UHC Moving toward Myanmar - World Bank Document
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Public Disclosure Authorized
Moving toward
UHC
Myanmar
Public Disclosure Authorized
NATIONAL I N I T I AT I V ES, KEY CHALLENGES, AND
THE ROLE OF COLLABORATIVE ACTIVITIES
Public Disclosure Authorized
re Authorized
Moving toward UHC: Myanmar
Myanmar’s snapshot 1 Myanmar’s snapshot
Existing national plans and policies to achieve UHC 2
61+39+C
Key challenges on the way to UHC 4 UHC Service Coverage Results of Joint External Evaluation
Collaborative efforts to accelerate progress toward UHC 6 Index (SDG 3.8.1, 2015) of core capacities for pandemic
preparedness (JEE, 2017)
61%
References and definitions 8 Score (for capacity) # of indicators (out of 48)
5 Sustainable 0
4 Demonstrated 2
Catastrophic OOP health expenditure
incidence at the 10% threshold 3 Developed 16
(SDG 3.8.2)
2 Limited 17
NO DATA 1 No capacity 13
Health results Performance of service delivery –
selected indicators LMIC
Maternal Mortality Under-Five Mortality (PHCPI, 2014-2015) Myanmar average
Ratio (WHO) Rate (WHO)
Per 100,000 Live Births Per 1,000 Live Births Care-seeking for symptoms
of pneumonia 58.2% 61.5%
Dropout rate between 1st
and 3rd DTP vaccination 5.3% 7.5%
453
Access barriers due to
178
110 treatment costs 34% 47.4%
50
Access barriers due to
distance 23.4% 35.8%
1990 2015 1990 2015
70 (SDG target) 25 (SDG target) Treatment success rate
for new TB cases 87% 80.1%
Life Expectancy Wealth Differential
at Birth (WHO) in Under-Five
Mortality (PHCPI)
Provider absence rate NO DATA 28.9%
67 Caseload per provider NO DATA
9
62 per day
NO DATA
Diagnostic accuracy NO DATA 47.9%
More deaths in
lowest than highest
wealth quintile Adherence to
2000 2015
per 1,000 live births clinical guidelines NO DATA 33.6%
See page 8 for References and Definitions. 1
Moving toward UHC: Myanmar Moving toward UHC: Myanmar
Existing national plans and
policies to achieve universal
health coverage (UHC)
SERVICE DELIVERY REFORMS (EHOs) and improvements in access to
In 2017, the government of Myanmar endorsed services in conflict-affected areas position
the National Health Plan (NHP) of 2017–2021, health as a bridge to peace, for example, by
which aimed to increase equity and financial certifying providers in border areas in basic
protection and extend access to the basic emergency obstetric care. Furthermore, human
Essential Package of Health Services (EPHS) resource reforms are being initiated, which
for the entire population by 2021. It is the first include assessing the role of Voluntary Health
of the three phases envisioned to reach UHC Workers and revising the job descriptions
by 2030, a goal which has the highest level of of Basic Health Staff in the context of
political commitment in Myanmar. The Plan delivering a basic package of services for UHC.
sets forth many service delivery reforms. The Other components, such as infrastructure
basic package of services is explicitly stated development, health information systems,
and covers a wide range of interventions for and public financial management, are also
reproductive, maternal, newborn, child, and identified and prioritized for strengthening to
adolescent health (RMNCAH); nutrition; ensure that health facilities at the township
communicable and noncommunicable level and below have all required inputs
diseases; and emergency conditions. Though to deliver services that are geographically and systems, including the introduction of risk platform for health, first established as a
the package is broader than RMNCAH, the accessible and affordable for all. pooling and active purchasing of services to reform of a Global Fund Country Structure in
NHP aims to improve health and nutrition reduce financial barriers to care. The Parliament charge of overseeing the national response to
for women and children in line with the HEALTH FINANCING REFORMS has agreed to proceed with the drafting of a AIDS, malaria, and tuberculosis (TB). MHSCC
Reproductive Health Strategic Plan of Progress toward UHC and achieving the goals Health Insurance Bill, and broader public has evolved to improve oversight, promote
2014–2018 and the National Strategic Plan for of the NHP will not be possible at Myanmar’s financial management reforms are under way collaboration, and increase accountability for
Newborn and Child Health Development of current low level of public spending. Despite in financing of provider services. Myanmar’s ongoing and new initiatives and policies. For
2015–2018. a substantial increase in public health 2016/17 Budget Policy Statement identifies example, the implementation of maternal
spending over the past five years, the public increasing the allocation to health and and child health strategies was discussed at
The NHP recognizes the important role of the share of spending remains low relative to education as fiscal policy objectives. The NHP the MHSCC to prevent duplication of efforts
private sector in expanding access to services. other countries at a similar income level. The also laid out a vision for strategic purchasing of and reduce additional administrative strain
The involvement of ethnic health organizations NHP advances new health financing models health services in the public sector, which would on the government. The Committee has
help provide access to health services more representatives of government ministries,
effectively and efficiently, including through United Nations agencies, international
private sector providers. Details on purchasing organizations, donors, international and local
The National Health Plan 2017–2021 aims to increase arrangements still need to be established and
defined in the Health Financing Strategy.
