Jan. 2024 Analysis of Access to Essential Health Services in Myanmar 2021-2023 A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 P. 1 © 2024 International Bank for Reconstruction and Rights & Permissions Development / The World Bank The material in this work is subject 1818 H Street NW to copyright. Because The World Bank encourages dissemination of its knowledge, Washington DC 20433 this work may be reproduced, in whole or in Telephone: 202-473-1000 part, for noncommercial purposes as long as full attribution to this work is given. Internet: www.worldbank.org Any queries on rights and licenses, including This work is a product of the staff of The World Bank with external subsidiary rights, should be addressed to contributions. 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Nothing herein shall constitute or be construed or considered to be a limitation upon or waiver of the privileges and immunities of The World Bank, all of which are specifically reserved. A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 P. 2 Preface & Acknowledgements T his report provides an analysis of access to essential health services in Myanmar from 2021 to 2023, based on publicly available sources of information as well as multi- ple assessments conducted jointly by the World Bank and World Health Organiza- tion during this timeframe. To receive email alerts for upcoming World Bank Myanmar monitoring products, please contact MyanmarMonitoring@worldbank.org For information about the World Bank and its activities in Myanmar, please visit https://www.worldbank.org/en/country/myanmar A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 P. 3 Contents Background...........................................................5 Sources of Information........................................6 Myanmar's crisis..................................................7 Myanmar's health system before crisis..............9 Health status trends since the crisis................. 13 Health financing since the crisis....................... 15 Access to essential health services................... 17 Health-seeking behavior................................................................................................... 17 Maternal and children health......................................................................................... 20 Household financial hardship.......................................................................................... 23 Non-communicable diseases............................................................................................. 25 Essential medicines..........................................................................................................26 Private healthcare sector..................................................................................................29 Conclusions........................................................ 31 A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 P. 4 Figures Figure 1 SOURCES OF HEALTH EXPENDITURE 11 Figure 2 INCIDENCE OF MALARIA CASES 14 Figure 3 MINISTRY OF HEALTH BUDGET ALLOCATION AND SPENDING ON HEALTH 16 Figure 4 ACTION TAKEN FOR ILLNESS OR INJURY (N=1500) 18 Figure 5 TYPE OF HEALTH CARE PROVIDER SOUGHT (N=1500) 19 Figure 6 TYPES OF HEALTHCARE PROVIDERS ACCESSED (PRIVATE) 19 Figure 7 TYPES OF HEALTHCARE PROVIDERS ACCESSED (PUBLIC) 19 Figure 8 TYPES OF HEALTHCARE PROVIDERS ACCESSED (POOR AND NON-POOR HOUSEHOLDS) 20 Figure 9 ANY REPORTED ACCESS TO ANTENATAL (ANC) AND POSTNATAL (PNC) SERVICES (ROUND 2 SWIFT ANALYSIS) 22 Figure 10 ANY REPORTED ACCESS TO CHILD IMMUNIZATION (ROUND 2 SWIFT ANALYSIS) 22 Figure 11 ANY REPORTED ACCESS TO CHILD IMMUNIZATION (ROUND 2 SWIFT ANALYSIS) 22 Figure 12 HOUSEHOLD MEMBERS ACCESSING COVID-9 VACCINATIONS (ROUND 2 SWIFT ANALYSIS, ROUND 3) 22 Figure 13 PERCENTAGE OF PEOPLE THAT HAD TO BORROW FUNDS TO PAY FOR HEALTHCARE 23 Figure 14 PERCENTAGE OF PEOPLE THAT HAD TO SELL ASSETS TO PAY FOR HEALTHCARE 23 Figure 15 FOOD INSECURITY EXPERIENCE SCALE IN MYANMAR (ROUND 3) 24 Figure 16 BREAKDOWN OF RESPONDENTS WITH HYPERTENSION AND DIABETES 26 Figure 17 TYPE OF HEALTH PROBLEMS REPORTED 26 Figure 18 HOUSEHOLD EXPERIENCES IN PRICE CHANGES FOR NCD MEDICINES (ROUND 3) 27 Figure 19 PROVIDER PERSPECTIVES OF PRICE CHANGES FOR HYPERTENSION AND DIABETES MEDICINES (N = 118) 28 Tables Table 1 KEY HEALTH STATISTICS FOR MYANMAR (2005-2020) 10 Table 2 TOTAL NUMBER OF HEALTH FACILITIES BY LEVEL (2020) 12 P. 5 1 Background A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 M yanmar faces a multitude of healthcare service deliv- ery and access challenges, which impact the health status of the population and the country's human capital. The COVID-19 pan- demic and political situa- tion since February 2021 have compounded these chal- lenges. Within this context, increasing vulnerability to communicable diseases, such as tuberculosis and ma- laria, exacerbate the health risks faced by the popula- tion, while a growing burden of Non-Communicable Diseases (NCDs) result in immediate health concerns with long-term implications for productivity. P. 6 2 Sources of A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 Information T his report aims to analyze the trends in access to essential health services in Myanmar from 2021 to 2023, uti- lizing publicly available sources of information and multiple assess- ments. An overview of the diverse assessments from which this report derives data is summarized in Box 1. It is important to bear in mind, while reading this report, that the context in Myanmar continues to evolve