WHO CCS Myanmar...WHO Country Cooperation Strategy [CCS], Myanmar 3 Table (1) Trends in Health Outcomes and Indicators over time, 1990-1997 SR. STATUS No. INDICATORS 1990 1995 1997

WHO Country Cooperation Strategy [CCS], Myanmar 1

q:\chs\WHO CCS Myanmar [28 June 00]

WHO Country Cooperation Strategy [CCS], Myanmar

1. INTRODUCTIONGlobally, significant changes in political, socio-economic, demographic, epidemiological frontshave been occurring during the past decade. The WHO needs to ensure that it continues to makethe greatest possible contributions to world health against this changing context. Thus, the needfor reforming WHO in the way it carries its business in these changing context.Initiated by Dr Gro Harlem Brundtland, the Director-General of WHO, in early 1999, the WHOCorporate Strategy provides a strategic framework for WHO to do its work better, do it moreeffectively and efficiently through collective and partnership action.The WHO Corporate Strategy is built upon the mission as enshrined in its constitution and thevalues and principles of the Global Health for All Policy reaffirmed by the World HealthAssembly in 1998. The Corporate Strategy identifies four strategic directions, priorities, for WHOsupport including the criteria of selecting priorities and WHO core functions in pursuing thesepriorities. The 105 session of the WHO Executive Board (EB) has endorsed the WHO CorporateStrategy WHO (EB 105/3) in January 2000. In this context, the Country Cooperation Strategy[CCS] forms the basis of WHO biennial programme budget formulation and preparation ofbiennial plan of action. CCS is a tool for coordination of support from HQ and Regional Office tothe country office and country. See Annex-1 for WHO Corporate Strategy.Based upon the Corporate Strategy, regional and countries' challenges and directions, theCountry Cooperation Strategy (CCS) aims to set out the strategic health sector agenda andpriority areas for WHO's support in the next four years. The objectives and expected outcomesand method of work of Myanmar CCS Missions were as follows:Objectives:1. To understand key health and development policy issues.2. To have an overview of support provided by other development partners.3. To examine WHO's current strategy and programme of work.4. To identify processes and mechanisms for the organization to work as one WHO.Expected Outcome:A report on CCS, outline the country's health and development policy issues and health priorities,support provided by other health partners, WHO's current strategy and programme of work, andchallenges and opportunities offered to WHO in the country, identifying the priority areas forWHO's support in 2000-2003.The Method of Work:As a SEARO initiative, the formulation of WHO CCS for Myanmar was conducted throughteamwork involving WHO Country Office, Regional Office and HQ. Preparatory work startedsince January 2000. An outline of plan of work was developed following a joint planning meetingbetween country and regional team members and subsequently through email from CO, RO andHQ, as necessary. The teamwork was coordinated by Director of Health Systems and CommunityHealth, SEARO. List of team members, activity schedule and the method of work is in Annex-2.One very important feature of the Myanmar CCS, was having an in depth country participationthrough a 4 day CCS seminar. This was an strategically important process in the view of assuringcountry ownership of the CCS outcome. This seminar was inaugurated by His Excellency, Prof.Mya Oo, Deputy Minister for Health and attended by 45 participants consisting of national high


level officials, UN agencies (UNDP, UNFPA, UNICEF & UNAIDS), bilateral agencies (AUSAID,JICA), International NGOs (Population Council, AMDA) and National NGOs (MMCWA andMNCWA).The seminar was conducted through a logical sequence of three Group Works by using amodified Delbecque technique. Color coded cards were used in each of the three working groupsto generating participants’ views on the their respective objectives, which are consistent with thatof the CCS. The information thus generated was displayed and discussed for reaching group andplenary consensus. In short, these outcomes provided valid inputs to the work of the CCSformulation mission. A detailed description of this process, including activity schedule andprogramme and the list of participants of the CCS Seminar is in Annex-2 .Following the CCS Seminar, the CCS Team proceeded further work by consolidating theinformation of the CCS Seminar and reviewing the data supporting the rationale and partnershipsupport for each priority area identified for WHO support. The salient feature of the first draft ofthe CCS report was presented by the team in a debriefing session with the Honourable Ministerand Deputy Minister of Health, along with all the senior Director Generals of the Ministry ofHealth. The objectives and expected outcomes of the WHO CCS formulation for Myanmar werefully achieved in terms of its substantive and departmental participatory objectives.2. NATIONAL HEALTH SITUATION2.1. Overall National Health SituationMyanmar is a country with 46.4 million people (CSO, 1997) with abundant of natural resourcesincluding land, water, natural gas, coal, petroleum, mineral and marine resources.Uplifting of health, fitness and education standards of the entire nation are one of the twelvenational socio economic development objectives of the country.Myanmar has been going through far reaching changes from centralized socialist to marketoriented system since 1988. These changes involved political consolidation forming newrelationship in the cooperation between various government sectors and civil society,strengthening decision-making and technical implementation and facilitate development inborder areas and national races. Economic changes have lead to open market and the creation ofmore employment opportunity but also increased population migration mostly internalmigration, which has health implication due to social and environmental changes. Demographicis among such changes. Population pyramid of Myanmar indicates ‘young population’ with 33%under 15 years of age; the declining fertility rate may have an impact on the future demographicdistribution. All these changes have tremendous effects on the health of the people.Myanmar has a rich tradition of voluntary spirit, mainly due to Buddhist belief of earningspiritual merit by giving to those in need, and due to the absence of a caste system. MMCWA(Myanmar Maternal and Child Welfare Association) provides one of the best illustrations of suchvoluntary spirit. The works of MMCWA has been internationally acknowledged. Myanmar nowis a member of ASEAN and BIMSTEC (Bangladesh, India, Myanmar, Sri Lanka, and ThaiEconomic Council) that opened the opportunity of inter-country cooperation for country’sdevelopment.As the country is striving to attain its health objectives, positive trends in various healthindicators are found as presented in Table1.


Table (1) Trends in Health Outcomes and Indicators over time, 1990-1997STATUSSR.

No.INDICATORS

1990 1995 1997

1. Infant mortality rate (per 1000 live births) 94* - #74.72. Under five mortality rate (per 1000 live births) 138* - #105.83. Total fertility rate (urban) (*) 3.56 3.49 3.454. Maternal mortality Ratio (per 100,000 live births) - - 230A, 580B

5. Births with some prenatal medical care (%) - 61* #766. Women using contraception # (%) 17 22 46.97. Children less than 3 yrs old with moderate and severe malnutrition @ (%) 37 40 358. Children with complete vaccination for (%) @

• DPT3• Measles• Polio

696870

757575

808182

9. Births attended by a trained attendant (%) # - 46 5610. Cases of ARI medically treated (%) - 26 5611. Cases of diarrhoea medically treated (%) - 24 6812. Severe malnutrition among children under three - 16 1213. Proportion of births weighing less than 2500 gms (**) 24 - -14. Prevalence of anaemia among pregnant women (***) - - 58%

*Population Change and Fertility Survey (1991), Dept. of Population.@ UNICEF estimates from MICS# Fertility and Reproductive Health Survey (1997), Dept. of PopulationA FRHS 1997, The State of World’s Children 2000 (UNICEF), UNFPA and MMCWAB Revised 1990 estimates of MMR (A new approach by WHO and UNICEF – 1996)(*) Statistical Year Book 1998, Govt. of the Union of Myanmar, Central Statistical Organization, Yangon(**) National Nutrition Survey, 1991(***) MoH/Myanmar, Situation Analysis of Household Nutrition Security, 1997

The CSO estimated life expectancy at birth combined for both sexes is 62.6 in 1997. In the area ofchild health, notable progress has been achieved primarily through strengthening of Basic Healthservices for the all children with special focus on under-served areas. Despite the linear declinein the utilization of institutional services (Statistical Year Book, 1998); there is an increasing trendin the coverage of antenatal and delivery services by trained personnel including treatment ofchildhood diseases. This may mainly be due to the domicilliary services provided by midwife andnurses, who provide basic services to the poor at free of cost.High maternal mortality ratio and high percentage of low birth weight, however, still remain aserious concern. Although no updated trend data is available, the Ministry of Population andUNFPA is currently undertaking a longitudinal study on maternal mortality, which is expected tobe completed by the end of year 2000. Currently the country adaptation of WHO/SEAROstandards for midwifery practice in four townships is about to be completed. These two studiesare mutually complimentary and would give direction for future scaling of program for reductionof maternal and perinatal mortality. Despite the increasing trend in CPR, there is still as high as44.4% of unmet demand for contraceptive (FRH Survey, 1997). Such high level of unmet needsleads to among others, a high risk of unsafe abortion and maternal deaths. In view of this,effective provision of integrated package of family planning, midwifery and essential obstetricincluding post abortion care through all levels of health systems is a priority concern.2.2. Access to and Utilization of Health ServicesWhile the government has set up a fairly widespread system of health care providers, utilizationtends to be relatively low. It is interesting to note that while treatment at Traditional MedicalCenters has risen more than four fold, the general usage of hospitals and dispensaries in 1996-1997 had fallen to less than 20% of the levels recorded 10 years before (Statistical Year Book, 1998).In depth interview with the national experts indicates that this could be due the combined effects


of three factors, i.e. the increasing private sector, introduction of user fee at the public institutions,and inadequate responsiveness of the health systems.2.3 Major Health Problems and Key Issues for Health2.3.1. Main health problemsAnalyses on the overall health situation suggest that: Communicable diseases remain majorhealth problems that constitute excess burden on the people, on the health services, and on theeconomy of the country. These indicate the need for interventions that aimed at modifying lifestyle and environment. Common childhood diseases particularly diarrhoea and acute respiratoryinfection is another area of public health concern which require an integrated response. Malariais a major concern of almost 59% of people of the country who live in high and moderate risk(National Malaria Programme, MOH, 1999). In 1998 alone malaria morbidity rate was 12 per 1000and mortality rate was 6.7 per 1000; proportion of malaria cases among OPD attendance was 9.4%with 16.2% hospital in-patient rate for malaria. Dengue/DHF is also becoming an increasingproblem, major epidemic occurred in 1998 with 13,000 cases (24 Months WHO CollaborativeReport, 1998-1999). TB compounded by HIV/AIDS has reemerged as a major health problemparticularly in the border areas. 5% of TB cases were HIV positive and 60-80% of AIDS patientshad TB. With estimated 1.6% of the population infected every year, about 100,000 people progressto develop tuberculosis. Over 29,000 new TB cases were reported and an estimated number ofpeople infected with HIV was over 440,000 in 1999. To cope with TB problem, Myanmardeveloped DOTS in 1997. 69% of townships and 80% of population will be under DOTS strategyby end 2000 (National TB Programme, 1999). Polio eradication programme has made significantprogress and is expected to reach the target by the end of 2000. Leprosy elimination has becomean achievable goal by the end of 2000 after intensified social mobilization efforts discovered morehidden cases and put them under complete MDT coverage.Maternal health is another area of health concern. Although the estimated maternal mortalityratios differ significantly from one estimate to the other, it varies from 230 per 100 000 live births(FRHS 1997) to 580 per 100 000 live births (Revised Estimates WHO-UNICEF, 1996). There areurban and rural differences too – higher MMR in rural areas (CSO, 1998). By whatever estimates,it is clear that pregnancy-related deaths constitute the leading cause of loss of healthy lives amongwomen of reproductive age. According to the on-going study on maternal mortality by MOH andUNFPA, 57% of maternal deaths occur at home and 4% on the way to the hospital; around 37% ofdeaths occur in public hospitals. Haemorrhage, eclampsia, obstructed labor and unsafe abortionconstitute major causes of maternal deaths.Nutrition is an area that needs greater attention. Evidence drawn from National Nutrition Center(NNC) surveys suggest that PEM under three years of age is 35%; IDD-visible goiter rate among5-11 years is 33.1%; iron deficiency anaemia in pregnant women is 58%; vit A deficiency-Bitot’sspot prevalence among under five is 0.4% and low birth weight in new born babies is 24%.Traditional medicine is formally recognized and practiced as an integral part of health services atdifferent level. Training and research projects are carried out on various diseases.Water supply and sanitation are improving and current situations are water supply rural 42.2%and urban 70.1%; sanitation rural 43% and urban 70.5%.2.3.2. Key issues in healthRecognizing the pivotal role of health for sustainable development of the country, the MOH iscommitted to strengthen its health system to meet the needs of the people. Making “health”central to human development, equitable access to essential primary health services has beenensured, even in the remote border areas and the poor.