nongovernmental organizations (NGOs), and
the private sector. The reorganization of the
equity and financial protection and extend access Ministry of Health and Sports, including
GOVERNANCE REFORMS
to the Essential Package of Health Services (EPHS) to The Myanmar Health Sector Coordinating
the remerging of the Departments of Public
Health and Medical Services, helps to facilitate
the entire population by 2021. Committee (MHSCC), chaired by the Minister, seamless oversight and decision making across
is the country-led multi-sectoral coordination the continuum of care.
2 3Moving toward UHC: Myanmar Moving toward UHC: Myanmar
Key challenges state/regional administrative units require
additional consideration.
progressively in three phases over the next
fifteen years (a basic package accessible to
on the way to UHC Major financial protection schemes. There
all by 2021, an intermediate package by 2025,
and a comprehensive package by 2030). This
is a long history of social health insurance/ package will also define cost-sharing ratios,
social security in Myanmar, but no if any, for nonpoor segments of Myanmar’s
comprehensive health insurance system; health population, providing clarity on expected costs
coverage remains extremely low. The social when seeking care and reducing uncertainty
security system established in 1956 covers about out-of-pocket fees.
WEAKNESSES AND BOTTLENECKS prevention and control, and limited budgets predominantly private sector employees in
IN SERVICE DELIVERY for facility maintenance and operations. The the formal workforce—coverage does not even GOVERNANCE CHALLENGES
Coverage of essential health services. Rates private sector is a major source of primary and extend to the families of insured employees. Rural-urban divide. Disparities in service
of maternal mortality, infant mortality, and ambulatory care, providing the majority of The scheme covers less than 2% of Myanmar’s availability, quality, and health outcomes exist
stunting in Myanmar are high compared to these services. However, Myanmar’s regulatory population, and social health insurance across Myanmar’s regions, conflict-affected areas,
other Association of Southeast Asian Nations bodies and frameworks for overseeing quality spending amounted to just 1% of government and socioeconomic groups. In rural and hard-to-
(ASEAN) countries. For most reproductive, of care and the competency of providers, health spending in 2014 (WHO GHED, 2017). reach areas, coverage of basic services is lower,
maternal, newborn, child, and adolescent particularly in the private sector, are nascent. Employees contribute 1–6% of their salary despite greater needs, and in some areas ethnic
health indicators, rates in the best-served Access to affordable medicines is a critical proxy and obtain benefits such as medical treatment, health authorities directly provide primary care
regions are double those in the least-served for quality of care due to being a significant maternity leave, and cash benefits for the sick. services. Financial incentives to retain health
regions. Service delivery is constrained by contributor to out-of-pocket (OOP) spending, There are currently no financial protection workers in less-secure, hard-to-reach areas,
difficult terrain, conflict in border areas, health but this has not been addressed strategically. schemes for the poor and informal sector— such as special consideration for postgraduate
systems challenges, particularly inadequate indigents were meant to be exempt from user studies, promotions, and studying overseas,
distribution of human resources, poor physical Pandemic preparedness. A 2017 Joint External fees when they were first introduced in Myanmar have been implemented. However, retention of
infrastructure, insufficient financing, and Evaluation (JEE) of International Health in the 1990s, but there are no mechanisms in health workers remains a challenge, resulting
low absorptive capacity. In remote and hard- Regulations (IHR) core capacities revealed place to ensure user fee exemption. in coverage gaps. Other priorities include
to-reach areas, it is difficult to deploy and that Myanmar’s overall level of pandemic strengthening implementation capacities at the
retain health workers. Despite an increase preparedness is low. The only two areas for Free and subsidized care. Since 2012, in theory, subnational level, moving beyond curative care
in the number of health workers per capita which there is currently demonstrated capacity care for all emergency, maternal, and childhood alone, and increasing multi-sectoral leadership
since 2010, that number still falls below the are national vaccine access and delivery, and illnesses has been provided free of charge in all at the central level.