rapidly. A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 P. 7 BOX 1 BRIEF OVERVIEW OF ASSESSMENTS ACCESS TO In collaboration with WHO, three phone surveys (August - HEALTHCARE September 2021; March–April 2022; February–March 2023)* PHONE SURVEYS used computer-assisted telephone interviews (CATI) to sur- *Three rounds of survey were vey 1,500 households in Myanmar. Round 1 survey questions conducted in partnership with WHO. The first round addressed health behaviors, access, costs, and service quality. was financed by WHO in collaboration with WB for Round 2 surveys in 2022 examined variations in health-seek- technical support, while the ing behaviors by household socioeconomic status. Round 3 second and third rounds were funded by WB, with technical in 2023 explored NCD and nutrition impacts on productivity. contributions from WHO. The limitations of the data are as follows: it only allows for national and rural-urban comparisons, and there is less data available from conflict-affected areas due to telecommunica- tion shutdowns. PRIVATE HEALTH In collaboration with WHO, a qualitative assessment of 44 FACILITY private health facilities (8 hospitals, 14 clinics per city) in ASSESSMENT Yangon and Mandalay was conducted in September–De- cember 2021 to establish understanding of facility types, services, and catchment areas by private sector and identify opportunities for possible private sector engagement in de- livering essential health services. AVAILABILITY A supply side study (March–June 2023) includes both quan- AND PRICING titative and qualitative data: monthly price and availability OF ESSENTIAL MEDICINES tracking for selected 58 essential medicines at 50 pharma- STUDY cies and 65 interviews with private sector stakeholders (in- cluding non-profit) to understand supply, demand, pricing, and import/distribution challenges. PROVIDERS’ Weekly polls and monthly surveys were conducted (April - PERSPECTIVE August 2023) using an online application platform utilized by STUDY approximately 2,000 practicing medical doctors to explore healthcare service provision trends from a provider perspec- tive, including changes in patient case load during shocks, barriers to service provision, access to resources to deliver care, changes in prices of essential medicines and fee struc- tures. It also aims to gain insight into providers' perspectives and to foresee the outlook of Myanmar's healthcare sector. P. 8 3 Myanmar’s A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 Crısis T he military takeover of 2021 sparked widespread protests and a Civil Disobe- dience Movement (CDM) led by public servants, resulting in violence, politi- cal instability, and reduced healthcare workforce in the public sector with approximately 50% joining the CDM.* Armed conflicts throughout the country have further worsened Myanmar's already fragile humanitarian sit- *Source: Myanmar Now, Analysis uation. According to a UN report published in March by Ko Cho and Thura Maung, February 2023. https://myanmar- 2023, four out of every five townships in Myanmar have now.org/mm/news/13925/ been impacted by conflict since the coup. Since then, while the current situation remains dynamic, the armed 1 Office of the United Nations High Commissioner for Human conflict has significantly escalated, particularly towards Rights (OHCHR), "Situation of the end of 2023, affecting more townships.1 As of No- Human Rights in Myanmar," factsheet, March 2023, https:// vember 2023, a report by Insecurity Insight, which mon- www.ohchr.org/sites/default/ files/2023-03/myanmar-fact- itors incidents impacting the health system in conflict sheet.pdf. zones, indicates that over 1,000 attacks have targeted 2 A Tragic Milestone: More hospitals and health workers in Myanmar. Since Feb- Than 1,000 Attacks on Health Care inMyanmar Since the Feb- ruary 2021, a total of 97 healthcare workers have been ruary 2021 Military Coup https:// insecurityinsight.org/wp-con- killed, 117 injured, and 880 arrested.2 The confluence of tent/uploads/2023/11/A-Trag- ic-Milestone-Myanmar-Press-Re- impacts from the COVID-19 pandemic and the political lease-November-2023.pdf crisis will be referred to as “the crisis” in this report. P. 9 4 Myanmar A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 Health System Before the Crisis O ver the course of a decade (2010-2020), health outcomes were improved and govern- ment spending on health in- creased. Estimates show a reduction in the maternal mor- tality ratio (MMR) from 243 3 "Trends in maternal mortal- deaths per 100,000 live births ity 2000 to 2020: in 2015 to 179 in 2020, with under-five mortality decreas- estimates by WHO, UNICEF, UNFPA, ing from 51.8 deaths per 1,000 live births to 43.2 during World Bank Group and UNDESA/Pop- the same period, as shown in Table 1.3 Despite improve- ulation Division," https://mmr2020. ments, the country’s human capital development con- srhr.org/data. tinued to lag behind other countries in the region, with P. 10 the average child mortality rate in ASEAN countries be- A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 ing 23 deaths per 1,000 births.4 Myanmar’s Human Capi- tal Index (HCI) is 0.49, indicating that a child born today 4 UNICEF, "Under-Five Mortality," https:// can only expect to be approximately half as productive data.unicef.org/topic/child-survival/un- der-five-mortality/. as they would be with a complete education, full health, 5 World Bank Group, "Myanmar Human and a well-nourished childhood. This is well below the Capital Index 2020," https://databankfiles. East Asia and Pacific average of 0.61, ranking Myanmar