Extensive research in health has been conducted by Department of Medical Research, MOH. Thekey issue to be addressed is greater need in utilization of the research results in the improving theprogramme and health systems performance.To address poverty and health issues, the Government has established the Ministry of Progress ofBorder areas and National Races and Development Affairs. Considering that communitiescontributions in the spirit of voluntarism provided over 66% of the inputs in the form of funding,labor and transport, the community ownership should be encouraged through their involvementin programme decision making and monitoring at local level. The key issue here includesdecentralization and fairer distribution of services in the marginalized area.With increasing trend towards privatization and the market-oriented economy, the poor are ingreater disadvantage. Evidence of inequity in health is clearly shown in the difference in healthstatus between people living in urban and rural areas (National Nutrition Survey, 1991, FRHsurvey, 1997 and Statistical Year Book, 1998, Table 1). The key issue is the need for public sector toprotect the interest of the poor.2.4. Partnerships in HealthThe external assistance is one of the major sources of financing in the health sector. Historically,the support of various partners, especially the UN agencies on health development activities inMyanmar started in the late 1940s. In the last decade of the 20th century, the pattern andmechanism of assistance from various partners changed. Major bilateral donors decided to scaledown their assistance but a number of international NGOs came into the scene. In 1996, externalassistance had increased to US$ 17.16 million, due to more assistance from those internationalNGO partners. In addition, some U.N. agencies have developed new modalities in theirassistance towards the area of health development. Among the multilateral donors, WHO,UNICEF and UNDP are the major contributors. Myanmar, as one of the countries of Associationof South-East Asia Nations (ASEAN), has adopted the activities of the ASEAN Medium TermPlan of Collaboration in Health and Nutrition 1998-2002, which is a base for partnership in healthbetween ASEAN countries.In Myanmar, the main areas of health in which both the international and national partners havecontributed are as follows: (i) infectious diseases control (emphases on malaria, vaccinepreventable diseases, HIV/AIDS/STDs, tuberculosis, leprosy), (ii) reproductive health, (iii) healthsector reform, (iv) anemia & malnutrition, (v) water & sanitation, (vi) health system developmentincluding quality of care and health manpower development, (vii) safe blood, (viii)accidents/disabilities, (ix) snake bite, (x) IEC, (xi) life style/tobacco, and (xii) health of the elderly.Mechanism of Partnership in Health. Partners involved in the field of health and their activitiesare elaborated in the Annex-3. The International Health Division (IHD) of the Ministry of Healthis the central co-coordinating body between donor agencies, NGOs and various departmentsproviding health care under the ministry. In case of external assistance from UN agencies, theIHD, the respective UN agency and Foreign Economic Relations Department (FERD) or Ministryof Foreign Affairs (MOFA) communicate reciprocally in two ways.There is a well-established relationship between MOH and WHO. In case of NGOs, two waycommunication between IHD and respective NGO is done through dialogue or correspondence.After completing the initial steps, the proposals on respective matters are submitted to AttorneyGeneral Office, Myanmar Investment Commission, Foreign Affairs Committee (FAC) of MOFAand then to the Cabinet. Subject to the Cabinet decision, Memorandum of Understanding (MOU)could be signed between the concerned health department and respective NGO.Other ministries related to health are also working in collaboration with the Ministry of Healthfor the health development. This collaboration is coordinated and strengthened by the NationalHealth Committee. The Ministry of Information and the Ministry of Education are indispensable


partners in disseminating health information and education. The Ministry of Health incollaboration with Ministry of Agriculture and Irrigation, Ministry of Progress of Border Areasand National Races and Development Affairs worked on the provision of safe water for thecommunity. The Ministry of Mines is the key partner of the Ministry of Health in theestablishment of universal iodization of salt in the country. in providing promotive andpreventive health services to the people.Challenges in partnership. With the introduction of market-oriented economy, privatization ofhealth care and the expansion of private sectors as main actor of economic growth, private-publicsector partnerships have become necessary. The private sector is expected to make an increasingcontribution to health sector and alternative public health financing would be explored andexpanded to unreached areas, i.e., border areas. For an effective partnerships, alternative meansof doing so are through introducing relevant laws, regulations etc.Role of WHO in partnerships. WHO has been a long standing and a most intimate partner forHealth Sector Development in the country. The government, especially the Ministry of Healthaccepts WHO as the main technical lead agency in health and deeply appreciates the supportgiven by WHO during the past five decades starting from WHO programme budget 1950-1951.There is a need for optimal utilization of existing resources through partnership. Partnershipshould mean avoiding duplication by working together for common objectives. This meansdrawing synergy and complementing each other’s work. This also means being mutuallytransparent and sharing both success and failures, but not blaming each other. In principle, theGovernment has basic responsibility to co-ordinate partners’ assistance. Frequent dialogue isneeded, which includes exchange of technical information and operational plans of activities ofpartners. Linkages between the partners include joint planning and joint budgeting exercises.However, this does not mean merging budgets. Co-ordination of the activities of all partners inhealth is essential tool for getting an effective partnership. Cooperation between partners andproject managers should be strengthened, too. Understanding the process of aid coordinationwould be beneficial to both partners and recipients for effective utilization of aid. Externalassistance contributes 14 % to national health expenditure and equals to 85.8 % of governmenthealth expenditure in Myanmar. Coordination and management of partners’ assistance should bestrengthened and upgraded.The MoH and WHO had jointly conducted the Aid Coordination Workshop in Myanmar inJanuary 1998 and recommended to have regular coordination mechanism among the partners.While MoH leads the role of coordination, WHO serve as technical backstopping to this process.The MoH has already formed the body led by Director-General of Health Planning for AidCoordination among partners for health development. The detailed activity monitoring are doneby the line departments and the respective Directors General are responsible for that. Theproblems / issues are regularly discussed in the executive board of the Ministry of Health whichoccurs once a week and issues need policy decision are solved at the higher coordination bodiessuch as Foreign Affairs Committee and National Health Committee. The CCS seminar in June2000 has reached a consensus that the aid coordination seminar involving all present andpotential partners should be done at least once a year and monitoring twice a year.The outcome of the Group Work III of the CCS seminar has indicated the scope, nature andlocation of support provided by major international and national health partners by each of thesix priority areas identified for WHO support during 2002-2005 (see Annex-4). Although theMyanmar Academy of Science appears to be the single major partner in health systemdevelopment, there are many other partners supporting priority health programmes. Suchpartnership support to the priority health programmes would also contribute in strengtheningthe health systems for delivering services which are responsive and fair in distribution. What is


needed, however, is to bring a greater coordination and synchrony among other partners andprogrammes in the management of these priority areas through health systems.2.5 Flow of FundsThe International Health Division (IHD) of the Ministry of Health is the central co-coordinatingbody between donor agencies and various departments providing health care under the ministry.In case of external assistance from UN agencies, the IHD, the respective UN agency and ForeignEconomic Relations Department (FERD) or Ministry of Foreign Affairs (MOFA) arecommunicating reciprocally in two ways. There is no fixed starting point among the agencies.There is a well established relationship between MoH and WHO. A joint Government / WHOCollaboration Programme Co-coordinating Committee, headed by the Deputy Minister forHealth, is responsible for planning, coordinating and evaluation of WHO collaborativeprogrammes. The committee meet every six months to monitor and evaluate the progress of theWHO collaborative programme. In case of NGOs, two way communication between IHD andrespective NGO is done through dialogue or correspondence. After completing the initial steps,the proposals on respective matters are submitted to Attorney General Office, MyanmarInvestment Commission, Foreign Affairs Committee (FAC) of MOFA and then to the Cabinet.After completing these formalities, Memorandum of Understanding (MOU) could be signedbetween the concerned health department and respective NGO.3. WHO COLLABORATIVE PROGRAMMESWHO Collaborative Programmes in Myanmar during the current and past two biennia haveembraced on a broad-based approach toward meeting the national health needs. The major thrustof WHO Collaborative Programmes over the past three biennia have been on the priorities withinthe six broad areas of National Health Plan: (1) community health care, (2) disease control, (3)hospital care, (4) environmental health, (5) health systems development, and (6) organization andmanagement. In general these collaborative programmes are found in line with the NationalHealth Policy (1993), the National Health Plan (1996-2001). It is also meet the four orientations ofWHO 9th General Programme of Work i.e. integrating health and human development in publicpolicies; ensuring equitable access to health services; promoting and protecting health; andpreventing and controlling specific health problems.The government utilized all the WHO resources to meet the need by focusing wisely on usingWHO as technical resources for priority programmes. This approach which acknowledges socio-economic and political constraints, epidemiological situation, difficulties poses by geographicfactors, would have make WHO country programmes more relevant. Its complementarity withthe programmes of other development partners would have been effective and efficient inassisting the government in meeting the country’s needs and priority.Due to country’s limited access to external funding sources, the number of projects supported byWHO collaborative programmes reflect strong national inclination for having WHO support asmany programmes as possible and spread WHO resources thinly among many areas of work.Thus, WHO collaborative programmes during the period under review could not shift from the“full menu approach” to a “selected priority areas”. Consequently the support provided throughWHO collaborative programmes did not fully match with the priority ranking order of the healthproblems.For example, malaria stood out as the highest ranking problem in the last five NHPlan since 1978,but malaria was ranked 5th in terms of WHO collaborative programme under regular budget.Similarly, tuberculosis, the second highest ranking since 1986, it ranked 21st in WHO collaborativeprogramme (1994-1995), and 12th in 1996-1997. The third highest-ranking priority i.e. HIV/AIDSand diarrhea and dysentery ranked 16th and 24th respectively in 1994-1995 WHO collaborativeprogrammes. However, support from other partners has fulfilled the gap.


