In late 2013, BCMF staff conducted a brief analysis of the current state of the health care system in Burma. The findings in this analysis are based on interviews with health care professionals working both on the Thai-Burma border and inside of Burma, site visits to towns and villages in Karen State and Mon State, interviews with refugees and displaced people living on both sides of the Thai-Burma border, and clinical interviews with Burma Children Medical Fund (BCMF) patients and their family members. Below is a summary of their findings:

 

Healthcare Spending in Burma

While the recent political reforms in Burma hold promise for the country’s future, its long-neglected healthcare system faces a number of challenges before it can deliver effective and affordable care to the people. Although the government increased spending on healthcare in 2013, the rise brought healthcare spending to 3.9% of the country’s total budget. While the increase is promising, Burma remains one of the world’s lowest countries in terms of total money allocated to healthcare. In comparison, spending on the military remains high. In 2013, spending on the military represented 20.1% of the country’s total budget. A recent Reuters report noted that Burma was the only developing country in Southeast Asia where spending on the military is higher than combined spending on healthcare and education.

 

Current Challenges

According to a June 2012 article in The Lancet, Burma has some of the worst health indicators in the world. Life expectancy is 56 years, 40% of all children under the age of 5 are moderately stunted, and Burma has more than 50% of all malaria-related deaths in Southeast Asia. This is in part due to poor diagnosis and treatment, but also to the widespread prevalence of counterfeit anti-malarial medication.

Although the majority of Burma’s population lives in rural areas, most health services continue to be concentrated in larger towns and cities. For example, according to a 2012 annual report published by the Myanmar Ministry of Health, rural health centers have only increased from 1,337 to 1,565 since 1988.

Kyeik Ou Ma

Furthermore, the country had 28,077 doctors nationwide in 2011, but many (16,617) are concentrated in the private sector. Private sector health care remains unaffordable for much of the population, and out of reach for the majority of the population living in rural areas. Most villages lack basic healthcare and patients often travel long distances to reach hospitals or clinics located in the nearest town. However, patients find that even many of these clinics lack basic supplies, medication and equipment.

Mike Toole, a public health expert and advisor to a consortium of international donors to Burma, told Agence France-Presse, “I visited a lot of township level hospitals and I’m always struck by the fact that there are a lot of staff but very few patients. Patients just don’t go there because they don’t get good quality services; there is a lack of equipment, basic medical supplies, and drugs.” Speaking about the government’s plans to increase healthcare spending in the coming years, Toole noted “It will need massive investment… with comparable investment by the government and donors; it would probably take at least 20 years, and possibly 30, to catch up with Thailand.”

Health care professionals in Burma readily acknowledge that more investment is needed and have stated that the goal will be to further increase health care spending to 6% in 2014. Health care professionals in Burma report that another challenge facing the country is that there are limited numbers of specialists such as cardiologists and neurologists in the country. Further complicating things is that the majority of these specialists only work in Rangoon or Mandalay. While the goal will be to expand such specialty services to all states and divisions, that goal still remains far out of reach.  In a recent Asia News article, Burmese Health Minister, Dr. Phay Thet Khin summarized the resource constraints facing the country. In a speech to the Senate in August of this year, he noted that there are only 15 neurologists and 12 neurosurgeons in the entire country. With the exception of Rangoon, Mandalay, and Naypyidaw, he said there are not enough specialists to serve the rest of the country. In his speech, the minister stated that there is a shortage of urologists, gastroenterologists, and other specialists, with no hope for improvements in the short term since it takes more than 10 years for a doctor to specialize in a particular field.

 

The Impact of Conflict

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The country’s long history of conflict and unrest adds another layer of complexity to the challenges Burma will face on the road to health care reform.

