Caring for the most vulnerable

As part of the NLD government’s plans to bring Universal Health Coverage to Myanmar by 2030, the Sun Quality Health Network has opened its doors to the poorest of the poor, offering subsidised health care to communities used to going without proper treatment.

By MARGARITE CLAREY | FRONTIER

WHEN SHE could no longer bear the unremitting headaches, fatigue and searing pains in her chest, Daw Le Le Win, 60, decided to see a specialist. Her neighbours in Shwepyithar Township lent her K20,000 for the consultation fee and her eldest daughter, a single mother and factory worker, helped her to a nearby clinic. After her fifth visit in three months, her bamboo home was beginning to crumble, as she had no money left to maintain it. Not long after, her health deteriorated even further.

The cost of seeking private health care in Myanmar is often enough to push poorer households into vicious cycles of poverty and illness. But with only 5.23 percent of the state budget allocated to health in 2017-18, public hospitals often lack sufficient medical staff and supplies; for a patient, the wait time can mean forgoing a paid day’s work. Consequently, those that can afford it opt for private health clinics but for many the financial burden is high.

The effects of decades of neglect of the public health system under military rule are clear. To take but one statistic, life expectancy at birth is the lowest among ASEAN countries and, at 64.7 years, is almost 10 years less than neighbouring Thailand.

Since coming to power in 2016 the National League for Democracy government has set out to improve the overall health status of the country. Its election manifesto contained no less than 15 health-related goals, including improving and expanding basic services, increasing the national health budget, and reducing infant and maternal mortality.

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At the top of the NLD government’s health initiatives are ambitious plans to bring universal health coverage to the entire population by 2030, and an “essential package of health services” by 2020. Described by the 2017-21 National Health Plan as “a path that is explicitly pro-poor”, the new policies strive to address socioeconomic disparities in accessing health care through reducing the out-of-pocket costs for patients.

While urban populations generally have more access to health services than people in rural areas, there is still a large gap between the poor and non-poor households, Dr Han Win Htat, national director of the Sun Quality Health Network at Population Services International (PSI) in Myanmar, told Frontier.

Shwepyithar Township resident Daw Su Su Hlaing, 38, holds her infant daughter. (Nyein Su Wai Kyaw Soe | Frontier)

Shwepyithar Township resident Daw Su Su Hlaing, 38, holds her infant daughter. (Nyein Su Wai Kyaw Soe | Frontier)

As a result, many health issues that could be easily treated are neglected until the problem is much worse. We see more and more people from peri-urban slums coming into large cities for secondary or tertiary treatment because they could not afford to take a day off or spend their earnings on health care when their disease was still treatable at the primary care level,” he said.

Piloting a way forward

In March 2017, PSI launched a pilot health insurance scheme with a select group of doctors from the Sun Quality Health Network targeting the “peri-urban poor” in Shwepyithar Township and Darbein in Hlegu Township. With funding from the Three Millennium Development Goals Fund, about 2,506 households have since been registered and issued a health-insurance card.

The aim is to explore a potential contracting mechanism under which private health providers, such as the Sun Quality Health Network, would receive future public health financing to help implement the government’s health plans.

The model being rolled out in Darbein and Shwepyithar brings subsidised primary health care services to the poor, so as to reduce the frequency by which otherwise treatable illnesses deteriorate to the point of specialised secondary or tertiary care, which is significantly more expensive to provide. PSI is monitoring the project in close collaboration with the National Health Plan Implementation Monitoring Unit.

Le Le Win is one of 1,563 beneficiaries assigned to Dr Yee Zin Oo, a Sun Quality Health Network provider at a clinic in Shwepyithar. With PSI’s health card, Le Le Win has to pay only K500 for a consultation with Yee Zin Oo – a fraction of the normal K3,000 fee.

Dr Yee Zin Oo, 52, treats insurance card holders at her clinic. (Nyein Su Wai Kyaw Soe | Frontier)

Dr Yee Zin Oo, 52, treats insurance card holders at her clinic. (Nyein Su Wai Kyaw Soe | Frontier)

“On one of my first appointments, Dr Yee Zin Oo diagnosed me with hypertension,” Le Le Win told Frontier. “With the medicine she prescribed me I am better able to manage my condition.

“I’ve even saved money for my grandson’s education – and to repair my home,” she said, gesturing to the new walls and roofing.

Treating the poorest of the poor

Hypertension, or high blood pressure, is a common condition in the elderly that can be easily managed with the right medication. However, failure to seek treatment can lead to a heart attack or stroke. In poorer communities like Shwepyithar, many people neglect their illness or fail to have it diagnosed at all simply because they cannot afford to seek treatment. Instead, they go to the local pharmacy and typically purchase painkillers or anti-allergens. Over time the condition worsens. 

