Disparities in health and health care in Myanmar
Authors: Phyu Phyu Thin Zaw, Thant Sin Htoo, Ngoc Minh Pham, Karen Eggleston
Journal: The Lancet (2015)

Myanmar (Burma) is undergoing a complex political and economic transformation, from a long civil war and military regime to a peace process and democratisation. Since 2011, the Myanmar Ministry of Health has started to rehabilitate the fragile health system, setting the goal of achieving universal health coverage by 2030.1Sein TT Myint P Tin N Win H Aye SS Sein T The Republic of the Union of Myanmar—Health System Review. World Health Organization, Geneva2014Google Scholar To achieve this target, Myanmar will have to face substantial challenges; arguably one of the most important difficulties is how to allocate limited health-care resources equitably and effectively. Attention to the most vulnerable people would substantially improve national health outcomes. Myanmar's life expectancy at birth of 66·8 years and infant mortality of 62·0 years are the worst in southeast Asia. Persistent inequalities exist in health outcomes in Myanmar's seven states and seven regions.2Teela KC Mullany LC Lee CI et al.Community-based delivery of maternal care in conflict-affected areas of eastern Burma: Perspectives from lay maternal health workers.Soc Sci Med. 2009; 68: 1332-1340Crossref PubMed Scopus (50) Google Scholar Residents of mountainous peripheral states suffer from remoteness, civil conflicts, and low socioeconomic development.3Department of PopulationMinistry of Immigration and PopulationThe 2014 Myanmar population and housing census. The union report. Census report. volume 2. Department of Population, Ministry of Immigration and Population, Nay Pyi Taw2015Google Scholar For example, infant mortality is 94·2 per 1000 births and under-five mortality is 149·1 per 1000 births near the eastern border of Myanmar, where malaria and tuberculosis prevalence are also high.4Beyrer C Lee TJ Responding to infectious diseases in Burma and her border regions.Confl Health. 2008; 2: 2Crossref PubMed Google Scholar The gap in life expectancy at birth between the areas with the highest and lowest values within Myanmar is more than 11 years, almost as large as that between Myanmar and the USA. Such disparities are not surprising when reliance on out-of-pocket financing is among the highest globally (81% of Myanmar's total health expenditures) because of no reliable health insurance system and the tight fiscal space for health. As an important step towards universal health coverage, the government increased health-care expenditures by 8·7 times from 2011 to 2015. However, resource allocation does not seem to be closely aligned with the goal of reducing health disparities.5UNICEFSnapshot of social sector public budget allocations and spending in Myanmar. UN International Children's Emergency Fund, Myanmar2013Google Scholar Conventional budget allocation, tied to population and infrastructure (figure3Department of PopulationMinistry of Immigration and PopulationThe 2014 Myanmar population and housing census. The union report. Census report. volume 2. Department of Population, Ministry of Immigration and Population, Nay Pyi Taw2015Google Scholar), gives disproportionately more resources to regions with better health, and fewer resources to several states with high health needs (as measured by infant mortality in the figure). Crafting policies to mitigate rather than exacerbate health disparities needs professional and innovative leadership, which is one reason why Myanmar's physicians are protesting militarisation of the Ministry of Health through the Black Ribbon Movement. Development of a workable health policy to distribute resources equitably is not only crucial to improve the health status of the population—raising the average by prioritising the needs of the most vulnerable people—but also to build trust, to support peace and reconciliation, and to control the spread of drug-resistant strains of tuberculosis and malaria. These diseases fester in the border areas of Myanmar, and could develop into important regional public health concerns. We declare no competing interests. Myanmar: can a new government give health to the people?Last week's general election in Myanmar brought an end to more than 50 years of military rule (incorporating a nominally civilian government since 2011). The incoming National League for Democracy (NLD) party, led by Aung San Suu Kyi, brings a historical opportunity to move administration away from military dominance and to return health to the people. Myanmar is a rural and ethnically diverse country of extreme poverty, with one of the most poorly funded state health-care systems in the world. The 2014 census confirmed a population of 51·4 million people, and a recent Lancet paper noted a maternal mortality ratio of 178 per 100 000 livebirths in 2015. Full-Text PDF Implementing health policy and systems research in MyanmarWe agree with Karen Eggleston and colleagues' (Nov 21, p 2053)1 assertion that one of the greatest challenges facing Myanmar is the optimum allocation of scarce resources, and add that evidence to inform this is needed urgently. We started working to generate such evidence shortly after the move to a nominally civilian government in 2011 opened the country up to more international collaborations. Here, we summarise the insights gained while doing one of the first multidisciplinary research programmes on the health system and tuberculosis control in Myanmar, which included two literature reviews, a mixed-methods situational assessment, a case-control study of risk factors for emergence of drug resistance, a qualitative study of barriers to accessing health services, and an economic analysis of patient costs. Full-Text PDF