threshold recommended by WHO. There are indicator-based and event-based surveillance public hospitals due to increases in government
significant inequities in both health status and systems. In addition to other specific gaps, health expenditures. A free medicine policy was Conflict and health. Myanmar, under the
coverage (i.e., rural/urban, state/region, income Myanmar currently has limited capacity in introduced in 2011/12, but there remains a lack leadership of the State Counsellor, is embarking
groups, etc.). Children in conflict-affected and preparedness, medical countermeasures and of clarity and poor communication on the scope on an inclusive peace dialogue and process.
hard-to-reach areas are especially vulnerable. personnel deployment, chemical events, and of the policy, and an overall lack of awareness on However, in some conflicted-affected areas,
Health staff are deterred from conducting radiation emergencies. what services are non-chargeable versus those overall underdevelopment affecting communities
outreach visits in some remote areas due to high that continue to have an element of “community is compounded by ongoing tensions and
transportation costs, which they often even pay THE STATE OF HEALTH FINANCING cost-sharing.” The EPHS will be introduced restricted movement of people and providers.
out of their own salaries. On the demand side, Overall funding for health. Total health
women and girls face obstacles to seeking care spending per capita in 2014 was estimated to be
and information about reproductive health due US$20, about 2% of GDP (WHO Global Health
to gender norms and traditional beliefs and Expenditure Database—GHED, 2017). Out-of-
practices around birth, feeding, and rearing. pocket (OOP) spending is the dominant source Health results and coverage of essential services vary
of health financing, comprising 51% of the total
Quality of care. A recent health facility in 2014 (GHED, 2017). Bottlenecks in the flow greatly by region – with coverage significantly lower in
assessment identified limited clean water of funding at the central level hinder effective rural and hard-to-reach areas.
accessibility for patients, inadequate regular program implementation at subnational levels
cleaning, limited staff training on infection and financial allocation inequities between
4 5Moving toward UHC: Myanmar Moving toward UHC: Myanmar
Collaborative efforts
to accelerate progress
toward UHC
EXISTING INITIATIVES SUPPORTED (i) increasing diplomatic and policy engagement,
BY EXTERNAL PARTNERS advocacy for sustainable and efficient domestic
External partners are engaged in Myanmar to and external financing, and generating evidence
build national capacity and strengthen the on financing and capacity gaps; (ii) improving
health system, in line with the priorities of the regional collaboration to address transborder
National Health Plan. The Tokyo Joint UHC transmission of infectious diseases; and (iii)
Initiative, supported by the government of Japan providing technical support for knowledge
and led by the World Bank (WB), in collaboration generation and sharing, and capacity building
with the Japan International Cooperation Agency in national and regional institutions. In line
(JICA), United Nations Children’s Fund (UNICEF), with the Sustainable Development Goals agenda
and the World Health Organization (WHO), is and the need for universal, equitable access to PLANS FOR FUTURE key system strengthening milestones. For
supporting the government of Myanmar and high impact interventions, UNICEF, the United COLLABORATIVE WORK instance, they will support the achievement
strives to accelerate progress toward UHC. This Nations Fund for Population (UNFPA), WHO, the of key pandemic preparedness targets or
support will enable nationally-led strategic Joint United Nations Programme on HIV/AIDS Policy and Human Resources Development milestones, such as the preparation of
health system strengthening to achieve UHC, as (UNAIDS), and the World Bank/Global Financing (PHRD)-funded advisory support pandemic preparedness plans that are linked
well as pandemic preparedness. Facility (H6 working group) are committed to The work under the Tokyo Joint UHC Initiative to disbursement of funds under the Essential
data-driven planning and implementation to falls within four key objectives: (1) conduct a Health Services Access Project under IDA18.
