House of Commons - Democracy and Development in Burma - International Development Committee

Democracy and Development in Burma - International Development Committee Contents

4 Health

121. Burma has some of the worst health indicators in Asia, and suffers amongst the highest rates of malaria and tuberculosis anywhere. There is a high maternal mortality rate of 200 per 100,000 live births and the child mortality rate is 62 per 1,000 births. Health is chronically underfunded by the Burmese Government at 0.9% of GDP, far lower than nearly all other low and middle income countries. The Burmese spent £14 per person on health in 2011. That compares to £23 in Laos, £32 in Cambodia and £59 in Vietnam. Burmese Government funding for this was £1.80 per person per year and external funding amounts to $1 per head.[139] The rest is known as 'out of pocket spending' paid directly by private households.[140] Burma's public health system is in a very poor condition. ICAI identified significant weaknesses against all the World Health Organisation's indicators of a functional health system, including the existence of a well-performing health workforce. Currently the ratio of skilled health workers to population is 1.1 health workers/1000 population, placing it on the list of crisis countries for urgent health workforce action.[141]

122. DFID has had nine health programmes in Burma (see table at appendix 2 of report with details):

· The Three Millennium Development Goal Fund;

· The Three Diseases Fund;

· Addressing Drug Resistant Malaria in Burma through Populations Services International;

· Delta Maternal Health Joint Initiative;

· Primary Health Care for minority communities on the Burma/China border through Health Poverty Action;

· Mae Tao Clinic on the Thai Burma border;

· Emergency Healthcare for IDPs on Eastern border through Christian Aid;

· Shoklo TB for accessible Tuberculosis treatment on the Thai Burma border; and

· Health services for Burmese refugees in three camps through Aide Medicale Internationale.[142]

123. The DFID budget for health 2011/12 to 2014/15 is £63.4 million with £45.8 million being spent on community and maternal health and £17.6 million on malaria. The Health headline results in DFID's Operational Plan are:

· 500,000 women and men receive appropriate treatment to contain the spread of drug-resistant malaria; and

· 153,000 unintended pregnancies are helped to be averted.

124. The Independent Commission for Aid Impact (ICAI) carried out a review of six of the nine DFID Burma health programmes in 2013. The review included programmes delivered through multilateral organisations, through NGOs, and through other medical agencies. ICAI gave a 'green' rating and ICAI's recommendations were all accepted by DFID.[143] Mark Foster of ICAI told us:

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Its assessment of the health programme emphasised the benefits derived from the senior health adviser's relatively long period in post. ICAI told us:

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In view of the importance of the next few years to Burma's future, we recommend that DFID staff, particularly in important sectors such as health, remain in post for longer than they might in other offices.

The Three Millennium Development Goal Fund

General approach and future

125. The Three Millennium Development Goal Fund (3MDG Fund) is the largest fund in DFID Burma's health portfolio - DFID expects to spend up to £80 million on it between 2012 and 2016.[146] The fund was established in June 2012 and is also funded by Australia, Denmark, the European Union, Norway, Sweden, and the United States of America. It is managed by the United Nations Office of Project Services and is scheduled to invest an estimated US$300 million over five years in Burma specifically on health. DFID's contribution makes up approximately 40% of the total fund and DFID chairs the 3MDG Fund Board. The fund works in selected townships throughout Burma.[147]

126. The fund developed out of the previous Three Diseases Fund[148] and the Joint Initiative on Maternal Neonatal and Child Health in the Irrawaddy delta region.[149] It is targeted at:

· improving basic maternal and child healthcare in communities;

· tackling HIV- AIDS, tuberculosis and malaria; and

· strengthening the systems that deliver health services.

The 3MDG Fund specifically provides services for populations not covered by the Global Fund in Burma for example those populations in non-government controlled areas and drug users.[150]

127. Some witnesses were critical of the 3MDG fund. Christian Aid argued that it should not focus on a limited number of diseases:

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Save the Children argued that channelling money through the 3MDG Fund reduced the speed and flexibility of decision making and increased transaction costs.[152] This was also a concern for ICAI who warned of a potential risk to flexibility.[153] Mark Foster explained that in a country that was changing so fast:

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However, in general ICAI gave strong support to the 3MDG Fund. Mark Forster told us that the 3MDG Fund looked "well targeted" and was "working on the right kind of things." He also said that it could have a "meaningful and substantive impact" because of the chance of working with and leveraging the Burmese Ministry of Health.[155] Fiona Campbell who had worked on the 3MDG Fund told us that the fund was having a transformational effect by showing it was "possible to deliver services to hard-to-reach areas and to vulnerable populations" which then encouraged funding to "come from other places."[156]

128. However, well designed and effective the 3MDG Fund, there are serious concerns about its future. Health will cease to be a priority for the EU in Burma after 2016. We wrote to the EU Commissioner Andris Piebalgs asking for an explanation of this and to ask that the EU continues to fund the 3MDG Fund. He has since replied, stating:

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The EU currently contributes $37.4 million, 11% of the 3MDG Fund, although only just over a quarter of what the UK is contributing it is still a significant amount. For the 3MDG Fund to continue past 2016 the EU, if it will not contribute further, must find another donor to replace it.