According to Karen News, before the KNU and the Burmese government reached a cease-fire last year, Karen health workers were at risk of arrest and detention. In government designated ‘black zones’ ‘shoot on sight’ orders were in place, and health workers risked death for providing health service to Karen communities. As a recent article on Devex noted, conflict also adds another layer of complexity for aid organizations interested in working in Burma, where aid groups need permission from local armed groups to enter territories under their control. In addition to the KNU and the Burmese military, other ethnic armed groups operating in Karen State include the KNU/KNLA Peace Council, the Border Guard Force, and the Democratic Buddhist Karen Army (DKBA).Currently, Karen State which has a population of 1.3 million people is one of the most resource starved regions in Burma. (Many of BCMF’s patients come from Karen State since it is the region that is closest to Mae Sot on the Thai-Burma border). The ceasefire between the Karen National Union (KNU) and the Burmese government that has been in place since January 2012 has allowed some progress in addressing the region’s needs as the two entities have begun working together to address some of the more pressing health care issues.  However, only small steps have been taken as both sides must first seek the cooperation and approval of their respective leadership before moving forward.  According to an article published in Karen News, in April 2013, officers from the Karen National Union (KNU) health department and Dr. Naing, the Karen State Health Director, met and agreed to cooperate to fight malaria, to prevent maternal deaths, and to work together to get recognition for Karen State health workers.  While government officials agreed in principle to the planned cooperation, they said they first needed to report the issue back to Naypyidaw for approval. Similarly, KNU officials stated that they needed to draft a detailed health care plan and report back to the KNU’s Central Executive Committee for their approval.

 

Corruption, Tea Money, and Additional Costs for Patients 

Even with increased investment in the healthcare sector, Burma faces a long list of challenges when it comes to improving healthcare in the country. Widespread corruption can mean that the government’s increased spending on the healthcare system may disappear before it reaches its intended target. According to the World Bank, Burma is in the lowest percentile for government effectiveness, regulatory quality, and control of corruption—all key factors when it comes to ensuring that the increased spending on healthcare reaches intended targets.

At the other end of the spectrum, patients are frequently expected to make under-the-table payments to ensure they receive quality care. Patients seeking care on the Thai-Burma border report that bribery is a common and a widely accepted aspect of getting healthcare in Burma.  In addition to the upfront costs of doctor visits, medication, and supplies, patients report having to pay for everything from extra blankets to using the washroom. Families also say that if they want to ensure their loved one receives quality care from hospital staff, they must be prepared to pay extra. Those that are not prepared to pay bribes can expect longer wait times, poor quality care, and some patients report that hospital staff may simply ignore them altogether.

 

What All of This Means for BCMF Patients

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BCMF serves a large number of patients with complex medical conditions; the majority of these patients came to Thailand in search of treatment after they ran out of options in Burma. Many BCMF patients report first seeking treatment at their local clinic or hospital where they received limited care. In many cases, they may have gotten an inaccurate diagnosis or been sent home with a one week’s supply of medication ineffective for their condition such as paracetamol, multivitamins or antibiotics. For those patients who do receive an accurate diagnosis, they are typically referred to a larger hospital in Rangoon as local hospitals and clinics do not have the capacity to treat patients with complex medical conditions.  Outside of Rangoon and Mandalay, there are few hospitals that are able to provide treatment for complex cases, and even at those facilities in Rangoon that do offer care, treatment continues to be cost-prohibitive.

BCMF patients and their families often report having to sell precious belongings or borrow from a local money lender to make the trip to Rangoon. They then spend additional money on investigation and testing, only to be told that the only viable treatment is surgery. Inevitably the cost of surgery is more than they can hope to earn in a lifetime. In Burma, patients must pay up front and in full before doctors will proceed with surgery or any kind of medical treatment. Out of options and hope, patients and their families return back home in debt and without treatment.

It is only after they hear about Mae Tao Clinic or BCMF from a friend or neighbor that patients then attempt to make the trip to the Thai-Burma border in a last-ditch effort to get treatment that remains out of reach in Burma. After arriving at Mae Tao, patients with complex medical conditions are then referred to BCMF staff who coordinate and fund their surgery in Chiang Mai.

Despite the progress to address Burma’s health care needs, options for patients in need of complex medical treatment remain limited. Burma is most definitely taking steps in the right direction when it comes to health care reform, but Burma watchers and public health experts point out that the task is monumental. For those that need treatment in the here and now, BCMF will continue to serve as many patients as we can.