worldbank.org/public/ddpext_download/hci/ HCI_2pager_MMR.pdf. 120th of 157 countries.5 TAB. 1 KEY HEALTH STATISTICS FOR MYANMAR (2005-2020) 2005 2010 2015 2020 Total health spending US$ per capita (CHE) 8 20 63 58 Government health spending % Health spending 7.3% 9.8% 22% 20% (GGHE-D%CHE) Out-of-pocket spending % Health spending 82.5% 80.7% 70.5% 72.7% (OOPS%CHE) Priority to health (GGHE-D%GGE) 1.3% 1.4% 5% 3.4% GDP US$ per capita 326 1,027 1,153 1,559 Maternal mortality ratio (MMR)* 321 293 243 179 Under-five mortality rate** 76.9 63.4 51.8 43.2 *Deaths per 100,000 live births; Source: WHO Global Health Expenditure Database (https://apps.who.int/ **Deaths per 1,000 live births nha/database/country_profile/Index/en) Myanmar’s healthcare system comprises public, pri- vate, non-profit, and ethnic health organizations (EHOs). In the past, most of the external aid to support the delivery of health services was channeled through Non-Governmental Organizations (NGOs) and EHOs instead of government institutions.6 During the dem- ocratic transition (2012-2020), there were important shifts towards increased levels of development assis- 6 World Bank, Myanmar - tance in Myanmar, including for the country’s health Essential Health Services Access Project (English), 2014, http:// sector. External financing has played a vital role in sup- documents.worldbank.org/curat- porting Myanmar’s healthcare system, with its contri- ed/en/842151468279560485/ pdf/PAD10200PAD0P1010Box- bution increasing from 7% in 2017 to 23% in 2018.7 385323B00OUO090.pdf. 7 Myanmar Budget Brief Financing of Myanmar's health sector has been June 2023 https://documents1. worldbank.org/curated/ shaped by the country’s complex economic, political, en/099062823041514369/ pdf/P17910602d6cbe0c- and social history. During 1988-2011, government in- 208e42071ef77554e5a.pdf vestment in the health sector ranked among the lowest P. 11 in the world, and household out-of-pocket expenditures A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 for health as a percentage of total health spending was the highest in the world. According to a 2018 assess- ment, around 16 percent of households in Myanmar in- curred catastrophic health spending, and every year, 3.4 percent of the population fell below the poverty line due to health expenses.8 As of 2020, out-of-pocket expenses comprised 72.7 percent of total health spending, with a 8 World Bank. October 2018. Myan- very large financial burden on households.9 mar health Financing System Assess- ment. https://documents1.worldbank.org/ While government allocations to health as a per- curated/en/506281543467798250/pd- f/132560-28-11-2018-13-35-16-MyanmarHF- centage of total government spending significantly SAFINAL.pdf increased from 1.2% in FY2011-12 to 4.2% in FY2020- 9 World Bank, "Out-of-pocket health ex- penditure (% of current health expenditure) 21, health system capacity to respond to population - Myanmar,", https://data.worldbank.org/indica- health needs remained limited. Essential inputs such tor/SH.XPD.OOPC.CH.ZS?locations=MM. as human resources for health were below global bench- FIG. 1 SOURCES OF HEALTH EXPENDITURE GOVERNMENT TRANFERS OUT OF POCKET SPENDING SOCIAL HELTH INSURANCE CONTRIBUTIONS VOLUNTARY HEALTH INSURANCE CONTRIBUTIONS EXTERNAL AID OTHER 100% 50% 0% 2000 2005 2010 2015 2020 https://apps.who.int/nha/database/country_profile/Index/en Source: WHO Global Health Expenditure Database – Myanmar P. 12 marks with only 17.8 doctors, nurses and midwives per A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 10,000 population,10 compared to the World Health Or- ganization's minimum threshold of 22.8 health workers per 10,000 population.11 In 2020, there were approxi- mately 19,000 health facilities in the country, of which 61 percent were publicly operated, with the remainder privately run (excluding those operated by EHOs). Most private facilities are general practitioners (GP), clinics and specialty centers concentrated in cities such as Yan- gon and Mandalay (Table 2).12 Findings from facility assessments conducted in 2019 with five EHOs revealed that these EHOs collective- 10 MOH-WHO Access to Health 2020. Re- ly provided services to over 500,000 individuals in view of the Myanmar Human Resources for Health in the Public Sector Eastern and Southeastern Myanmar through more 11 SEARO 2018. Decade for health work- than 100 health facilities (clinics) that operate in both force strengthening in the South-East Asia Region 2015–2024. conflict-affected and remote regions of the country.13 This number represents only a small portion of the total 12 Myanmar Private Health Sector Assess- ment, 2022 (Global Financing Facility – World number of EHOs in Myanmar, indicating the scale of Bank Group) EHO health service contributions. 