To improve sustainable financing and address maternal and child mortality, including situation analysis, review existing preparedness Future efforts can further build on PHRD-
strengthen regional and cross-sectoral policy development and ensuring the supply capacities, and identify stakeholders; (2) supply funded pilot activities to generate evidence for
cooperation in the East Asia and Pacific (EAP) and quality of RMNCAH services, in accordance a cost national preparedness plans; (3) develop mobilizing resources under IDA18 to better
region that includes Myanmar, the government with international norms and standards. The a financing plan to address financing gaps; and support the UHC agenda.
of Australia, the World Bank, WHO, the Food H6 working group will support the National (4) strengthen a framework for governance and
and Agriculture Organization (FAO), the World Health Plan 2017–2021 with joint technical institutional arrangements. Fulfilment of each H6 support
Organization for Animal Health (OIE) and other expertise, ensuring appropriate prioritization, of the objectives will produce a relevant national Given Myanmar’s participation in the Global
partners are supporting the following objectives: and mobilization of resources. plan, while the fourth objective is also intended Financing Facility (GFF) as a recipient of
to produce a governance framework for training the GFF Trust Fund, the H6 will use this
and capacity building at the state/regional levels. opportunity to facilitate the development of
Furthermore, the joint work will closely cooperate an investment case to analyze, plan for, and
with other investments in health, such as those implement prioritised efforts to promote
by the Global Fund and Gavi, to contribute to financial sustainability in the context of
health system strengthening. Considering that accelerating progress on UHC. It will also
nutrition and water and sanitation compose the support government-led mechanisms to
foundations of heath for all, challenges in these convene inputs from civil society, the private
fields also will be considered under the joint work. sector, and multilateral and bilateral agencies.
H6 support will build on existing MHSCC
These advisory activities will complement other governance structures while ensuring that
development partners’ investments, supporting these embody the two key principles of
the implementation and achievement of inclusiveness and transparency.
6 7Moving toward UHC: Myanmar
References & Definitions (page 1 indicators)
UHC Service Coverage Index (2015) – Life Expectancy at Birth (2000-2015),
WHO/World Bank index that combines 16 Maternal Mortality Ratio (1990-2015),
tracer indicators into a single, composite Under-five Mortality Rate (1990-2015) –
metric of the coverage of essential health WHO Global Health Observatory:
services. For more information: WHO/World http://apps.who.int/gho/data/node.home
Bank (2017). Tracking UHC: Second Global
Monitoring Report. Wealth Differential in Under-five Mortality
(Single data point, year varies by country)
Catastrophic out-of-pocket (OOP) health – Indicator used by the Primary Health Care
expenditure incidence at the 10% threshold Performance Initiative (PHCPI) to reflect equity
(Single data point, year varies by country) – in health outcomes. For more information:
WHO/World Bank data from Tracking UHC: https://phcperformanceinitiative.org/indicator/
Second Global Monitoring Report (2017). equity-under-five-mortality-wealth-differential
Catastrophic expenditure defined as annual
household health expenditures greater than Performance of service delivery – selected
10% of annual household total expenditures. indicators (Single data points, years vary by
country) – Indicators used by the Primary Health
Results of the Joint External Evaluation of Care Performance Initiative (PHCPI) to capture
core capacities for pandemic preparedness various aspects of service delivery performance.
(2016/17, year varies by country) – A voluntary, PHCPI synthesizes new and existing data from
collaborative assessment of capacities to validated and internationally comparable
prevent, detect, and respond to public health sources. For definitions of individual indicators:
threats under the International Health https://phcperformanceinitiative.org/about-us/
Regulations (2005) and the Global Health our-indicators#/
Security Agenda. 48 indicators of pandemic
preparedness are scored using five levels (1 is no
capacity, 5 is sustainable capacity).
https://www.ghsagenda.org/assessments
Photo credits:
Page 3: Meriem Gray / World Bank
Page 6 & 7: Tom Cheatham / World Bank
Co-authored by:
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