Since joining the PSI programme in March 2017, Yee Zin Oo has diagnosed and treated many new patients with hidden illnesses. She has been working in Shwepyithar since 1991 but this is the first time she has been able to treat the poorest of the poor.

Of the PSI card-holders assigned to her clinic, 75 percent are new patients. For each card-holder, Yee Zin Oo receives a capitation payment from PSI in the form of a fixed sum that takes into account local epidemiology, the average number of visits each patient will make, and the associated costs of these visits, particularly medication and equipment.

Sitting in her single room clinic, which she opens daily with the help of her husband, Yee Zin Oo told Frontier that she commonly treats patients for pneumonia, diarrhoea and tuberculosis.

“These diseases are far more common in poor households because of unclean living conditions, lack of electricity, and because people have not been educated in basic health and sanitation,” she said, her eyes flickering to a queasy-looking teenager waiting in the reception.

Preventable deaths

Tuberculosis, pneumonia and self-induced abortions are the primary killers in this community, she told Frontier. “When women arrive in my clinic with blood flowing heavily down their legs there is nothing I can do but send them to hospital for specialised care,” she said. Instead, Yee Zin Oo works closely with her female patients to encourage family planning, contraceptive use and healthier eating for pregnant women.  

One of her patients is Daw Su Su Hlaing, 38. As we sat down on a bamboo mat in the home she shares with her husband and children, Su Su Hlaing propped her infant daughter up on her lap. She collects plastic for a living, while her husband does odd jobs for Yangon Electricity Supply Corporation. On a good day they bring home K8,000, but the work is irregular and often they earn nothing at all.

Shwepyithar residents register for a health insurance card. (Nyein Su Wai Kyaw Soe | Frontier)

Shwepyithar residents register for a health insurance card. (Nyein Su Wai Kyaw Soe | Frontier)

When Su Su Hlaing fell pregnant in 2016, money was scarce. “It felt like a waste to spend so much [K7,000] on a doctor’s appointment,” she said. She didn’t see an obstetrician and gynaecologist once during her nine-month term. When she went into labour, the doctors and nurses at the hospital told her she needed to have a caesarean section, but at K200,000 the family was unable to afford it. By the time she gave birth, her baby was dead.

“This time around I was very worried,” she said stroking her daughter’s thanakha-brushed forehead. She had only just fallen pregnant again when she registered for PSI’s health insurance card.

As a card-holder, Su Su Hlaing qualified for a cash-transfer of up to K200,000 for a caesarean birth, on the condition that she attended at least four antenatal visits at her assigned Sun Quality Health clinic. “I went each week for a check-up at Dr Yee Zin Oo’s clinic,” Su Su Hlaing told Frontier. “When I didn’t have enough money for a trishaw, I walked.”

Changing health behaviour

Proximity and availability of service providers remain the biggest challenge presented by the pilot. Although the co-payment is only K500, there is little to no public transport in Darbein or Shwepyithar. Getting to the assigned clinic by taxi or trishaw can easily add K1,500 to the patient’s out-of-pocket spending. “With this in mind many people may still prefer to go to the local pharmacy,” Han Win Htat told Frontier.

Nyein Su Wai Kyaw Soe | Frontier

Nyein Su Wai Kyaw Soe | Frontier

Changing behaviour is half the battle, he explained. Of the 11,000-people invited to join the UHC pilot, only 69 percent showed up for registration. “Generally, only people with chronic illnesses or those who expect to get sick, such as the elderly or families with small children, register. This is a challenge for service providers and an important lesson to be retained for future implementation,” Han Win Htat said.

Making sure that doctors treat card-holders as well as they do full-fee paying patients will also be important. Although the pilot began with five doctors, they had to drop two because of reports that they were behaving discriminatorily toward card-holders.

Although the project has faced hurdles, Han Win Htat is confident that with adequate funding and continued support from the Ministry of Health and Sports, PSI and the Sun Quality Health Network will be able to expand the universal health coverage programme to other areas of the country.

For card-holders like Su Su Hlaing, the PSI scheme means no longer skipping meals or taking loans to see a doctor. All of the programme participants that Frontier interviewed said they no longer wait until they, or their children, are very sick to seek treatment. This significantly lessens the likelihood of them dying of treatable illnesses, like pneumonia. “It is much easier now, said Su Su Hlaing, “I don’t feel stressed like I used to.”

TOP PHOTO: Nyein Su Wai Kyaw Soe | Frontier

By Margarite Clarey

By Margarite Clarey

Margarite Clarey is a Yangon-based journalist and researcher. She writes about development, human rights, conflict and displacement.
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