13 Community Partners International, "Ethnic Health Organizations in Myan- mar," 2019, https://www.cpintl.org/up- loads/8/7/0/2/87020218/2019-10_cpi_poa_ exec_summary_web.pdf. TAB. 2 TOTAL NUMBER OF HEALTH FACILITIES BY LEVEL (2020) Facility Level Public Private Total Remark Hospitals (incl. Specialty, Referral, General) 1,144 253 1,387 Secondary + Tertiary Specialty Centers/ Specialty Clinics N/A 144 144 Tertiary Health Stations/Sub-stations 10,477 0 10,477 Primary Maternal and Child Unit/Health Posts/Sub-posts / 441 7,390 7,831 Primary Primary Clinics Total 12,062 7,787 19,839 Source: Ministry of Health & Sports Three *Private data includes hospitals, general practitioners Year Achievement 2016-2019 and MOHS (GPs) and dental clinics Private Healthcare Division. P. 13 5 Health AVA I L A B I L I T Y A N D P R I CI N G O F ESSEN TI A L M ED I CI N ES I N M YA N M A R Status Trends Since the Crisis A vailable data on routine child immunization, incidence of communicable diseases and 14 Expanded Program on Immunization prevalence of mental health is- (EPI) is a global initiative launched by the World Health Organization (WHO) in 1974 sues depicts concerning trends to provide access to life-saving vaccines to in health status from 2021 - 2023. children under the age of five in developing countries to reduce the incidence of vac- The coverage of vaccines includ- cine-preventable diseases such as measles, polio, diphtheria, tetanus, pertussis, and ed in the Expanded Program on tuberculosis. Immunization (EPI) —for Bacillus Calmette-Guerin 14 15 World Health Organization, "Country (BCG), Diptheria-Tetanus-Pertussis (DTP) and Measles Profiles: Myanmar," https://immunizationdata. who.int/pages/profiles/mmr.html —declined significantly from 87%, 87%, and 91% in 2020 16 UNICEF Myanmar, "Humanitarian Situa- to 48%, 45%, and 44%, respectively, in 2021.15 Analysis of tion Report No. 12,", https://www.unicef.org/ media/134576/file/Myanmar-Humanitarian-Si- data from the most recent last five-year cohort of rou- tRep-December-2022.pdf. tine immunization coverage reveals that over 1.6 million children were identified as either unimmunized or un- der-immunized.16 P. 14 According to reports published by WHO17 and oth- A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 er international organizations, there is compelling evidence that the burden of key communicable dis- eases is increasing. A significant increase in drug-re- sistant malaria has been documented with concerns of sparking a wider global malaria threat.18,19 This escalation is associated with the disruption of the country's public health system in certain regions, pri- marily caused by armed conflicts and their associat- ed consequences. The crisis has led to disruptions in healthcare services, resulting in an increase in ma- 17 SEAR/WHO, "Public Health Situation Analysis laria cases17 (Figure 2) and a decline in tuberculosis Myanmar," dated November 15, 2022, https://cdn. who.int/media/docs/default-source/searo/myan- (TB) case detection as compared to previous years.20 mar/documents/public-health-situation-analy- Approximately 150,000 TB cases evaded detection af- sis-myanmar-sear-who.pdf ter the crisis, with an estimated 30,000 TB deaths in 18 CPI. World Malaria Day: Could Myanmar's Crisis Unleash a Global Malaria Threat? 25 April 2022. 2022.17Almost 15 percent of TB cases coexist with HIV, https://www.cpintl.org/field-notes--updates/world- malaria-day-could-myanmars-crisis-unleash-a- and an estimated 18,000 new cases a year are expect- global-malaria-threat ed to arise as the crisis continues unabated. It is esti- 19 Think Global Health. Drug-Resistant Malaria Is mated that 0.6 percent of people in Yangon have Drug Up 1,000 Percent in Myanmar. 18 May 2023. https:// www.thinkglobalhealth.org/article/drug-resis- Resistant TB, with nearly 80% of cases undiagnosed.17 tant-malaria-1000-percent-myanmar The reported percentage on coverage of people receiv- 20 Incidence of tuberculosis (per 100,000 people) – Myanmar. See World Bank, "Incidence ing anti-retroviral therapy (ART) has also decreased.21 of Tuberculosis (per 100,000 people) - Myanmar," https://data.worldbank.org/indicator/SH.TBS.INC- Finally, health status trends include an increase in D?locations=MM. the burden of mental health concerns. A 2022 study 21 UNAIDS Country Factsheets – “Myanmar”, https://www.unaids.org/en/regionscountries/coun- found that approximately one-quarter of the popula- tries/myanmar tion suffers from moderate to severe depression, with 22 PATH Myanmar, "Measuring Depression Se- younger individuals and those in areas of crisis more verity in Myanmar through PHQ-9 Questionnaire," September-October 2022. likely to be affected.22 FIG. 2 INCIDENCE OF MALARIA CASES P. Falciparum + mix cases P. Vivax Positivity Rate (%) 2020 2021 2022 2020 2021 2022 2020 2021 2022 3000 20000 15 15000 2000 10 10000 1000 5 5000 0 0 0 JAN MAR MAY JUL SEP NOV JAN MAR MAY JUL SEP NOV JAN MAR MAY JUL SEP NOV Source: SEAR/WHO. Public Health Situation Analysis Myanmar, November 15, 2022. P. 15 6 Health A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 Financing Since the Crisis S ince 2021, a noticeable decrease in pub- Only 2.5 % lic health spending has been observed, now standing at 2.5% of the union bud- get in 2023/2024 as compared to 4.6% in 2018/2019 (Figure 3). Additionally, of the union budget in there is no projected external financ- 2023/2024 are allocated ing for health sector loans in fiscal year to the health sector. 2023/2024. This diminishing spending on healthcare has compounded already substantial out-of- pocket health expenditures, resulting in increased rates of medical impoverishment and catastrophic expendi- tures (see 7.3 Household Financial Hardship). A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 P. 16 FIG. 3 MINISTRY OF HEALTH BUDGET ALLOCATION AND SPENDING ON HEALTH ALLOCATED BUDGET BE ACTUAL EXPENDITURE PS, TA, PA OUTTURN AS A % OF UNION BUDGET % OF GDP 1600 MMK BILLIONS 4,6% 5,0% 1400 4,2% 4,5% 3,7% 4,0% 1200 3,5% 1000 2,8% 3,0% 800 2,5% 2,5% 600 2,0% 1,5% 1,5% 400 1,1% 0,7% 1,0% 1,0% 200 0,5% 0 0,0% 2018/19 2019/20 2020/21 2022/23 2023/24 Provisional Actuals (PA), Actuals (A), Temporary Actuals Source: Myanmar Budget Brief June 2022, The World Bank – Myanmar (TA), Budget Estimates (BE) https://elibrary.worldbank.org/doi/abs/10.1596/38008 P. 17 7 Access A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 