Although spread out into 40 projects or plan of actions, WHO collaborative programmes havehad catalytic role in producing some strategically important results. A draft decision paper on“Myanmar: Main Health Policy Issues and Country Strategy” developed by WHO ICO Mission incollaboration with senior officials of Department of Health Planning, serves as the backgroundpaper in matters relating to future health policy and health development in the country. Anotherstrategic outcome was that the country established a WHO-Government coordinationmechanism, which meets formally or otherwise, every six month. A flexible but strategicapproach such this one has been instrumental in involving various levels of decision making forplanning and implementing of WHO collaborative programmes.Some highlights of WHO collaborative programmes is also evident from the regional officeperspective when reviewing plans in each department carried out during 1998-1999.Under the area of eradication of specific communicable diseases, successful implementation ofNIDs and subnational NIDs for polio eradication was organized and National CertificationCommittee was established. WHO also provided assistance in implementation of MDT strategyfor elimination of leprosy, prevalence rate was reduce from 53.4/10,000 (1987) to 2.5/10,000 beend of December 1998.The area of prevention and control of specific communicable diseases continue to receive supportfrom WHO. Efforts to reduce dengue/DHF case fatality rate made continued progress withestablishment of three dengue training wards using standard sets of equipment sent by WHO.Training programmes on case management for physicians from all state and division levelhospitals have been conducted in these training wards.Control of malaria has been identified as priority programmes and is being implemented underthe primary health care approach. RBM Initiative has been endorsed and plan of action forresource mobilization has been developed with the coordination of the government, WHO,UNICEF and UNDP to support implementation at local level. WHO technical assistance wasgiven to the implementation of malaria control in 40 townships funded under UNDP-HDI project.Realizing malaria as a common problem shared by neighboring countries, WHO facilitatedintercountry collaborative programme for control of border malaria on bilateral and multilateralapproach. To cope with the problem of multidrug-resistant malaria, UNICEF and WHO workjointly under RBM Mekong Project with countries in the Mekong Basin. Myanmar, Thailand,China (Yunnan Province), Laos PDR, Viet Nam and Cambodia are the six countries collaboratingin this project. WHO SEARO’s support to organizing annual Health Ministers’ Meeting has beeninstrumental in facilitating collaboration for health between Myanmar and her neighboursTuberculosis continued as an issue of primary concern which becomes even more serious healthproblem compounded with HIV/AIDS and failure in treatment compliance. WHO continuedrendering technical assistance in term of expertise, training and diagnostic tools and drugs. In1998, DOTS is being implemented in 153 out of 324 townships, covering 60% of the county’spopulation. 39 townships were benefited from TB control assisted by WHO under UNDP-HDIproject. An additional $ 272,000 extra budgetary funds was mobilized by WHO for TB control in1999.In the area of reproductive health, health of women and children, WHO provide technicalassistance in transforming the traditional MCH concept to the comprehensive reproductive healthapproach. Priority was given to capacity building for need assessment in essential reproductivehealth needs and development of plan of action.In the area of promotion of environmental health, the government gave high politicalcommitment of Water and Sanitation (WATSAN). WHO continued to provide technical assistancein capacity building for rural water supply development programme, water analysis laboratory,environmental engineering in sanitation and pollution control. The national figures for sanitation


coverage has increased from 45.2% in 1997 to 61.7% in 1999. With change in strategy from supplydriven donor-financing to self reliance and self help financing through social mobilization processit is expected construction of 1 million latrines will be completed by end of 1999.With the support of ICP-II funds 237 officials from Myanmar have attended 139meetings/seminars/workshops during biennium 1998-1999. At the same period, an amount of 11short term consultancy work have been carried out in Myanmar covering technical aspects in theareas of nursing, traditional medicine, essential drugs, medical records and health informationmanagement, quality control of laboratories, tuberculosis, malaria, and primary health care.By all account, the results of WHO collaborative programmes during 1998-1999 are in consonancewith the four WHO strategic directions as well as the National Health Policies and Prioritieswhen one viewed the collaborative programme of 1999-2001 against those in the past threebiennia. The number of PoA in the last biennia has come down to 27 in 2000-2001 and they areclassified under various clusters. Such harmonization reflects, among others, the robustness ofjoint planning exercises conducted during 1998-1999 between WHO and national partners inpreparing the PB 2000-2001.The fifteen policies of the National Health Plan 1993-2001, when viewed against the four WHOstrategic directions, indicate that:

• The 15 national health policies relate well to the four WHO strategic directions• Although these 15 policies cut across all the four strategic directions yet most of them

cluster around strengthening health systems.4. PRIORITY HEALTH AREAS FOR WHO SUPPORT DURING 2002-2005The six priority health problems proposed for WHO support are selected by the CCS seminar byusing the eight criteria that the participants jointly developed in the seminar for selectingpriorities for WHO support for 2002-2005. These are as follows:4.1 Myanmar Criteria for Selection of PrioritiesSelection criteria for priorities should be in harmony with the national political, economicand social objectives.4.1.1 Potential for significant change in national burden of diseases with existing cost-effective

interventions considering local situation.4.1.2 Health problems with major impact on socio-economic development and a

disproportionate impact on the lives of the poor.4.1.3 Opportunities to reduce health inequalities within (vulnerable groups, national

races/localities) and between countries4.1.4 Comparative advantages of WHO: particularly in relation to the production of public

goods, building consensus around policies, strategies and standards, initiating andmanaging partnerships.

4.1.5 Major demand for WHO support based on country’s needs.4.1.6 Urgent need for applicable new technologies.4.1.7 Availability of support from other agencies and partners.4.1.8 Potential to strengthen development of human resources and research.4.2 Major Priority Health Areas Identified for WHO Support for 2002-2005

4.2.1 Health Systems: Improving PerformanceSince health systems are the vehicle for all technical interventions, strengthening health systems isa pre-requisite for improving the provision of all health services. Without a well functioning


health system the technical interventions are not likely to have a major impact on health incomes.Health systems development is already one of the government's priority as stated in its nationalhealth policy and plan thus the priority area for WHO support (see Annex-5).

4.2.2 Excess Burden of DiseaseMalaria, tuberculosis and HIV/AIDS have become major public health concerns. Leprosy andpolio are on the verge of being eliminated while Dengue Haemorrhagic fever is on the rise(see Annex-6). With longer years of life expectancy, major NCDs (CVDs, Cancer, Diabetes andChronic Pulmonary Diseases) become prominent. Thus these health problems become priorityareas for WHO support (see Annex-6).

4.2.3 Women’s HealthAs women bear the greatest biological burden of reproductive health, pregnancy-related deathsconstitute the leading of loss of healthy lives among women in reproductive age in Myanmar.Haemorrhage eclampsia, obstructed labour and unsafe abortion constitute the major causes ofmaternal deaths. There is also need to follow the Beijing Plus 5 and institutionalize disaggregateddata into HMIS and mainstreaming women's health concerns in all health policies andprogrammes. All these areas need WHO's support in partnerships (see Annex-7).4.2.4 Child and Adolescent HealthInfant Mortality Rate (IMR) and under 5 Mortality Rate (U5MR) are known indicators of qualityof life. In Myanmar, although there has been a decline in the last decade, both the IMR and MMRare still considered to be high. As adolescent population constitutes 20.5% of the total population,and their health habits set the health pattern for their entire life span, investment in adolescenthealth would give many health dividends. Thus child and adolescent health becomes a priorityarea for WHO support (see Annex-8).

4.2.5 Environmental HealthEnvironmental Health has been high on an agenda in the National Health Plan 1996-2001. Inspite of the fact that, for the next period in this area, collaboration of some partners is anticipated,WHO's role in the water quality monitoring and technical support in areas of safe drinking waterand sanitation is indispensable (see Annex-9).

4.2.6 Risk FactorsTobacco is a major risk factor which relate to illnesses and deaths worldwide. Unsafe bloodassociates with the increase of HIV/AIDS. Malnutrition especially among infants, children andwomen has adverse health outcomes not only for women and children but also leads to low birthweight and quality of future generations. Thus they become priority areas for WHO support (seeAnnex-10).The above priority areas are presented as follows using matrix format which shows for eachpriority some important challenges opportunities, type of WHO support needed includingexpected results and partners involved.


5. CONCLUSIONThe interdepartmental and participatory method, involving all the three levels of WHO includingnational decision-makers, has been key to successfully achieving the objectives and expectedresults of the WHO CCS formulation for Myanmar. The use of modified Delbecque technique byusing color-coded cards was instrumental to generating individual views and reaching consensuson the pertinent topics relating to CCS objectives. As a result, the outcomes of this CCS exerciseare as much owned by the national as by WHO.The strong national consensus of this CCS outcomes emanates from the fact that the priorities forWHO support, as presented in the matrix formats (Section 4) were identified by the nationals byusing the Myanmar relevant criteria which they jointly developed during the Group Work I. TheGroup Work I had also analyzed the four WHO strategic directions against the 15 policies of thenational health plan (1993-2001) and these 15 national health policies were found well-relating tothe four WHO strategic directions. Although these 15 policies cut across all the four strategicdirections, most of them cluster around strengthening health systems. The priorities identified forWHO support for 2002-2005 are consistent with this collective observation.Using the eight criteria developed through the Group Work I, six major priority areas for WHOsupport for 2002-2005 have been identified by the Group Work II, which have been recommendedby the plenary through the consensus. These are presented in matrix format under Section 4. Theevidence-based data for selecting these priorities are detailed in Annexes 5-10.The information on the priorities, presented in matrixes in Section 4 of the report, indeed, providethe basis for mobilizing “one WHO” support including the assessment of the performance in thecontext of WHO corporate strategy. These matrixes also provide “at a glance” list of national andinternational partners who support these priority areas at country level.The outcome of the Group Work III of the CCS seminar has indicated the scope, nature andlocation of support provided by major international and national health partners by each of thesix priority areas identified for WHO support during 2002-2005 (see Annex-4). Although theMyanmar Academy of Science appears to be the single major partner in health systemdevelopment, there are many other partners supporting priority health programmes. Suchpartnership support to the priority health programmes would also contribute in strengtheningthe health systems for delivering services which are responsive and fair in distribution. What isneeded, however, is to bring a greater coordination and synchrony among other partners andprogrammes in the management of these priority areas through health systems.The CCS seminar strongly recommended that a detailed plan of action on each of these priorityareas should be jointly developed by involving the concerned expertise. The team suggested thatthe annexes of this report, particularly those providing evidence-based rationale for each of thepriority identified for WHO support for 2002-2005, should be used as important reference forjointly developing detailed plan of action for Myanmar in the near future.Timing wise, the CCS formulation seems to have occurred in an opportune moment. The outcomedocument of the CCS formulation is expected to provide inputs to the formulation of theforthcoming National Health Plan for Myanmar which is soon to occur.ACKNOWLEDGEMENTSWe, the members of the WHO Country Cooperation Strategy [CCS] for Myanmar, would like toexpress our grateful appreciation and thanks to His Excellency, Major General Ket Sein, Ministerof Health and His Excellency, Professor Mya Oo, Deputy Minister for Health, Government of theUnion of Myanmar, and the senior colleagues in the Ministry of Health for their valuableguidance, unfailing support and warm hospitality among the WHO Country Cooperation


Strategy Formulation Mission.Thanks are also due to many colleagues, including the partners from several national andinternational organizations, who helped us in completing this CCS formulation through aparticipatory approach.Last, but not the least, we are thankful to the support staff from both the regional and MyanmarWHO country offices for their efficient support accorded to the CCS team throughout its work.

