Paying for Health and Innovating for Value in Myanmar
Paying for Health and Innovating for Value in Myanmar
In Myanmar, 50 years of military dictatorship left behind a seriously underdeveloped health system, serving barely one in twenty of the country’s 60 million people. You might expect that the first minister of health under civilian rule would be despondent. But on my recent trip I found the opposite: Dr. Pe Thet Khin and his team are aligned around an ambitious vision for building a strong health system for the country.
The challenges are daunting: for years, Myanmar (also known as Burma) has ranked among the world’s lowest in public sector health spending per capita, as the government prioritized military spending instead. As recently as 2010, less than 1% of Myanmar’s government spending went to health, compared to 6% to 13% for nearby Cambodia, Laos, Thailand, and Vietnam. This low commitment to health left people in Myanmar suffering from diseases of poverty, including tuberculosis (4th highest rates in the world [PDF]), malaria (highest rates in Asia [PDF]) and maternal and child mortality.
Steps toward Increased Health Financing and Universal Coverage
In light of these challenges, it was encouraging to hear from the Minister and his team that the national budget quadrupled health spending in the FY2012-2013 budget, with a near-term focus on medicines, medical equipment, and building infrastructure for health insurance. It was equally thrilling to learn that Myanmar’s government has begun planning a long-term move towards universal health coverage (UHC). It was actually quite striking that the theme of UHC came up in meetings with the Ministry of Health, with the Health Committee members from Nobel Laureate Daw Aung San Suu Kyi’s National League for Democracy (NLD) party, with the Myanmar Medical Association, and with some donors and NGOs.
The government’s long-term goals are ambitious: 90% coverage in risk-pooling/prepayment schemes and “close to 100%” coverage for vulnerable populations in safety-net programs. Myanmar has begun piloting a community-based health insurance in one township and will expand its Social Security Scheme to cover the most disadvantaged.
Other countries’ successful experiences will serve as models. Not surprisingly, countries that have increased domestic health spending as part of their commitment to UHC have made significant gains. Over a period of several decades, Thailand has pursued a vision of universal health coverage that has now reached 98% coverage. China and the Philippines are other great regional examples.
Looking beyond Asia, Rwanda boosted government spending and instituted one of the world’s most progressive systems of universal health coverage (UHC). Rwanda’s Mutuelles de Sante is a community-based health insurance (CBHI) approach that administers health coverage at the local level and ensures access for rural populations, the very poorest, and those working in the informal sector—the groups most difficult to reach with traditional health insurance. Central government funding is an essential component of this innovative system: once needy recipients are identified within their community, the government (along with international donors) covers their premiums. After ten years, assisted by technical support from MSH, over 90% of Rwandans are insured and out-of-pocket spending is down to 23%. Like for Eugenie, a Rwandan mom we’ve written about before, the insurance card brings access to many services that were once unaffordable, and key health indicators have reflected this improvement.
Every country’s path to UHC will be different. Myanmar’s government has recognized the need for increased tax-based financing. In this regard, it will have at least one great advantage: economic growth. Growth means more tax revenue and greater domestic health funding. International assistance funds play an important role, especially in the focus areas of maternal and child health, AIDS, TB, and malaria, and these funds appear likely to grow substantially. But it’s domestic contributions that will ensure the long-term viability of health coverage in Myanmar.
Better Value in Medicines
A symptom of the chronic government underfunding of health is that people in Myanmar can’t rely on insurance or social protection mechanisms to pay for their care. A staggering 82% of total health spending in Myanmar is out-of-pocket, the 2nd highest rate in the world. More than half of this spending goes towards medicines, most of which are obtained not from reliable sources, but unlicensed local drug sellers. No one knows for sure, but one local NGO leader with whom I met figured at least two drug sellers per village. This would mean at least 100,000 unlicensed drug sellers, far more than the few thousand hospitals, clinics, private providers, and pharmacies (PDF).
For reasons of access and convenience, these drug sellers are usually the first line for medical care. This is especially true in rural areas where 70% of the population still lives. But the medicines they sell are often ineffective or even harmful. Customers usually get small packets of sut say, bags of 4-6 pills—usually modern drugs, including anti-inflammatories, but rarely what the consumer really needs. Yet major killers such as malaria and tuberculosis are routinely self-treated with sut say. Preventable deaths and disability are the result. Even more worrying for the rest of the world is that, in the case of malaria, this chaotic approach to self-treatment is contributing to an alarming risk of resistance. According to some experts, Myanmar risks become the “gateway for worldwide resistance” (PDF) to artimisinin, one of the most effective anti-malarial drugs when used in two-drug combination.
In short, the prevailing practice among unlicensed drug sellers is too often a waste and a risk to health. An innovative approach would not only combat this practice, but harness the strengths of local drug sellers. If you train them, license them and monitor them, you’ve got a decentralized system for delivering essential medicines. In Tanzania, where MSH worked with local leaders to implement this pioneering approach through the Accredited Drug Dispensing Outlet (ADDO) program, dispensers throughout the country can now provide appropriate medicines, supplies and instructions for family planning, HIV prevention, malaria and diarrhea treatment, and safe delivery kits. It has also empowered sellers who are women. This type of network provides an infrastructure for expanded services and can provide a platform for distributing the products eventually covered under an insurance scheme.
The Years Ahead
Despite decades of military dictatorship, I was impressed with the passion, energy and vision for a better Myanmar. As a family physician and UHC advocate, I’m particularly excited to watch as Myanmar joins more than 100 other countries making progress toward universal health coverage in 2013—a year in which the world will consider UHC as a potential post-2015 development framework for global health and Ban Ki-Moon will report to the UN General Assembly on global progress towards this goal. As we pause to look back at 2012’s success stories, I can’t help believing that Myanmar will be a success story in 2013 and the years to come.
Jonathan D. Quick, MD, MPH, is president and chief executive officer of Management Sciences for Health. Dr. Quick has worked in international health since 1978. He is a family physician and public health management specialist.