to Essential Health Services 7.1 Health-seeking Behavior H ealth seeking behavior has dra- matically changed throughout Myanmar's crisis 2021-2023. The Myanmar Poverty and Liv- ing Conditions Survey (2017) found that among individuals who experienced illness within the previous thirty days, 21 per- cent refrained from seeking treatment, while 77 percent sought medical assistance from either private or public healthcare providers (54 percent opting for private pro- viders; 23 percent opting for public providers). The first round of the Access to Healthcare Phone Survey in 2021 found that only 51 percent of households sought care from healthcare providers, indicating a decline in the population’s access to the formal health system. How- ever, in the third round, the trend showed a return to levels close to those observed prior to the crisis, with 65 percent of households seeking medical attention from healthcare providers for the most severe injury or illness experienced in the preceding 30 days (Figure 4). P. 18 FIGURE 5TAKEN FOR ILLNESS OR INJURY (N=1500) A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 FIG. 4 ACTION ROUND 1 ROUND 2 ROUND 3 DID NOTHING CONSULTED TRADITIONAL HEALTH SERVICE PROVIDER INCLUDING TELE CONSULTATION CONSULTED SERVICE PROVIDER WITH NO FORMAL HEALTH EDUCATION SO CALLED ’QUACK’ OR HEALTH VOLUNTEER TRIED UNSUCCESSFULLY TO GO TO A MEDICAL FACILITY/HEALTH SERVICE PROVIDER CONSULTED WITH MIDWIFE, NURSE, HEALTH ASSISTANT WENT TO AMEDICAL FACILITY/CONSULTED A HEALTH SERVICE PROVIDER INCLUDING TELECONSULTATION USED MEDICINE I HAD IN STOCK/WENT TOPHARMACY OR DRUG STORE 0% 20% 40% 60% 80% 100% Source: World Bank estimates using data from the World Bank and World Health Where people seek care, both in terms of level of Organization’s survey on Measuring Access to care and sector of service delivery (public or private), Health Services Phone Surveys, 2021-2023. has changed substantially since 2021. Across Survey Rounds 1-3, private healthcare providers remained the preferred choice for households, increasing from 34 per- cent of healthcare seekers in 2021 to 59 percent in 2023 (Figure 5). The proportion of households not seeking formal care has dropped dramatically from 52 percent to 18 percent, while the use of public sector facilities has remained low. Notably, there has been a shift in where treatment is sought, from primary to secondary care, with households increasingly accessing private hospi- tals and specialist clinics rather than private doctors and GP clinics (Figure 6). In terms of public facility-based providers, there has been a moderate shift from health centers and sub-centers to government hospitals (Fig- ure 7). However, Round 3 analysis showed these general trends do not hold for poor households, which are still more likely to seek care from primary rather than sec- ondary care providers (Figure 8). A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 P. 19 FIG. 5 TYPE OF HEALTH CARE PROVIDER SOUGHT (N=1500) PUBLIC PRIVATE NO FORMAL/FACILITY CARE 59% 52% 46% 39% 34% 23% 15% 14% 18% 2021 2022 2023 Source: World Bank estimates using data from the World Bank and World Health Organization’s survey on Measuring Access to Health Services Phone Surveys, 2021-2023. FIG. 6 TYPES OF HEALTHCARE PROVIDERS ACCESSED (PRIVATE) ROUND 1 N=727 ROUND 2 N=908 ROUND 3 N=1229 OTHER PRIVATE NGO/FAITH BASED FACILITY PRIVATE HOSPITAL/ SPECIALIST CLINIC PRIVATE DOCTOR/GP’S CLINIC 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Source: World Bank estimates using data from the World Bank and World Health Organization’s survey on Measuring Access to Health Services Phone Surveys, 2021-2023. FIG. 7 TYPES OF HEALTHCARE PROVIDERS ACCESSED (PUBLIC) ROUND 1 N=727 ROUND 2 N=908 ROUND 3 N=1229 TRADITIONAL MEDICINE FACILITY HEALTH VOLUNTEER GOVT. HOSPITAL GOV. PRIMARY HEALTHCARE 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Source: World Bank estimates using data from the World Bank and World Health Organization’s survey on Measuring Access to Health Services Phone Surveys, 2021-2023. A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 P. 20 FIG. 8 TYPES OF HEALTHCARE PROVIDERS ACCESSED (POOR AND NON-POOR HOUSEHOLDS) NON POOR POOR NON POOR POOR OTHER PUBLIC FACILITY PRIVATE HOSPITAL/ SPECIALIST CLINIC MOBILE CLINIC PRIVATE DOCTOR/GENERAL HEALTH VOLUNTEER PRACTITIONER’S CLINIC GOVT. HOSPITAL OTHER PRIVATE FACILITY GOVT. HEALTH POST MOBILE CLINIC GOVT. HEALTH CENTER 0% 20% 40% 60% 80% 0% 20% 40% 60% 80% Source: World Bank estimates using data from the World Bank and World Health Organization’s survey on Measuring Access to Health Services Phone Surveys, 2021-2023. 7.2 Maternal & Child Health R ound 2 and Round 3 of the health survey included an additional fo- cus on examining the accessibility of routine healthcare services for household members who had re- cently given birth or had children under the age of two. Approximate- ly 10 percent of respondents report- ed not receiving antenatal or postnatal care services during their most recent delivery. Similarly, more than 90 percent of households with children under two years of age indicated some level of access to routine immuni- zations, primarily through public healthcare providers. However, it is important to note that these figures solely reflect self-reported access to these services and cannot be directly compared to population-based assessments of health service coverage, where indicators evaluate the comprehensiveness and timeliness of service ac- cess, such as whether a child received all recommended routine immunizations by the age of two. P. 