CHS/SEARO, 15 Jun 2000

*Towards a Strategic Agenda for the WHO Secretariat Statement by the Director-General, WHO, at the 105th Session of EB, 24 January 2000

2Reduce excess

Mortalityand

Morbidity

1Place healthat the center

of thedevelopment agenda

3Deal

effectivelywith the

leading risks

4Strengthen

Health Systems

Health SystemMalaria, HIV/AIDS, TBTobaccoMaternal HealthSafe BloodMental HealthCancer, Cardiovascular DiseasesDiabetes, Chronic Respiratory DiseasesFood Safety

WHOPriorities

WHO Corporate StrategyWHO Corporate StrategyWHO Corporate Strategy

WHO Constitution - Mission

HFA policies

4 Strategic Directions and 6 Core Functions

Annex-1

1

Activity Schedule : CCS Development Myanmar[Revised on 15 May 2000]

MONTHSSr.No. Activity

JAN FEB MAR APR MAY JUN JUL

1. HQ participation requested/explored

2. WR initially contacted

3. RO team's preparatory meetings organized

4. Mission's objectives, expected outputs and method of workdiscussed/ascertained/adhered

5. Types of work identified and assigned to respective mission members

6. Dummy outline of mission report and dummy matrixes discussed anddeveloped

7. Collection and review of information by team members done at RO/CO

8. Information collated, analyzed and exchanged between RO/CO/HQ

CHS/SEARO06 Apr 2000

Annex-2

2

MONTHSSr.No. Activity

JAN FEB MAR APR MAY JUN JUL

9. Draft Working papers reviewed and ready by RO/CO/HQ

10. Country visited by the RO CCS Team, including HQ partner, and workconducted according to the agreed programme of work

11. Country perspectives obtained and analyzed through CCS seminar

12. Final draft of report prepared and debriefed at CO level 27

13. Finalization of the report 28

14. Presentation of the report by the team to DRD and RD 29

1

Annex-3Major partners involved in the field of health- UNICEF is supporting the following priority areas in health: vaccine preventable

diseases, malaria, reproductive health, HIV/AIDS, health sector reform,malnutrition and water and sanitation. Myanmar-UNICEF cooperation under the1996-2000 country programme has resulted in a progress in child health, e.g. inimmunization programme, Baby Friendly Hospital Initiative Project, andElimination of Iodine Deficiency Disorders. In some areas, UNICEF's support iseither both countrywide and different areas (e.g. in vaccine preventable diseases,HIV/AIDS, anemia/malnutrition, and water & sanitation), or limited to differenttownships (in the areas of malaria, reproductive health and health sector reform). In1/3 of a total number of townships (100), there has been a comprehensive assistancein the areas of health, nutrition, education and water sanitation, which has beendone in close cooperation with other partners. UNICEF's nature of support ismaterialized in advocacy, IEC, technical support, training, provision of drugs andbasic equipment. Health, Education, Water & Sanitation focusing onwomen/children (a "right-based support") is the scope of UNICEF's support.

- UNDP. Since 1994, UNDP has been selectively supporting key health areas withinthe framework of Human Development Initiative. Major inputs are flowing towardsthe community at the grassroot level. Main priority areas with the UNDP assistanceare (i) Primary Health Care Services, in 36 townships – HDIE and 23 townships –HDI III, (ii) HIV/AIDS – whole country, and (iii) water & sanitation – 36 townships(HDIE) and 23 townships (HDI III). In addition, UNDP also covers community-based programmes for malaria, tuberculosis and leprosy. UNDP's focus is ontraining/advocacy, resource provision and partnership building. Target groups areall levels of health professionals and all levels of the community/village level. TheHuman Development Index project under UNDP was implemented during theperiod of 1994-1996 in the areas of primary health care, HIV/AIDS, training andeducation , environment and food security. In that period, 33% of total HDI budget(US$ 25.6 million) was allocated to health. In the extension of the project in 1996-'98,36% of the total HDI budget (US$52.1 million) went to health sector.

- UNFPA. Since 1996, this U.N. agency has been a major supporter of Birth SpacingProject. For the next period of 4-5 years, priority area is virtually reproductive health,especially births spacing (ongoing), and Integrated Reproductive Health Services(which includes birth spacing, MCH, RTIs, STDs, HIV/AIDS, post-abortion care andARH information). It covers 72 townships in 11 States/Divisions. UNFPA focuses itssupport on training, IEC, contraceptive supplies, management information system,improvement of health facilities, medical supplies, RTI drugs' supply and MMCWAvolunteers training. It would consist of a short-term and long-term trainingprogramme for health personnel, and in-country training programme for BHS andvolunteer health workers.

- Population Council. This international NGO is supporting the areas of (i)reproductive health (especially post-abortion care, adolescent reproductive healthand quality of care in basic services) and (ii) HIV/AIDS. Most activities have beenimplemented in collaboration with U.N. agencies and International & NationalNGOs. In the area of reproductive health, all townships in Bago Division have beenincluded. In the HIV/AIDS area, covering of townships varies according to projects.The main nature of the Population Council support is directed to training, research,technical support and research. All categories of health personnel and members ofnational NGOs are included.

2

- Myanmar Maternal and Child Welfare Association ( MMCWA). The MMCWA is anational NGO which was established in 1991 with the main mission of promotion ofnationwide maternal and child welfare activities. Serving 321 townships, at presentMMCWA has 1, 4 million members serving as volunteers throughout Myanmar. Incollaboration with the Ministry of Health, the MMCWA participated in manyactivities to enhance the improvement of maternal and child health status. The focusof its work is at the village level, by working closely with the communities.MMCWA carries out a country wide campaign to advocate breast-feeding and birthspacing, participated in the immunization programme of infants and children andmade available nutrition programme to children. The health education activitiescover 279 township with approximately 2 million attendance. MMCWA is also veryactive in disseminating information for protection against HIV/AIDS and control ofthe disease. Since 1998, MMCWA expanded its work into two areas: reproductivehealth among the adolescents and youths and community based programme for theelderly.

- Myanmar Academy of Medical Sciences. This national NGO focuses mainly onhealth and health development, assisting the health sector in areas of health systemdevelopment, human resources development, education/training, health services,health technology and role of GP in health system. Taking into account a scope ofsupport directing to an academic and professional development, and a nature(advisory role-"think-tank"), support is centrally based; however, the activities mayalso be supported in any part of the country.

- Myanmar Red Cross Society. Red Cross Society focuses its support in the priorityareas of STD/HIV/AIDS (in border areas), water & sanitation (in dry-zone areas),safe blood (countrywide), accidents and disabilities (countrywide) and snake bite(countrywide). Red Cross Society technically supports capacity building and peereducation, human resources development and donor's motivation.

- Myanmar Medical Association. This national NGO supports the work in the priorityareas/issues of Reproductive Health, STD/HIV/AIDS, tuberculosis, development ofhuman resources for health, life style/tobacco and accidents, and snake bite, inaddition to assisting in support for IEC documents. It focused on advocacy andtechnical support in training of general practitioners and specialists. The MyanmarMedical Association's support is directed to central level (Dept. of Medical Sciences,Dept. of Health), as well as to international NGOs. It covers 60 townships (for IECissue) and capacity building in every township (snake bite).

- Myanmar National Committee for Women Affairs (MNCWA). The MNCWA is anational NGO established in 19 — and it has a country-wide network. Theorganization is giving emphasis to reduction of MMR, malnutrition and anemia,improving reproductive health and MCH services, TFI, healthy life style and healthof the elderly etc. The nature of support is through advocacy, training, partnershipbuilding, community mobilization, etc. The organization has some pilot activitiessuch as TFI (healthily life style) at district level (Pathein district) and township levelfor health of the elderly and essential obstetric service (at Ye Kyi township).

- Association of Medical Doctors of Asia (AMDA). AMDA is working in Meikhtila,Thazi and Pywebwe townships for primary health care project. The nature ofactivities includes advocacy, training, resource provision and technical support to alllevels of health staff and communities in the project townships.

1

Annex-4GROUP WORK III

Priority Area Scope Nature of Support Location

Vaccinepreventable

diseases

Advocacy for resourcesIECTechnical supportTraining of all levels in coordination with DOH and WHOSupport of operational cost for specific activitiesVaccines, injection equipment, cold chain

Country wideDOH andNGOs/INGOs

Malaria

AdvocacyIEC, Social mobilizationTechnical supportTraining of health personnel at PHC level, microscopist trainingIMMCI training for clinical managementHRD fundingAnatimalarias, microscopes, dip-sticks and ITNRBMI

Malaria endemic areascurrently around 32townships, to beincluded in AFTs withDOH, Disease controland I/NGOs DOH,I/NGOs

ReproductiveHealth

AdvocacyIEC, Social mobilizationTraining of health professionals in ESSD (district hospital, township hospital)and provision of basic equipmentANMW, AMW, TBA training and provision of equipmentIMMCI drugs, essential drugs for MW, TBAS andhospitals for ESSD

Currently ESSD inaround 50 townships,ANMW in order areas(30 plus townships) infuture AFTsDOH, I/NGOs

HIV/AIDS

AdvocacyEIC, Social mobilizationBehavioural Change and Development SHAPE in schools and out of schoolsand out of schoolCare Counselling supportTechnical support for PMCT, ESSD supplies and PMCT supplies for theactivitiesSTD HRD and provision of drugs

Country wide

25 townships25 townships

26 townshipsUNAIDS, NAP, NGOs

2

Priority Area Scope Nature of Support Location

Health SectorReform

As part of IMMCI currentlyIn AFTs convergence of health, nutrition, education and WES in townshipswill include human resource development, community participation,community financing (?)

100 townships by 2005DOHS, otherdepartments

AnaemicMalnutrition

AdvocacyIECHuman resource development, all levelsModel building for nutrition interventionsProvision of measuring equipment, ferro c folicProvision of vitamin A

Nation wideNation wide100 townshipsin AFTsin AFTsNation wide

WES Advocacy for sanitation coverageProvision of supplies, technical assistance

Country wide100 townships

IMR/U-5 MRreduction

IMMCINutrition, EPI, women’s health…

GROUP WORK III – Sub Group A : Myanmar Academy of Medical SciencePriority Area Scope Nature of Support Location

Health andHealth

Development

Academic andProfessionalDevelopment

Advisory Role (Think Tank) Centrally based but activities may be in anypart of countrySpecific AreasHealth System DevelopmentManpower DevelopmentEducation/TrainingHealth ServicesHealth TechnologyRole of GP in Health System, etc.

1

Annex-5National Health Situation1 Development challengesThe last decade has been characterized by a number of political and economic changes,which have contributed to improve the overall health of the population, as shown by thedifferences in mortality rates of the children and infants between 1990 and 1997, and thesteady increase of life expectancy. However, nearly one in four households or about 13million people have expenditures below minimum subsistence levels with significantregional variation in poverty rates1. These rates are approximately the same in urbanand rural areas, but 71% of the poor live in rural areas. Since poverty is a major cause ofill health, and productivity of the work force is a major contributor to economic, thechallenge for Myanmar is therefore to ensure: (a) adequate investment in health,especially for the poor, and (b) fair distribution of the benefits resulting from economicgrowth.1.1 Political changesAfter a quarter century of economic decline during which the prevalent developmentparadigm was termed “the Burmese way of socialism”, the State Law and OrderRestoration Council (SLORC), a military government, assumed power in late-1988. Thisgovernment, whose central body became the State Peace and Development Council(SPDC), has taken action mainly in the following areas:• Negotiation and conclusion of cease fire agreements with a number of “insurgent

groups” representing various ethnic groups leaving in border areas;

• Fight against the narcotic drugs which is ongoing;

• Discussions since 1993 on a new multiparty Constitution, which is still ongoing• Co-operation between the ministries of various sectors, other governmental

authorities and non-governmental organizations. They can be felt at both the highdecision-making level and technical implementation levels. Myanmar has become amember country of Association of South East Asian Nations (ASEAN) and BIMSTEC(Bangladesh, India, Myanmar, Sri Lanka and Thai Economic Council) and thereforehas opened the opportunities for the development of the country.

