed, and 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 critical to the achievement of the NHP (2017-2021) commitments and will lay solid 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 in identifying gaps in the health system from the ground up. It emphasized the need to strengthen these township-level health systems as a critical 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 oversee 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, this initiative was developed as a phased approach, focusing first on 78 townships and then expanding 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 the township level and below is essential because most 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 the township level and below are the gatekeepers of the health system. Strengthening the quality and availability of primary health care in rural areas is technically and politically astute. Thirdly, well-equipped, well-resourced, and high-functioning township health facilities can be crucial in mitigating the overburdening of the secondary and tertiary health sectors.

However, the rollout of the THWGs and the implementation of the basic EPHS at township level and below has yet to proceed as smoothly as planned. Clear guidance is needed on how to craft township health plans and 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 yet to meet commitments. They must be increased to ensure that township health plans can be effectively implemented.

To help extend health services to rural communities, developing a community-based health workers (CBHWs) program is necessary as soon as possible. This will require drafting standard operating procedures and guidelines for CSOs and NGOs operating under the stewardship of the MoHS. After receiving training, these CBHWs can provide integrated health services that 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

There needs to be more than an increase in government investment and overseas development assistance 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 cannot reach the country’s entire population with the EPHS. Cooperation and engagement between the government and other health care providers (private, EHO, CSO, NGO) are essential to ensure complete and equitable coverage and avoid duplication in service delivery. One significant barrier to this engagement is financing. Current financial rules and regulations inhibit financing mechanisms through which the government can purchase health services from 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 to the public financial management system are needed to support improved budgeting and the full use of allocated funds.

There is also an urgent need to diversify financing sources for health services 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 the 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 standardizing clinical skills would be one of the first steps toward recognizing EHO health workers. Therefore, standard operating procedures (SOPs) must be developed in an inclusive way that clearly outlines the clinical competencies and skills required to deliver 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 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.