21 Poor households appear to have less access to essen- A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 tial maternal, newborn and child healthcare. An anal- ysis of Round 2 data using the World Bank's Survey of Well-being via Instant and Frequent Tracking (SWIFT) approach (Figures 9-12) reveals that households clas- sified as poor reported lower access to antenatal care (poor: 83.6 percent; non-poor: 91.3 percent), postnatal care (poor: 91.9 percent; non-poor: 96.3 percent), and child immunization services (poor: 83.6 percent; non- poor: 91.3 percent). Moreover, a higher proportion of poor households accessed child immunization services through public providers (poor: 99 percent; non-poor: 93.5 percent), while a lower percentage utilized pri- vate for-profit providers (poor: 1 percent; non-poor: 5.1 percent). In Round 2, over 80 percent of households reported that their household members had received COVID-19 vaccinations, which increased to over 90 percent in Round 3. Notably, the SWIFT analysis of Round 2 data indicated a slightly higher vaccination rate among non-poor households than poor households (83 percent; non-poor: 86 percent). A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 P. 22 FIG. 9 ANY REPORTED ACCESS TO ANTENATAL FIG. 10 ANY REPORTED ACCESS (ANC) AND POSTNATAL (PNC) TO CHILD IMMUNIZATION SERVICES (ROUND 2 SWIFT ANALYSIS) (ROUND 2 SWIFT ANALYSIS) ANC PNC 95% 97% 96% 99% 98% 96% 95% 94% 92% 97% 96% 100% 100% 89% 91% 87% 84% 90% 80% 80% 70% 60% 60% 50% 40% 40% 30% 20% 20% 10% 0% 0% NATIONAL URBAN RURAL POOR NON POOR NATIONAL URBAN RURAL POOR NON POOR Source: World Bank estimates using data from the World Bank and World Source: World Bank estimates using data from the World Bank and World Health Organization’s survey on Measuring Access to Health Services Health Organization’s survey on Measuring Access to Health Services Phone Surveys, 2021-2023. Phone Surveys, 2021-2023. FIG. 11 ANY REPORTED ACCESS FIG. 12 HOUSEHOLD MEMBERS ACCESSING TO CHILD IMMUNIZATION COVID-9 VACCINATIONS (ROUND 2 (ROUND 2 SWIFT ANALYSIS) SWIFT ANALYSIS, ROUND 3) PUBLIC PRIVATE ROUND 2 ROUND 3 0% 1% 100% 100% 96% 5% 5% 95% 94% 94% 95% 93% 14% 90% 90% 99% 99% 86% 85% 95% 94% 85% 83% 85% 80% 80% 75% 75% NATIONAL URBAN RURAL POOR NON POOR NATIONAL URBAN RURAL Source: World Bank estimates using data from the World Bank and World Source: World Bank estimates using data from the World Bank and World Health Organization’s survey on Measuring Access to Health Services Health Organization’s survey on Measuring Access to Health Services Phone Surveys, 2021-2023. Phone Surveys, 2021-2023. A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 P. 23 7.3 Household Financial Hardship B etween 2021-2023, three rounds of survey found that the number of respondents resorting to borrow- ing funds or selling assets to pay for healthcare increased (Figures 13-14). Moreover, half of the surveyed medi- cal doctors reported raising their ser- vice rates by 10-20 percent in 2022, with many indicating the likelihood of further rate in- creases in 2023. This is anticipated to exacerbate finan- cial hardships and potentially lead to patients foregoing necessary medical care. FIG. 13 PERCENTAGE OF PEOPLE THAT FIG. 14 PERCENTAGE OF PEOPLE HAD TO BORROW FUNDS TO PAY THAT HAD TO SELL ASSETS FOR HEALTHCARE TO PAY FOR HEALTHCARE ROUND 1 ROUND 2 ROUND 3 ROUND 1 ROUND 2 ROUND 3 25% 25% 21% 20% 18% 20% 15% 15% 13% 15% 12% 12% 11% 11% 11% 10% 10% 10% 10% 10% 5% 5% 0% 0% PUBLIC PRIVATE PUBLIC PRIVATE Source: World Bank estimates using data Source: World Bank estimates using data from the World Bank and World Health from the World Bank and World Health Organization’s survey on Measuring Access to Organization’s survey on Measuring Access to Health Services Phone Surveys, 2021-2023. Health Services Phone Surveys, 2021-2023. P. 24 The convergence of various factors such as conflicts, A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 escalating inflation and food prices, loss of livelihoods, and logistical challenges has compelled many house- holds to adopt coping mechanisms, including reducing their food consumption.23 Round 3 findings indicate that households have encountered difficulties accessing an adequate food supply due to resource limitations as 21 % of households reported depicted in Figure 15. As of early 2023, Round 3 results revealed that 36 per- cent of households expressed concerns about insuffi- cient food availability, while 21 percent reported be- being unable to afford ing unable to afford or access healthy and nutritious or access healthy and food. Additionally, 24 percent indicated consuming less nutritious food in 2023 food than they believed necessary. Notably, nearly 5 per- cent of respondents disclosed that their households had 23 Data collected in October 2020 through the World Bank’s high frequency phone sur- completely run out of food, with 2.5 percent confirming veys in Myanmar (https://documents1.world- having gone an entire day without eating. The survey bank.org/curated/en/594341603898784461/ pdf/Current-Situation-and-Implica- also highlights that urban households were more likely tions-for-Household-Welfare.pdf) to experience food insecurity. However, urban house- 24 “Household dietary diversity Score (HDDS) is a qualitative measure of food consumption holds exhibited slightly higher Household Dietary Di- that reflects household access to a variety of versity Scores (HDDS) compared to rural households foods. https://www.fao.org/nutrition/assess- ment/tools/household-dietary-diversity/en/ (Urban 7.52 vs. Rural 7.09).24 FIG. 