• Reforms for economic development (see below)1.2 Macro-economic situation and economic reformsA significant program of market-oriented economic reforms has been instituted inMyanmar since the State Law and Order Restoration Council (SLORC) assumed powerin late-1988, which has resulted in:• High GDP growth rates in the mid-1990’s. However, in recent years economic

activities have slowed down and foreign reserves decreased. To compensate for thedecline in tax revenue and reduce the budget deficit the government has cut downon capital and public expenditures. The latter has put further hardship on the poor.

1 Myanmar: An Economic and Social Assessment. World Bank, September, 1999.The data for poverty estimation come from two primary sources: the government’s biennial HouseholdIncome and Expenditure Survey (HIES) and the UNDP-financed Human Development Baseline Survey(HDIBS) of 1997. The 1997 HIES covered 25’000 households in 45 townships in all states and divisions,and was designed to be representative of the country’s rural and urban areas.

2

• Expansion of the private sector. But a series of measures, such as new import/exportrestrictions and foreign exchange controls taken since 1997 have been a set back toprivate sector development.

2 National health policies and health sector reformsIn 1990 a high-level inter-ministerial and policy-making body for health health-relatedmatters, the National Health Committee (NHC) was set up by the government. TheSecretary of the SPDC chairs this Committee. It developed the still prevailing NationalHealth Policy that contains fifteen broad policy directions, some of which call for healthsector reforms, especially as regards reorganization and management of health services(including the private sector, as part of health systems decentralization), as well ashealth care financing.2.1 National health policiesThe 1993 national health policy consists of fifteen policy directions for healthdevelopment, which are based on the principles of PHC and HFA. More specifically, itexplicitly stated that:• The private sector would make an increasing contribution to the health care

provision;• Alternatives to public health financing would be explored;• Coordination of services delivered by different ministries would be improved;• Services would be expanded to border areas.2.2 Re-organization and management of health servicesThe structure of the statutory health care system follows the political and administrativestructures of the country. The Union of Myanmar is comprised of seven States located inthe border areas and seven Divisions located more centrally. These are divided into 64districts, 324 townships, 2470 wards, 13747 village tracts, and 62920 villages.In each of the country’s 14 Divisions and States military commanders serve as Chairmanof the Pace and Development Councils At the State or Divisional level, which have bothmilitary and civilian membership. These Councils also exist at district and townshiplevel. The Township Health Departments are the backbone for primary and secondaryhealth care covering a population that ranges on average from 100,000 to 200,000inhabitants. A Health Director heads the Health Departments at divisional/state anddistrict levels. At township level it is a Township Medical Officer (TMO). The roles ofthese Heads are both - technical and managerial.The health system remains largely centralized. The Health Departments’ heads areresponsible for preparing operational plans in line with the directions given by eachnational technical programme. Their control over resources is limited to the:• Allocation of a very small amount of the recurrent budget for operational costs,

excluding the centrally provided salaries (fixed costs) and supplies (includingdrugs).

• Transfer of “Basic Health Workers”, such as the Rural Health Center HealthAssistants; Lady Health Visitors; and Midwifes.

The Health Departments’ heads are allowed to mobilize additional resources, essentiallydonations, through their Health Committees. Public health hospitals have gained a tinybit of autonomy on their budget as far as the use of 25% of their revenues from user feesis concerned (see below).

3

2.3 Health care financing: new mechanismsDuring the last decade a number of new mechanisms have been introduced. These are:

• At the hospital level:- Fees for drugs (currently 43 out of approximately 300 items) which are charged

at manufacturing price and therefore slightly cheaper than drugs sold in theprivate sector; the government pays for the other costs related to drug supplyand distribution. It is estimated that 85-90% of these items is given free of charge,as part of the exemption rules. All the revenues generated through these fees goback to Central Treasury.

- Fees for the “hotel services” of central and special hospitals are charged toinpatients. The pricing of these services depends on the commodities offeredwithin the wards. Only 25% of the revenues generated go back to CentralTreasury. The rest of revenues is to be shared in equal parts for drug purchase(for the poor), maintenance, and staff welfare.

• At the township level (health centers):- The “cost-sharing for drugs” scheme consists essentially of charging fees for

essential drugs based on a country-wide pricing list (which is slightly cheaperthan the private sector). Exemptions are not to exceed 10% throughout thecountry, regardless of poverty distribution. The government supplies the initialstock of drugs. The revenues generated are put on a saving account of thegovernment bank whose interest rate (10%) is lower than the current inflationrate. The township drug requirements are pooled for bulk purchase at centrallevel. This scheme covers now 114 townships.

- The recently introduced Trust Funds for the poor which are to be financedthrough local donations and other revenue generation activities. Only theinterest rates from the saving accounts on which the Trust Funds are put can beused for purchasing drugs for the poor.

Key issues:Ø Health sector reforms are limited and introduced very progressivelyØ The health systems remains very centralizedØ Some of the new financing schemes do not provide any incentives for managers

of health services to perform betterØ Since most essential drugs remain free of charge at the hospital level, there is no

incentive to seek care at the first contact level of the health system: there istherefore a need for a proper referral system

Ø The performance of new financing schemes and their impact on the poor need tomonitored and assessed

Ø The safety nets for the poor are not sufficient to protect their health3 Health systems performanceAccording to the WHO World Health Report 2000, the assessment of overallperformance of the health system in Myanmar puts it amongst the lowest range ofcountries. In the “Index of Overall Performance” achievement is related to availableresources. Total health expenditures is estimated to be around 100 US$ per capita peryear. According to this analysis, the health system in Myanmar is performing rather less

4

than its full potential – at less than 20% of what could be achieved, given its resources.Possible explanations to this rather poor performance are to be related to the four mainfunctions of the health system, as laid out in this section.3.1 StewardshipThe Government plays several roles within the health sector, including: planning,organization, coordination, financing of health services, regulation and delivery ofhealth care, as well as production of human resources and some consumables.3.1.1 Policy formulation and national health planningThe MOH articulates priorities and strategies through a series of medium term NationalHealth Plans (NHP). The current one is for the period 1996 to 2001. Two committees, theSteering Committee and the Working Committee, formed by staff from the centralMOH, health related ministries and national NGOs formulate the NHP, which istranslated into operational plans at the lower levels of the health system. The frameworkfor this plan is based on six broad programmes, out of which four aim essentially atstrengthening health systems. The programmes are further developed in 47 projectswith an estimated budget required for their implementation and indicators to measurethe health problem reduction.A minimum essential data set has been developed as part of the health managementinformation system. About 1000 indicators have been identified. Most focus onmorbidity and mortality. It is intended to avoid parallel information collection systems.However, vertical programmes continue to collect their own particular data. Assessmentof implementation of the NHP occurs on an annual basis. The current healthmanagement information system does not encompass the private sector, except for ahealth care directory of clinics and drug sellers.3.1.2 Health legislation and regulationMuch current legislation stems from the colonial times. In the current political system,the National Health Committee (NHC), as mentioned above, makes most of the policydecisions, without parliamentary legislation. If NHC considers that health legislation isrequired, the MOH submits a draft bill to the Attorney General’s Office, who thensubmits it to the SPDC through the Cabinet to become a law.A number of laws have been created or updated during the last decade. These are:“Amendment of Burma Medical Act- 1989”,;“Nurse and Midwifery law-1990”;“National Drug Law- 1992”; “The Child Law-1993”; “Narcotic and Psychotropic DrugsLaw-1993”,;“Communicable Diseases Law-1995”; “Traditional Drug Law-1996”; “National Food Law-1997”; “Myanmar medical Council Law- 2000”; “MyanmarTraditional Medical Council Law-2000”.As regards the private sector, the regulatory work has been initiated, especially for thelicensing of private practitioners.

Key issues:Ø National health planning is still very much a formalized State exercise, involving

a very limited number of key actors;Ø The approach used is project based, using mainly broad health indicators to

assess performance;Ø The health budget is inputs based versus result/performance oriented

5

Ø The information collected on a routine basis contains a very large number ofindicators which do not necessarily serve managerial purposes

Ø Major regulatory challenges include: the regulation of the rapidly growingprivate sector; the need for establishing effective management procedures;

Ø Already established laws need to be monitored and evaluated3.2 FinancingPublic expenditures on health, as a % of GDP, show a drop from 1.01 in 1991/92 to 0.36in 1996/97 with an estimate of 0.28 for 1997/98. MOH budget as a share of theGovernment budget has also dropped from 7.6% in 1991/92 to 3.4 % in 1998/99. Interms of expenditures, Government Health Expenditures (GHE) as a share of total stateexpenditures have dropped from 3.14% in 1991/92 to 1.49% in 1996/97 with an estimateof 0.94% for 1997/982.3.2.1 Main sources of fundingThe estimated share of the national health expenditures in 1996/973 concerns thefollowing sources:• Government: 14.6 %• Social Security: 0.6 %• Community contribution: 0.7 %• Private households 69.9 %• External assistance: 14.2 %3.2.2 Allocation of government resourcesGovernment health expenditures (GHE) are financed by central taxation that throughthe Union Government Consolidated Fund.The structure of GHE in terms of capital and recurrent costs shows an increase in capitalcosts from 24.29 % to 54.15 % during the period 1987/988 to 1996/97. This trend mightget reversed this year due to the general increase of salaries for civil servants (see sectionon human resources development).The recurrent expenditures in 1997/98 were distributed as follows: salaries (59%), drugsand supplies (22%); maintenance (16%); and transport allowances (3%).According to MOH, the largest share of overall government health budget has beenallocated in ??? to curative services, i.e. the hospital sector (44%), followed by publichealth and disease control interventions (35%), then drugs and supplies (15%), andfinally administration (6%). Within the hospital sector, 42.8% of the budget was allocatedto the district and township hospitals which are the first and second referral levels.85% of overall health expenditures are attributable to the Department of Health (DOH)which employs 93% of the 45’000 health workers (MOH 1997/98).

2 MOH. Analysis of Government expenditures during 1987/88 to 1997/98. By Mr U. Aung Kyiang,Director of Department of Health Planning. December, 1998.

3 MOH. Analysis of Government expenditures during 1987/88 to 1997/98. By Mr U. Aung Kyiang,Director of Department of Health Planning. December, 1998.

6

3.2.3 Other health care financing schemes (than mentioned under health sector reforms)The Ministry of Labor operates a Social Security Scheme, created in 1954), which covered2.3% of the country’s entire work force (but not their dependents) in 1998. Medical careis provided in two fully equipped hospitals located in the two largest cities of thecountry, and through a network of social security clinics in the towns. The benefitpackage includes: illness, maternity (including some allowances), disability and survivalpension. Funding of this scheme is shared between the employer, the employee and thegovernment (respectively 2%, 1%, and 1% of the total salary) and goes to a savingaccount of the government’s bank, which generates currently a 10% interest rate.

