After decades of institutional neglect of the health sector, recent efforts have been made to improve the health status of the population. These efforts translated into a rise in public spending on health from 0.2 per cent of GDP in 2009 (the lowest in the world) to slightly over 1 per cent in 2014. They also led to visible improvements in the fight against communicable diseases – malaria, tuberculosis, and HIV/AIDS. Despite these efforts, considerable challenges remain.
The health status of the Myanmar population is still poor and does not compare favorably with other countries in the region. Life expectancy at birth, for example, is 64.7 years in Myanmar, the lowest among ASEAN countries. Moreover, hidden behind the national averages are wide geographic, ethnic and socio-economic disparities.
The Myanmar health system currently faces many challenges. These relate to the availability and distribution of inputs (e.g. human resources, physical infrastructure, essential medicines and supplies, financial resources) and to weaknesses in key functions such as supportive supervision, referral, supply chain, health management information system, and public financial management. Limited oversight, leadership and accountability further exacerbate these challenges.
Myanmar currently allocates only 3.65 percent of its total budget on health, which is extremely low by global and regional standards. As a result, out-of-pocket (OOP) spending by households remains the dominant source of financing for health. It can push or keep households in poverty and it prevents many from seeking necessary health care.
Universal Health Coverage (UHC) is defined as all people having access to needed health services of quality without experiencing financial hardship. Myanmar’s political leadership has expressed a strong commitment to accelerating progress towards UHC, which has also become a global priority. The National Health Plan (NHP) aims to strengthen the country’s health system and pave the way towards UHC, choosing a path that is explicitly pro-poor. The main goal of NHP 2017-2021 is to extend access to a Basic Essential Package of Health Services (EPHS) to the entire population by 2020 while increasing financial protection.
The NHP also aims to promote further alignment at several levels:
• Among programs (e.g. by encouraging more integrated training, joint supportive supervision, better aligned
referral mechanisms, a more streamlined health information system)
• Among development partners (DPs), through stronger oversight and coordination
• Among the different types of providers, through the engagement of Ethnic Health Organizations (EHOs), Non-
Governmental Organizations (NGOs), private-for-profit providers, etc.
• Among implementing agencies by ensuring that projects and initiatives contribute to the achievement of the NHP goals
Extending the Basic EPHS to the entire population will require substantial investments by the Ministry of Health and Sports (MoHS) in supply-side readiness at Township level and below and in strengthening the health system at all levels. It will also require active engagements of health providers outside the public sector, including private-forprofit GP clinics, EHOs and NGOs. Services and interventions will need to meet the same minimum standards of care, irrespective of who provides them.
Geographical prioritization The NHP will be operationalized nationwide to deliver the Basic EPHS based on existing capacity. Investments to expand Townships’ capacity by improving service availability and readiness, however, will be gradually phased in, prioritizing Townships with the greatest needs. This will be based on objective criteria. Initially relatively crude indices will be used, constructed using available data from both public and private sectors. The Health Input Scoring Index (HISI) summarizes a township’s situation with respect to infrastructure and health workforce, and compares it to national norms defined in terms of population and area. The Health Output Scoring Index (HOSI) captures a township’s performance on selected key output indicators in relation to specified thresholds. Assumptions relating to the norms and thresholds can easily be adjusted to assess alternative scenarios. These indices will be refined as more and better data becomes available. From the prioritized list of Townships, the actual number of Townships, in which investments in service availability and readiness are to be initiated each year, will be determined by overall fiscal space for health and the capacity to deploy additional resources.
Service prioritization Another form of prioritization is in the definition of the EPHS, which will grow over time, starting with a Basic EPHS to be guaranteed for everyone by 2020. The size of the package largely depends on what the country can afford and deliver. If a service is currently excluded from the package, it only means that access to this service cannot yet be guaranteed for all. The content of the Basic EPHS is currently being defined based on objective criteria. It emphasizes the critical role of primary health care and the delivery of essential services and interventions at Township level and below, starting within the community.
Planning at Township level – Inclusive planning at the local level will be essential to achieve the NHP goals. The planning will be based on a good understanding of current situation: who is doing what and where; which services and interventions reach which communities; where are the gaps and who could fill them. This information will be fed into a national database that will be regularly updated and that will support planning and monitoring efforts at all levels of the system. Using this information, stakeholders at Township level will be able to jointly plan and cost actions that need to be taken to fill coverage gaps and meet the minimum standards of care. These actions will need to be prioritized to fall within the broad resource envelope (specifying human, material and financial resources) communicated by the State or Region. All of this will be captured in an Inclusive Township Health Plan (ITHP) using national guidelines and templates. These will be introduced nationwide, irrespective of whether the Township is being prioritized for additional investments. States and Regions will have a key role to play in supporting and overseeing the planning and budgeting process, as well as the implementation of the ITHP.
Systems building – The provision of a Basic EPHS at Township level and below is conditional on a well-functioning health system. Supply-side readiness requires all the inputs, functions and actors’ behaviors to be aligned. In conjunction with the operationalization of the NHP at the Township level, investments will be needed to strengthen key functions of the health system at all levels. Health systems strengthening efforts will be organized around four pillars: human resources, infrastructure, service delivery and health financing.
A clear health financing strategy will be developed to outline how resources will be mobilized to finance progress towards UHC and how risk pooling mechanisms will be developed to help improve affordability of care and address the substantial barriers to seeking care, especially among the poor and vulnerable. The health financing strategy will, for instance, determine whether a mechanism to target the poor needs to be established or not, and what will be done to ensure the informal (non-poor) sector can access services without experiencing financial hardship. Temporary measures to reduce out-of-pocket spending on health by poor and vulnerable households will be adopted, harmonized and/or extended while these risk pooling mechanisms are being developed.
Supportive environment – Successful implementation of the NHP will also require a supportive environment. This includes adequate policies developed within a robust regulatory framework, strengthened MoHS leadership and oversight, enhanced accountability at all levels, a strong evidence base that can guide decision making, improved ethics, etc.
Community engagement – While supply-side readiness is at the core of the NHP 2017-2021, the demand side cannot be ignored. The NHP includes elements that will help create or increase community engagement and the demand for essential services and interventions. Focusing on the Basic EPHS, for example, will clarify entitlements and manage expectations. The introduction and strengthening of accountability mechanisms, including social accountability, will help give communities a voice, which in turn will enhance responsiveness of the system.
The NHP will be translated into annual operational plans that will elaborate on implementation details. Considerable coordination and close monitoring will be required to ensure implementation remains on track. A strong M&E framework will be developed to that end. The framework will look explicitly at equity under its various forms. Implementation research will be an integral part of the M&E framework. It will help assess whether the NHP is being implemented as planned, and identify areas where corrective measures need to be taken to put implementation back on track.
Immediate tasks to be carried out include (but are not limited to):
• The finalization of the Basic EPHS
• The costing of the NHP
• The prioritization of Townships where investments in improving service availability and readiness are to be made
• The development of the NHP M&E framework
• The institutionalization of implementation research • The preparation of a ‘national’ approach for the assessment of service coverage at Township level
• The development of a ‘national’ approach to the elaboration of an Inclusive Township Health Plan
• The identification of most urgent efforts needed to strengthen the health system and further develop the enabling environment