15 FOOD INSECURITY EXPERIENCE SCALE IN MYANMAR (ROUND 3) % % % % . % WORRIED UNABLE TO EAT EAT LESS RAN OUT NOT EAT FOR ABOUT FOOD HEALTHY AND OF FOOD THE WHOLE NUTRITIOUS FOOD DAY Source: World Bank estimates using data from the World Bank and World Health Organization’s survey on Measuring Access to Health Services Phone Surveys, 2023. A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 P. 25 7.4 Non-Communicable Diseases T he burden of NCDs appears to have increased since the crisis. The pro- portion of household respondents that reported a chronic illness increased between 2022-2023 (Figure 16). In 2023 nearly half of households (49.5%) reported the presence of at least one member with hypertension, while one in five households (20.5 percent) had at least one member with diabetes. Moreover, among those individ- uals who self-reported having diabetes, a substantial 70 percent also reported coexisting hypertension. Among those with either hypertension or diabetes, approximate- ly 80 percent reported experiencing an increase in cost of medicines over the past six months, with the majority reporting increases exceeding 20 percent. The surveys also revealed that 84 percent of house- holds with members affected by hypertension had re- sorted to cutting back or skipping doses of medication due to the burden of medication costs. Almost half of these households (48 percent) faced moderate to severe challenges in acquiring the necessary medications. No- tably, 17 percent of households resorted to loans to cov- er medication expenses. As for diabetes, 86 percent of respondents reported regular medication adherence, although 59 percent faced difficulties in obtaining the required medications. Merely 16 percent of respondents reported skipping medication due to cost-related issues in the past six months. A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 P. 26 FIG. 16 TYPE OF HEALTH PROBLEMS REPORTED ROUND 2 ROUND 3 100% 91% 86% 80% 60% 40% 20% 14% 9% 0% ACUTE CHRONIC Source: World Bank estimates using data from the World Bank and World Health Organization’s survey on Measuring Access to Health Services Phone Surveys, 2021-2023. FIG. 17 BREAKDOWN OF RESPONDENTS WITH HYPERTENSION AND DIABETES RURAL URBAN RURAL URBAN 60% 57% 60% 57% 52% 52% 48% 48% 50% 43% 44% 40% 40% 30% 20% 20% 10% 0% 0% FEMALE MALE FEMALE MALE Source: World Bank estimates using data from the World Bank and World Health Organization’s survey on Measuring Access to Health Services Phone Surveys, 2021-2023. 7.5 Essential Medicines T he ongoing crisis has precipitated a fresh array of challenges within within medical supply chains, re- sulting in the scarcity of crucial es- sential medicines and rendering them unaffordable for many. Quali- tative research focusing on essential medicines has revealed a nearly two- fold surge in prices during the waves of the COVID-19 pandemic in 2020 and 2021. Particularly, respiratory infections, vitamins, cough medicine, and antibiotics experienced an average increase of 40 percent in their P. 27 prices. However, prices reverted to pre-wave levels after A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 each wave subsided in 2020 and 2021. In 2022, depre- ciation of MMK and frequent fluctuation in currency exchange rates led to price escalations across all drug categories, ranging from 30 percent to 200 percent. Medicines for NCD treatment such as amlodipine and metformin were particularly impacted during periods without COVID-19 waves. Essential medicines now cost more than twice their pre-crisis prices, with metformin rising from MMK 750 to MMK 1,300 and paracetamol escalating from MMK 1,100 to MMK 2,500.25 In the Round 3 survey, nearly 80 percent of respon- dents observed increased medication prices within the preceding six months, with 65 percent reporting in- creases exceeding 20 percent (Figure 18). The providers’ perspective study corroborates this trend, with nearly all respondents noting an upsurge in anti-hypertensive and anti-diabetic medications costs, primarily falling with- 25 World Bank in 20 to 50 percent (Figure 19). According to survey re- and World Health Organization's sults, prescribing less expensive alternative drugs has study of supply side emerged as a coping mechanism many doctors employ essential medicines, 2023 in response to the mounting prices of medications. FIG. 18 HOUSEHOLD EXPERIENCES IN PRICE CHANGES FOR NCD MEDICINES (ROUND 3) DIABETES MEDICATIONS N=380 DIABETES MEDICATIONS N=380 HYPERTENSION MEDICATIONS N=458 HYPERTENSION MEDICATIONS N=458 100% 100% 79% 79% 80% 80% 66% 65% 60% 60% 40% 40% 20% 19% 20% 20% 12% 10% 12% 14% 8% 10% 1% 1% 3% 2% 0% 0% DON’T KNOW UNCHANGED DECREASE INCREASE DON’T KNOW SLIGHTLY ~10% MODERATELY ~20% CONSIDERABLY >20% INCREASE INCREASE INCREASE Source: World Bank estimates using data from the World Bank and World Health Organization’s survey on Measuring Access to Health Services Phone Surveys, 2023. A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 P. 28 FIG. 19 PROVIDER PERSPECTIVES OF PRICE CHANGES FOR HYPERTENSION AND DIABETES MEDICINES (N = 118) INCREASED THE SAME DECREASED INCREASED THE SAME DON’T KNOW 1% 2% 2% 2% % % Source: World Bank estimates using data from the World Bank’s study on private sector healthcare providers’ perspectives on healthcare service provision (2023) Shortages of medicines are attributable to various fac- tors, including price hikes, fluctuations in currency ex- change rates, changes in the importation process and procedures, closures of ports and companies, panic buying, reduced imports, and the decision to halt im- ports