Key issues:Ø A constant decrease of government financing since 1990Ø Under financing of the MOH which is the main health care providerØ There is an important discrepancy between budget estimates and actual

expenditures (expenditures correspond approximately to half of the budgetedamount)

Ø The proportion of private household expenditures (out-of pocket payments) isvery high

Ø The sustainability of the Social security considering its very low coverage (riskpooling and sharing) and the raising health cost linked to new technologies and arelatively inflation rate

3.3 Resources development3.3.1 Health facilities and equipmentMyanmar has embarked upon the upgrading of central and specialty hospitals atYangon and Mandalay with human and technological resources, so as to keep abreastwith the advancement of biomedical sciences and technological development and wouldserve as highest level tertiary specialist care. Yangon, the capital, will serve thepopulation of the lower part of Myanmar and Mandalay city the upper part of Myanmarto ensure equal health care for lower and upper Myanmar.The Ministry of Progress of Border Areas and National Races and Development Affairstook responsibility for health care of ethnic minority groups residing in border areas ofthe country since 1989. To provide medical care and promote health status of thosepeople who reside in six border regions, 40 hospitals, 78 clinics and 24 health centershave been established with adequate manpower and equipment.3.3.2 Human resources for healthThe ratio of nurses and midwifes to doctors in the public sector is low (there isapproximately 1 nurse and 1.5 midwives for 1 physician). As of 1997, about 60% of alldoctors in the country are working in the private sector.

7

3.3.2.1 The labor market and wagesThe share of the public sector employment in the total represents approximately 8% andhas remained relatively unchanged over the last decade. Real wages in the public sectorhave been eroded significantly by persistently high inflation. This brought thegovernment to increase the salaries of all civil servants by a multiplying factor of almost5 in April 2000. Public sector employees also receive non-wage benefits, including freetransportation, subsidized housing, health and pension benefits, and other payments-in-kind such as rice. Private sector wages remain however higher than in the public sector.3.3.2.2 Production, training and educationThe Department of Medical Sciences (DMS) is responsible for the production of healthpersonnel. There are three institutes for production of medical doctors, two instituteseach for production of dental surgeons, nurses, paramedics, pharmacists and oneinstitute for health assistants in the MOH. Apart from the institute of nursing at thecentral level, there are one nursing school in each State or Division and one midwiferyschool in most of the districts.MOH has established staffing norms for each type of health facility and recently aprojection model has been introduced to adjust human resource production to actualneeds. It is already clear that Myanmar needs to produce more nurses, midwifes andbasic health personnel to improve the current skill mix that is currently biased towardsmedical doctors. The current macro-economic imbalances and the limited governmentbudget for health need also to be taken into account for the production of healthpersonnel. does not allow for a frameworkUniversity training is virtually free of charge. The government is therefore bearing theproduction costs while a large number of medical doctors engage in private practicewithout being taxed or contracted by the public sector.There is little information available on the relevance and quality of education/training.Since one of the government’s priority is to re-organize health services and improvetheir performance, management development is key. Modern management of healthsystems and services requires continuous training to keep up abreast of internationalbest practice to improve quality of health care and optimize use of available resources.3.3.2.3 Deployment and retainment of staffDeployment of staff is done in line with the staffing norms for each type of facility. Anumber of incentives have been put in place for remote areas. These include:• Compulsory service after graduation for a minimum of two years• Double salary• Free housing• A number of additional allowances• Preference given for postgraduate trainingThere are no country-wide criteria for assessing performance of health personnel.Current rewarding of performance, such as certificates for the best workers, is based ondecisions made by the Health Department heads at the various levels of the system.

Key issues:Ø Imbalances in skill mix

8

Ø Production of human resources needs to be linked to health needs andworkload requirements, as well as available resources for wages and otherincentives

Ø While an incentive system has been put in place for those working in remoteareas, the working environment is not always conducive to goodperformance (chronic shortages of equipment, drugs and supplies)

Ø There is no measurement system for assessing the performance of healthpersonnel

Ø The human capacities need to be strengthened in relation to decentralization,especially as regards management development

3.3.3 Drugs and other consumablesMyanmar has an essential drug policy and formulary. The Ministry of Industry hasestablished the Myanmar Pharmaceutical Factory for producing drugs, vaccines andother supplies. There is a significant gap between provision of drugs to the public healthsector and its requirements resulting in a continuous shortage of drugs at health facilitylevel. One reason for this seems to be the insufficient government reserves of foreigncurrencies to import the necessary raw materials for the production of consumables.Otherwise, drugs are purchased through tendering of local private pharmaceuticalenterprises.Current drug management in health facilities, purchasing and dispensing, is quitecomplex, because of the multiple potential providers operating in health facilitiesthrough different drug stores. There might also be several sources of finance.The private market for pharmaceutical products is particularly large in Myanmar. It hasbeen developed fundamentally to respond sufficiently to the needs of patients from theprivate sector. The pharmaceutical market includes the direct dispensing of drugs byphysicians and the sale of drugs by private drug stores for the use of private buyers orpatients in a public facility. Most of the drug stores are simply small commercial shopswith very few staff. After establishment of Food and Drug law in 1993, many drug storeshave to sell the drugs registered in the Food and Drug Administration under the MOH.As regards to the private market for pharmaceutical products, government charges withspecial rate / exemption of taxation to import the essential drugs or vaccines to bringdown the drug prices in the market. The Pharmaceutical trade Association has beenestablished and the MOH has been able to have more coordination in terms of qualityassurance and control of imported pharmaceuticals and vaccines.A recent consumption survey, conducted by MOH, showed that, on average, only US$0.30 per capita is spent on drugs.

Key issues:Ø Insufficient local production of consumables to meet the requirementsØ Shortages of essential drugs within the public sectorØ Complexity in drug management due to multiple providers and finance

sources3.3.4 ResearchThe Department of Medical Research (DMR) is responsible for management of basic andapplied medical, biomedical and health research. Recent research has mainly focused onmajor causes of ill health, such as malaria, diarrhea, anemia, iodine deficiency disorders,

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snake bites, viral hepatitis and intestinal worms. Some health systems research is doneunder the Department of Health Planning and by a new independent body, i.e. theMyanmar Academy of Medical Sciences.3.4 Provision of health services3.4.1 Main health care providersAlthough the private sector is growing rapidly, the government is still the main healthcare provider. Beside the MOH the following ministries are involved directly orindirectly in health care provision: Defense; Co-operatives; Transportation; Labor;Mines; Energy; Industry; Social Welfare, Relief and Settlement.The MOH covers all of the health care services including preventive, promotive, curativeand rehabilitative, as well as traditional medicine, while the other ministries tend toconcentrate more, if not exclusively, on curative services.Way before the introduction of economic reforms, a significant number of physicians,nurses, basic health staff and paramedics employed by the public sector did engage inprivate practice outside of office hours to increase their income.With the market-oriented economy, “modern” private professional medical care,providing exclusively curative services, is growing rapidly. Since 1988, 17 privatehospitals and 10 private maternity homes have opened in Yangon alone. Over 100private labs and 2 diagnostic centers offering advanced diagnostic procedures such asElectro Magnetic Resonance Imaging (EMRI) and endoscopies also exist. Many healthprofessional from the public sector are now also working part-time in private hospitalsand clinics.The number of private practitioners (GPs) of medicine and dentistry running their ownclinics is increasing rapidly, especially in the cities and big villages. They are openedthroughout the day, i.e. also opened after office hours. This might explain the significantdecrease in hospital utilization since 1994, especially as regards ambulatory care. It isestimated that nearly 80% of all care contacts are now with the private sector.The oldest private medical care market is traditional medicine. Traditional Medical carein Myanmar has been much influenced by Ayuvedic concepts from India and byBuddhist teachings. The traditional practitioners are very active throughout the countrybut mainly in rural communities. Today, about 30000 practitioners are estimated to existin the country but currently only about 5000 traditional doctors are registered. Theimportance of this sector is reflected by the existence of a special Department ofTraditional Medicine (DTM) within the MOH which is concerned mainly productionand registration of traditional medicines and medical practitioners.3.4.2 Choosing interventionsThe various health services that are provided at different levels of the health system andby different health care providers reflect to some extent the national policies and priorityprogrammes. But no systematic health needs assessment has been made to assess thehealth needs of the population and all available resources within the country. Such anassessment could help in identifying and selecting a minimum set of cost-effective andaffordable health interventions for each type of facility, taking into account all thedifferent health care providers. Currently, the services provided by different health careproviders within the public and private sectors are not necessarily complementary. And,the relationships between the different health facilities, including the referral systems,are not well defined.

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Key issues:Ø Multiplicity of health care providers with a rapidly growing unregulated

“modern” for profit private sectorØ Absence of a coordinated approach to health services provisionØ Competition for the same, rather scarce, resources between the public and

private sectorsØ Government has little control over some aspects of private sector activity such as

quality assurance, cost and price trendsØ The demands for new and high technology are likely to result in rapidly

increasing health costs, especially within the private sector

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Annex-6EXCESS BURDEN OF DISEASE(a) Communicable DiseasesAnalyses on the overall health situation suggest that communicable diseases continue tobe a major public health problem that constitute excess burden on the people, on thehealth services, and on the economy of the country. Malaria is a major cause ofmorbidity and mortality. Tuberculosis is one of the major public health problems inMyanmar, and it is considered as the second priority disease in the National Health Planafter malaria. HIV/AIDS is a disease of national concern and occupies a third position.Leprosy and polio are on the verge of being eliminated or eradicated and efforts mustbe taken to ensure that final campaigns and interventions are completed. Dengue andDengue Haemorrhagic Fever is becoming an increasing problem in the country. Allthese diseases have been considered as major challenges for the next 4-5-years period.Current available technical strategies for communicable disease control have alreadybeen accepted and adopted to country-specific needs. However, WHO technical supportin the implementation of the strategies is required. During the period 2002-2005, WHOwill continue to support the Ministry of Health in implementing effective communicabledisease control programmes to reduce excess mortality, morbidity and disability,especially in populations with limited access to health services that is the poor and thosewho live in border areas.In this priority area, the following opportunities may facilitate work of WHO in itsstrategic directions:

(i) high level of political commitment for communicable diseases control;(ii) collaboration with other sectors/ministries;(iii) partnership with all international and national partners in health, and(iv) social mobilization activities.

Challenges for communicable diseases control in Myanmar include(o) need for institutional strengthening,(i) drug and vector resistance,(ii) ecological changes,(iii) migration of population,(iv) high risk behaviour, and(v) limited availability of drugs.

First, WHO would emphasize the formulation of clear implementation strategies for thepriority diseases. These strategies should be focused on local situation to increase accessto basic health services including quality diagnosis and effective treatment for high riskand vulnerable population and be prepared to address situations at differentgeographical areas, particularly in border areas. They should also consider provisionand management of drugs. Second, special attention should be given to advocacy effortsaimed at community, especially in communities with limited access to health services.Third, increased attention should be given on monitoring the performance of states /divisions and townships in controlling communicable diseases and identifying thosewhere disease control activities need to be intensified. Fourth, infectious diseasessurveillance system development would include a central surveillance capacity as thebasis for decision making process to identify and intervene in the case of epidemics and

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emerging infectious diseases. Fifth, strengthening the capacity of health laboratories toensure the quality of programmes and to support surveillance for early warning andepidemic response.WHO support in the communicable diseases control will include the followingdirections:

1. The development of a strong state/division and township surveillance system inthe context of integrated national level surveillance system as evidence base fordecision making.

2. Monitoring performance of state/division and township CDC programmesrelated to the priority infectious diseases. Focus will be on the use of improvedtools to solve local specific programme problems, including cross border healthproblems.. This would include cross border issues.

3. Activities of health laboratories for disease surveillance, its quality andsustainability.

4. Advocacy to the states/divisions and townships in highest priority toprogrammes in reaching those with low access to health services.

5. Building partnership and co-ordination in communicable diseases control.6. Disseminating and adapting new WHO regional/global policies, strategies,

guidelines and evaluation reports related to infectious diseases control.Expected results from WHO Collaboration.The following results from WHO collaboration for a period 2002-2005 may beanticipated:

(i) capacity in early detection and prompt treatment & transmission reduction ofmalaria and dengue / dengue haemorrhagic fever cases aimed at reduction inmortality and morbidity; capacity in surveillance for decision making includingearly intervention of epidemics;

(ii) joint and synchronized approach and expanded national response to HIV/AIDSin Myanmar;

(iii) increased cure rates for TB, improved case detection rate, and nationwide DOTScoverage;

(iv) leprosy elimination confirmed; and(v) poliomyelitis eradication confirmed.

Partners beyond the Ministry of Health.For this priority area, the following partners are expected to be involved:UNICEF, UNDP, UN AIDS, UN FPA, Population Council, AZG, World Vision,Myanmar Maternal and Child Welfare Association (MMCWA), Myanmar Red CrossSociety and Myanmar Medical Association.

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(b) Non communicable diseasesCardiovascular diseasesIn the last two decades, mortality and prevalence due to Cardio Vascular Diseases(CVDs) have continuously declined in most developed countries, but show increasingtrends in the developing countries. The most common CVDs in Myanmar is coronaryheart disease, rheumatic heart disease and stroke. A study in the country showed thatmajor risk factors identified for coronary heart disease are: smoking, hypertension andraised cholesterol level.CancerGlobal data showed that cancer is almost equally distributed between developed anddeveloping countries. As the previous major NCDs, the incidence of cancers inMyanmar is in a rising trend, as shown by the Radiotherapy Dept. of Yangon GeneralHospital.( morbidity rate per 100000 population was 87 in 1981 and 117,2 in 1994). Thereis only 1 cancer registry for the whole country situated at YGH. The commonest types ofcancers in the region are mouth/oropharyngs, oesophagus, stomach and lowerrespiratory tract for male (trachea, bronchus, lung ) and for women are cancers of cervix,breast, mouth, oropharyngs and oesophagus. A number of these cancers are highlyamenable to primary and secondary prevention. Tobacco, which is widely used in ourregion, is a major cause of cancers of the upper digestive ad respiratory tracts. It isestimated that 91% of oral cancers in this part of the world are directly related to tobaccouse.Facilities for screening and proper management of cancer patients are limited in mostcountries of the region. Patients brought to the hospital are often in advanced stage andin curative stage at the time of diagnosis.Diabetes mellitusIn Myanmar, the National Health Committee has identified diabetes as one of the healthproblem in the country. At present there is no information on the prevalence of diabetesin the country. The magnitude of the problem and the differences of diabetes in ruraland urban areas is also not yet known. There is a close relation between obesity anddiabetes, sedentary lifestyles and changes to dietary habits which have led to anincreasing prevalence of obesity in relatively young age groups. Diabetic patients ifundiagnosed or inadequately treated, developed multiple chronic complications leadingto irreversible disability and death. In addition to NIDDM which is rather silent chronicand often unidentified as killer among the adults, the IDDM is affecting children.Yangon general hospital showed the average age of NIDDM of clinic and ward patientsare 55,3 years and IDDM is 21.74 years whereas in Mandalay hospital is 54 and 31 yearsrespectively.Unfortunately there is still inadequate awareness about the real dimension of theproblem among the general public. There is also lack of awareness about the existinginterventions for preventing diabetes and the management of complications.Inadequacies in primary health care systems, which is until now not designed to copewith additional challenge posed by chronic NCDs, resulted in poor detection of cases,sub-optimal treatment and insufficient follow up leading to unnecessary disabilities adsevere complications often resulting to early deaths.

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To change people's behavior, it is important to know the practices and the underlyingreasons and to have the clear idea of the preferred behavior. The aim of healthpromotion policies and programmes should be to stimulate health awareness andresponsibility and to promote condition and behaviors which favor health.Accidents and injuriesRoad traffic accidents are the unavoidable consequences of the development intransportation. Accidents ad injuries lead to a substantial number of deaths anddisabilities each year and can cause considerable economic loss due to the missedworking days during recovery and long term disability. In many countries, victims aremostly males around reproductive years .The data on injuries and accidents, especially impacting to health consequences, areoften incomplete. Only for Yangon and Mandalay, the two big cities in Myanmar,statistical studies on the epidemiology of road traffic accidents are found. For the rest ofthe country, such data is unavailable. .The study of the insurance claims for motorvehicle accidents over the last decade was an average of 1200 claims per annum fordeaths.Mental disordersNeuropsychiatric conditions account for 10% of the disease burden measured in DALYsin low and middle income countries and 23% of DALYs in high income countries. Thedisease burden due to depression is estimated to be increasing in both developing anddeveloped countries. Mental Health will be the subject of World Health Day in the year2001.The World Health report 1999 showed the large proportion of the burden ofdiseases resulting from neuropsychiatric is attributable to depression, which is alsopredicted to increase in developing and developed countries. The mental health project,which was launched in 1990 is still on going in the country..Challenges

• The steadily increased trend of major non-communicable diseases ( CVD, cancer,diabetes mellitus) in the country

• The NCD cases in the community (mostly: cancer and diabetes) are oftenundiagnosed or detected at fairly advanced stage by which it is too late or needsophisticated and costly treatment

• The unreadyness of primary health care in providing care and treatment forNCD cases.

• Lack of community home based care for major NCDs chronic cases• Data on major NCDs are mostly available from the hospital reports which does

not reflect the true status of the diseases in the community . Surveillance of majorNCDs are not available or yet to be established .

• Inadequate control measures and management of major NCDs• Lack of awareness in the community towards NCDs• To integrate mental health into the primary health care delivery system.

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Opportunities

• Most of the non communicable diseases are preventable . Some cancers arepreventable and early diagnosis is possible.

• Health education for the public on major risk factors of NCDs and how toprevent NCDs

• To introduce the integrated approach for the management and control of majorNCDs sharing common risk factors , which are diabetes and CVD.

• Promotion of public awareness and healthy life activities as main strategies forthe prevention and control of CVD and diabetes.

• Conduct selective screening of risk groups, early detection and appropriate casemanagement

• Training of health personnel at the primary health care level on control of majorNCDs

• To promote early detection of mental health and proper treatment for mentallyill persons in the community.

Proposed for WHO role and support

• To develop national strategy for control and management of major NCDsincluding the development of community home based care

• To strengthen surveillance system of major NCDs to obtain best estimate ofcommunity based data

• To conduct integrated approach of management and control of major NCDssharing similar risk factors ( CVD and diabetes)

• Technical support in development of manuals and training of health personnel torender mental health services at primary care level

Expected results

• Strengthening community data base on major NCDs• Development / establishment of national strategy on management and control of

major NCDs including community home based care

• Strengthening the NCDs prevention and control programmeName of partners (Intra, intersectoral coordination)

1. Myanmar Medical Association2. Professional Organizations3. Diabetic Association4. Department of Health, Health Education Division, Dept. of Medical Research,

Dept of Traditional Medicine.

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Annex-7WOMEN’S HEALTHThe overall situation of women's health in terms of increased life expectancy and femaleliteracy has improved over the years. The gender related development index (GDI)seems to have increased from 0.339 in 1970 to 0.478 in 1995 ( Health Situation in theSouth-East Asia Region 1994-1997, WHO, SEARO). An increasing GDI is a proxyindicator of narrowing gender disparities, including health disparity between men andwomen.As women bear the greatest biological burden of reproductive health problems, overone-third of all deaths among adult women in the developing world are due toreproductive health problems, as compared to some 12% in men. Although estimatedmaternal mortality ratios vary considerably (140/100,000 live births, 1993, hospital basedstudy, MOH; 500/100 000 live births, Admason, 1996; 580/ 100 000 live births, RevisedEstimates of MMR by WHO and UNICEF, 1996; 230/100 000 live births, FRHS,1997), it isclear that pregnancy-related deaths constitute the leading cause of loss of healthy livesamong women of reproductive age in Myanmar. There are urban and rural differencestoo, higher MMR in rural areas (CSO, 1998). According to the on-going study onmaternal mortality by MOH and UNFPA, 57% of maternal deaths occur at home and 4% on the way to the hospital. Around 37% of deaths occur in public hospitals.Haemorrhage, eclampsia, obstructed labour and unsafe abortion constitute major causesof maternal deaths.Although not widely reported, unsafe abortion is recognized as among the leadingcauses of maternal mortality and morbidity in the country. The proportion of maternalmortality due to abortion varies from 38.3 % (Krasu, hospital-based study, 1992) to 60 %(Yangon's Central Hospital,1994). About one third of all pregnancies is seem to end inabortion at the population level (Ba Thike, 1997).Such high prevalence of unsafe abortion underscores the high level of unmet needs ofcontraceptive methods, which is 44.4 % as reported by the FRH Survey, 1997.Some 58% of pregnant women suffer from nutritional anaemia which is a majorcontributor of maternal deaths and low birth weight. The National Nutrition Survey,1991 has indicated a high prevalence i.e. 24% of low birth weight in the country.The grim statistics of maternal deaths underline the continued neglect of women'shealth, among others. Most maternal deaths are preventable. Cost-effective technologiesfor preventing maternal deaths do exist. What is needed, however, is to equip the healthsystems with cost-effective interventions such as good family planning services,effective access to essential obstetric care including post abortion care, and emergencyobstetric care through effective community-based referral systems.Although there is the paucity of data and inadequate diagnostic facilities particularly inthe rural settings, reproductive tract infections (RTIs), sexually transmitted diseases(STDs) and HIV-AIDS also appear to be among the major causes of women's ill-health.A major issue in women's health is the lack of disaggregated health information by sex,age and other relevant variables. In this, the focus should be on institutionalizingdisaggregated data in health information system and mainstreaming women'sperspectives in all health policies and programmes. Myanmar National Committee for

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Wormen' Affairs (MMCWA) have jointly initiated with MoH a study on violence againstwomen and women's health and development profile.Although underreported, domestic violence against women is increasingly recognizedas a public health problem. Following the WHO SEARO Regional Consultation onViolence against Women, Myanmar,1999, the Myanmar National Committee forWomen’s Affairs (MNCWA) conducted in 12 townships a study on domestic violenceagainst women. This study is completed and currently the findings are being analysed.Poverty related social problems, alcoholism disharmony among in-laws and adulteryseem to be the four major causes of domestic violence against women. MMCWA hasadopted preventive and rehabilitative strategies to respond the needs in this area ofviolence against women. Currently, MNWCA is carrying out training for police,medical and social workers.