of less commonly used brands. Interviews con- ducted with pharmacies, importers, and distributors indicate that shortages of certain brands persisted for periods ranging from 2 weeks to 6 months in 2022 due to delayed import permits or licenses, currency fluctua- tions, and limited supply. Since mid-2022, some brands have become unavailable as companies refrain from im- porting them due to increased prices resulting from in- flation. The availability of specific brands depends on importers and pharmaceutical companies, with some being restocked within days while others require up to 6 months for replenishment. Regarding the retail and wholesale pharmacies op- erating in the for-profit private sector, no significant changes or challenges were reported initially in sourc- ing and delivering medicines during the initial peri- od of the pandemic (2020). Companies utilized their transportation systems to source and distribute medi- cines, delivering products to respective warehouses and P. 29 stores. However, some companies encountered diffi- A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 culties in distributing medicines due to lockdowns and regional instability. In 2022, with the escalation of fuel and logistics prices and employee salaries, companies began utilizing third-party delivery services in the last quarter of the year. The primary logistics challenge lies in the high transportation costs attributed to rising fuel prices, necessitating an end to free delivery services. Not-for-profit organizations interviewed in 2023 have faced obstacles in medicine procurement due to po- litical instability and conflict, leading to changes in procurement procedures and an increased reliance on local suppliers. Despite experiencing an average price increase of 45 percent for primary healthcare items compared to 2020 and 2022, most organizations have managed to secure funding and donor support to sus- tain their activities. However, challenges persist in dis- tributing medicine to conflict-affected areas and obtain- ing tax exemption certificates. Concerns about access to healthcare and medicine shortages continue, particu- larly in rural areas. 7.6 Private Healthcare Sector L imited information is available re- garding the specific impacts of the pandemic and political crisis on the private healthcare sector since 2021. Prior to the crisis, a significant por- tion of public sector health person- nel engaged in private dual practices, while an informal sector for pharma- ceuticals existed alongside. Since February 2021, the private healthcare sector has experienced increased de- mand for services, but also more significant regulato- ry and cost burdens. These challenges impede private provider capacity to delivery healthcare services to the P. 30 public. During the interviews for Private Health Facili- A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 ty Assessment in 2021-2022, the respondents stated that expansions and major investments in private hospitals were halted due to weakened Myanmar currency, un- predictability in the business environment and higher costs, among other challenges. Since 2021, acquiring licenses for new private health- care facilities and importing drugs has become more arduous and time-consuming. In addition, private healthcare providers face challenges such as shortages of healthcare workers, escalating pharmaceutical prices and an environment of uncertainty. An assessment conducted in 2021 with private health- care providers highlighted their interest in expanding services, particularly for underserved and vulnerable populations. These providers expressed a desire to col- laborate with relevant development partners and inter- national health organization to enhance access to essen- tial healthcare services. Over the period of 2021-2023, 26 https://myanmar-now.org/ there has been an increase in collaborations between en/news/prominent-private-hos- private healthcare providers and development partners, pital-shut-down-by-junta-or- der-in-mandalay/ particularly with innovative contracting arrangements. A NA LYS I S O F ACCESS TO ESSEN TI A L HEA LTH SER V I CES I N M YA N M A R 2 0 2 1 - 2 0 2 3 P. 31 T Conclusion he healthcare system in Myanmar has encountered severe disruptions due to the COVID-19 pandemic and the political instability since 2021. The impact of these events has been felt across all levels of the healthcare sector. Reduced service capacity and a lack of trust in the public sector have compelled more individuals to seek care from oth- er types of healthcare providers. At the same time, the volatility of currency markets and challenges in importation have led to price in- creases for essential medicines. The ongoing conflict within the country further compounds the situation, creating additional obstacles for healthcare providers in delivering essential services and collecting vital infor- mation as well as other health data. The international community and humanitarian or- ganizations must forge innovative collaborations in response to these challenges. There is a growing imper- ative for international development organizations and donors to engage with private healthcare providers, in- cluding both for-profit and non-profit entities, to ensure the delivery of essential healthcare services to the people of Myanmar. These partnerships should aim to harness the capacities of the private healthcare providers, and allocate increased resources to deliver essential health services as well as alleviate household financial burden for accessing care, especially for vulnerable households.