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Annex-8CHILD AND ADOLESCENT HEALTH1. Child HealthInfant Mortality Rate (IMR) and Under 5 Mortality Rate (U5MR) are known indicators ofquality of life. In Myanmar, although there has been a decline in the last decade, boththe IMR and MMR are still considered to be high.The leading causes of death in under 5 children were reported to be ARI, diarrhoea,malaria, DHF and malnutrition and death was mostly due to insufficient quality of caredue to lack of diagnostic skills and failure to recognize danger signs of the disease forreferral. The diseases are considered preventable and / or curable and with proper PHCservices, and treatment from trained health personnel who would be able to diagnosecorrectly and give timely interventions, or referral the mortality rate of infants shouldfall.Due to high IMR and U5MR in developing countries, and most of the children weresuffering from more than one disease, this indicated that an integrated approach todiagnosis and treatment if diseases in infants and the concept of IMCI was developed. InMyanmar, there was a felt need to integrate the maternal component as well because ofthe U5MR survey (1995) indicated that peri-natal conditions contributed andconsequences of maternal malnutrition, and complications during pregnancy anddelivery contributed 15% to the under 5 mortality. Thus the programme “IntegratedManagement of Maternal and Childhood Illness” was established. It was envisaged thatby 2001, this would progress to “Woman and Child Health Development” programmeand quality of health care would improve sufficiently for the MMR and U5MR to falland reach the expected target.Challenges:

• Capacity building: only 30% of health staff can give proper management of ARI,80% of training courses conducted are not according to planned curriculum

• Lack of skill based and participatory training methodologies

• Lack of systematic and integrated planned training programme• Inadequate training materials, training ads and facilities• Expansion of IMMCI coverage – quality of training; logistic and resources;

supervision and monitoringOpportunities:

• Political commitment

• Strong dedicated group of professionals• Established health infrastructure• Acceptance of BHS staff• Inter- and intrasectoral cooperation

Priority areas for WHO support:

• Review and technical input on the maternal component of IMMCI• Technical support in exploring options to introduce IMMCI in pre-service

training of health

• Quality standard setting for training• Establishment of new WHO collaborating center

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2. Adolescent HealthThe adolescent population (10-19 years) is estimated at 9.3 million which comprises20.5% of the total population. Among the student population of 8.25 million, adolescentsaccount for 26%. However, only 23% of the adolescents attend school, with the schooldrop-out rate being highest in the 10-14 age group (44%). The labour force participationin the age group: 15-19 years is 68% for males and 58% for females. With regard tonutrition, the calorie intake reported was 80% and the protein intake 86% of the requiredamounts, respectively. Among adolescent girls, anaemia was found in 26% of cases. Inthe capital city of Yangon, adolescent pregnancies in 1998 were reported to be 9% of thetotal deliveries. The peak prevalence of STD in the 15-24 age group was reported to be32%The sentinel surveillance data for the 15-19 age group revealed that HIV infection wasthe highest among the intravenous drug users (59%). The major categories of problemsare sexual maturation and behaviour, pregnancy and child birth, induced abortion, STD,HIV/AIDS, alcohol, smoking and alcohol use were significantly more among malestudents. The incidence of unprotected sex was quite low among male and femalestudents but considerably higher in new military recruits (17.4%).With regard to health services, the adolescents in the formal education sector are servedby school health teams, in major towns and cities, while the other are catered for thoughthe routine health services system. Emphasis has been given to institutionalstrengthening particularly in respect of STD, both in the government and private sectors.Training for health staff in HIV/AIDS prevention and control, birth spacing and life-saving skills has been supported by UN agencies as well as national and INGOs.Community Education programmes at all administrative levels are also much inevidence with the support of many different organizations.Although certain intervention programme for adolescents have been initiated in thecountry, the adolescent population and the basic health staff are largely unaware of theimportance and availability of such services. In contrast, however, the programme,“Motivation of Adolescent Health through Sports and Physical Education”,implemented by the Department of Sports and Physical Education and supportedthrough WHO’s collaborative programme is widely known and well accepted. The aimis to protect and promote physical fitness and promote healthy life styles and behaviourin adolescents.Challenges:

• Need to strengthen IEC materials and counseling services• Adolescent-friendly health services• Appropriate training needs• Involvement of adolescents in designing youth-friendly services

Opportunities:• Political commitment to address the health, social and development needs of the

adolescents and youths• Multi-sectoral coordination (families, communities, NGOs, health and other

sectors )Priority areas for WHO support:

• Development of National Policies and strategies to promote integrated healthand development of CAH

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• STD/HIV: adolescents are more vulnerable because of peer pressure to expose torisk factors. Prevention of HIV/AIDS/STD for youths and adolescents is animportant component of NAP’s work plan.

- Life skill training for women and youth- School based and community education programmes- Capacity building of community organizations and volunteers for

targeted intervention of mother-to-child transmission• Integrated package of Child and Adolescent-friendly health services that address

priority child and adolescent health development problems and improve access

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Annex-9HEALTHY ENVIRONMENTa) SAFE DRINKING WATER(1) Challenges: - Need for Coverage/availability

- Need for quality surveillance and monitoring- Need for Intersectoral coordination- Need for IEC

(2) Opportunities - Political Commitment- Intersectoral- Participation of CommunityType of WHO Support- Technical Support- Partnerships- Institutional Strengthening/Capacity Building

(3) Expected Results- Improvement of Health Status- Improved Coverage of safe drinking water- Healthy life style e.g. cleanliness

(4) Partners- WHO, UNICEF, UNDP, UNCHS, UNHCR- INGOs- National NGOs- Private Sector

b) SANITATION(1) Challenges

- Need for coverage e.g. Sanitary Latrines etc.- Need for Inter sectoral coordination.- Need for IEC

(2) Opportunities- Political Commitment- Mass Movement e.g. National Sanitation Week- Intersectoral coordination- Community Participation

(3) Type of WHO support- Technical Support- Institutional Strengthening/Capacity Building- Partnerships

(4) Expected Results- Reduction of Food and Water Pollution- Decline of Water and Food borne Infections- Improved Coverage of Sanitary Latrines- Healthy Lifestyle

(5) Partnerships- WHO, UNICEF, UNDP, UNCHS, UNHCR- INGOs- National NGOs- Private Sector

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Annex-10MAJOR RISK FACTORS HAZADOUS FOR HEALTHTobacco use and alcohol consumptionTobacco is a major risk factor for several other NCDs as well. The last decade haswitnessed a major increase in tobacco related illnesses and deaths worldwide. It isestimated that tobacco kills 3/5 million people every year. A survey in Myanmar in1993-94 showed that 44.6% students between age of 10-20 years of age smoked. Chewingtobacco, in its varied forms is also very popular in many countries in the region. Thecausal relationship between tobacco uses and disease such as cancers, CVDs and chronicrespiratory disorders is increasingly being studied. The Tobacco Free Initiative is amongthe WHO top priority cabinet project. It is also endorsed as regional priority by theSouth East Asia Health Ministers meeting in 1999. Health aspects of tobacco smokingbeing given more attention and health messages are given through mass media.Some significant activities has been an ongoing process in all countries highlighted theWorld No Tobacco day each year with special focuses on sponsorship by tobaccocompanies ad target groups such as school children , youth and hospital workers.Alcohol use is also quantified as a major cause of disease burden particularly in adultmale. A preliminary study on alcoholism in 1 urban and 1 rural area in Myanmar during1999 showed that 20% of the alcoholic population is defined as alcoholism. 77% of themcomplained of having physical problems such as peptic ulcer and gastritis, 49% ofhaving mental health problems, depressions by which 3% underwent for medication.WHO highlighted that only 25% depressed patients are not getting proper treatment ofantidepressant. During the delirium tremens state violence to self or to others iscommon.Unsafe BloodThe safe blood is a priority area in the country with special attention given by theMinistry and also by the NGOs such as Red Cross, and also was the theme of the WorldHealth Day 2000. The National Blood Policy was drafted in July 1998. and the NationalBlood Committee has formulated the Blood Law. Currently laboratory support for bloodsafety is ensured at the 369 hospitals (4 teaching hospitals, 15 general hospitals, 17specialist hospitals and 290 township hospitals) all over the country. The emphasis isbeing given to obtain quality and safe blood from voluntary non-remunerated donors.Currently the donated blood units are being screened for transfusion transmissiblediseases. The blood screening coverage is : 100 % for HIV antibody, 80% for HBSantigen. Malaria and VDRL is also tested in most of the blood. Appropriate componenttransfusion is possible only in four blood banks all over the country. Other blood banksare facing resource constraints for processing of blood components.Malnutrition and Food SafetyAlthough nutrition promotion activities are continuously implemented, the status ofnutritional problems are: PEM under three years of age is 30.58%; IDD-visible goiter rateamong children 5-11 yrs of age is 33.08%,; Iron Deficiency anemia in pregnant women is58.06%; Vit-A deficiency-Bitot’s spot prevalence among under 5 is 0.37% and low birthweight in new born babies is 23.4%. Surveys suggests that the situation has improvedsomewhat during the 1990s for children under three years of age. As a good nutritional

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status is basic requirement for the health of community, it is extremely necessary tocarry out Nutritional Promotion Activities planned in such a way as to preventmalnutrition and related diseases in accordance with the existing conditions. A newFood and Drug Administration (FDA) was established in 1995 under the DOH. Theobjective was to protect health of the people through promotion of food safety bysystematic effective control of food products.Challenges• General: To change people's behavior through encouragement of preventive

measures .The aim of health promotion policies and programmes should be tostimulate health awareness and responsibility and to promote condition andbehaviors which favor health. To study the practices and underlying reasons and tohave clear idea of the preferred behavior.

• For Tobacco :The challenge to develop long term and comprehensive and multi-sectoral policies in stopping tobacco use,

• For Safe blood: The need of resources to establish a proper quality assurance systemin every level of blood transfusion services.

• For Malnutrition and food safety: High prevalence of moderate and severemalnutrition among children under 3 years old. 58% of pregnant women suffernutritional anemia . 24% of low birth weight. The work of FDA is impeded by a lackof appropriately trained staff in programming and management and specific foodinspection and control.

Opportunities

• For tobacco: Advocacy for healthy public policies and for a ban of advertisement oftobacco products has been intensified in India, Indo, Maldives, Nepal Sri ad Thai.Myanmar can learn success stories and failures from neighboring countries. Thegreat interest of NGOs to support community based tobacco preventionprogrammes . Global TFI

• For safe blood: Donors are mainly voluntary and non-remunerated. Donorrecruitment is through volunteer and religious organizations such as; UnionSolidarity and Development association, Myanmar Red Cross Society, MingalarByuhar and Myittar Byuhar Buddhist associations.

• For malnutrition: Existing data bases ( national nutrition survey ), existing healthinfrastructure pipeline , national policy and strategy on nutrition programme ,active participation of MMCWA and others

Proposed for WHO role and support

• For tobacco: By strengthening its advocacy role, the WHO can support the country infacilitating the development of a regional policy framework for tobacco and alcoholcontrol to guide country actions. The country is in need for assistance in antismokingcampaigns. To support country in developing information system base on tobaccosissues of production, consumption and health risks

• For safe blood: Training for transfusion medicine for pathologists, medical officersand laboratory technicians and support for establishment of quality control systemin every level of transfusion services.

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• For malnutrition: Technical support in promoting breast feeding, setting standardsfor infant feeding , developing tools for rapid diagnosis and management ofnutritional anemia particularly among pregnant women. Provide technical supportfor standards and monitoring of micronutrient supplement.

• For food safety: Training of staff in the field of laboratory services both themicrobiological as well as instrumental analysis. In the field of food inspection- (onecontrol officer and one food inspector). Upgrading food control system throughchemical, reagents, laboratory equipment, etc..

Expected results

• Established national policies on non tobacco use• Raised awareness among consumers and potential consumers on tobacco related

problems

• Reduction of malnourished cases among infants, children and women• Provision of safe blood strengthenedName of partners (Intra, intersectoral coordination)

• For tobacco free initiatives: MOH, NGOs, Other relevant sectors such as Dept. ofTrade and Commerce, Dept. of Agriculture and NGOs for public campaigns,community awareness on the hazards of risk factors and ban tobacco use

• For Safe Blood programme: Red Cross international , UNICEF

Documents

WHO CCS Myanmar...WHO Country Cooperation Strategy [CCS], Myanmar 3 Table (1) Trends in Health Outcomes and Indicators over time, 1990-1997 SR. STATUS No. INDICATORS 1990 1995 1997