129. We are impressed by, and strongly support, the Three Millennium Development Goal Fund (3MDG Fund). We welcome its focus on building capacity both in Government-controlled areas and in ethnic areas. We are, however, disappointed by the EU which is refusing to provide funding beyond 2016 and hence threatening the future of the 3MDG Fund. We urge the EU to continue to fund the 3MDG Fund after 2016; if it is unwilling to so, the least it can do is find a donor to replace its contribution.

MATERNAL AND CHILD HEALTHCARE

130. In Burma one woman dies for every 260 babies born and only one in three women use any modern method of contraception. The leading cause of death and disability for women is pregnancy and child birth.[158] However we were surprised to hear on our visit to Burma of its low fertility rate compared to neighbouring countries. Burma's fertility rate as of 2011 was 2.0 births per woman which is the same as the UK whereas Laos was 3.2, Cambodia 2.9 and Indonesia 2.4.[159]

131. The 3MDG Fund's work on maternal and child health works across six townships in the Irrawaddy delta covering an estimated population of 1.7 million.[160] These services are provided by the Burmese Department of Health with support from NGOs. Fiona Campbell explained how the work in the Delta had been successful in showing how a small input could have a significant output for example the provision of transport so that midwives could get out to the villages.[161]

132. The Head of DFID told us that it would be moving into the ceasefire areas[162]— it will soon be extended to Chin State and other ethnic regions. The Shan Women's Action Network (SWAN) was disappointed that DFID had decided not to support their reproductive and child health care programme. Shan state is an ethnic minority region where there has been armed conflict and is currently covered by a ceasefire. SWAN informed us that there were currently no other local organisations, international NGOs or UN agencies working there except for the Back Pack Health Worker Team who were active in certain townships. SWAN said that DFID's help was desperately needed to help alleviate the "extremely high maternal and child mortality rates" in the area.[163] However DFID had turned down the proposal on the basis that it was "not in line with DFID Burma's health strategy".[164]

133. We have been impressed by the careful focusing of the 3MDG Fund's maternal and child healthcare programme in the Irrawaddy delta determining what works and what does not and how a small investment can make a big difference. We are pleased that it is being rolled out elsewhere in Burma so that women and children in conflict and ceasefire regions who are desperately in need of care will soon also be receiving it.

134. The evidence the Shan Women's Action Network (SWAN) provided indicates how much needs to be done in the health sector in these areas. We are pleased that the 3MDG Fund seeks to address this but urge DFID to carefully consider its criteria for funding organisations such as SWAN so that they too can receive DFID support.

HIV/AIDS

135. The 3MDG Fund has largely focused on HIV prevention among drug users. In addition 3MDG Fund provides a grant to UNAIDS to work on the HIV prevention and care policy and for HIV treatment in certain regions of Shan state where there are no Government or alternative services available.

136. Only 25% of people with HIV in Burma who need anti-retroviral drugs receive them because of a drug shortage.[165] The Committee met a group of HIV sufferers in Mandalay representing different groups including male and female sex workers and those who had contracted HIV from their partners. They told a depressing story of HIV treatment in Burma where anti-retroviral drugs were scarce and there was still discrimination against HIV sufferers. The discrimination was leading to delayed diagnosis as people did not want to come forward for testing. The scarcity of drugs led to waiting lists for treatment so that when people were found to be HIV positive they were being treated far too far into the development of the disease—in reality having to wait for someone who was receiving the drug to die so they could then receive their allocation. The group also complained of a very low doctor to HIV patient ratio. Their main concern was that development agencies and NGOs were reducing their focus on HIV/AIDS in Burma when they believed pressure on the Government and support needed to be increased.

137. DFID should develop a more focused policy on drugs especially the provision of anti-retroviral for HIV. They should be administered to patients as early as possible to give the best chance of survival.

MALARIA

138. Resistance to the anti-malarial drug artemisinin has emerged along the eastern borders of Burma. The Malaria Consortium believes that Burma may be the most important country in the world in determining whether drug resistant malaria spreads from South East Asia to Africa.[166] The history of the spread of resistance to previous malaria drugs suggests that Burma acts as a gateway for the spread of resistance to Bangladesh and India, and then onto Africa. DFID said the modelling the impact of the spread of drug resistance suggests that malaria deaths could increase by 25% and economic productivity losses could be over US$4 billion annually.[167]

139. The Malaria Consortium criticised the current surveillance system in Burma as ineffectively capturing malaria among mobile populations such as migrant workers, loggers and gem miners in forest areas, cross border populations and vulnerable and remotely settled people who were at greater risk of infection.[168] Charles Nelson of the Malaria Consortium told us that 70% of people with malaria on the Bangladesh Burma border did not have any symptoms although were carrying the malaria parasite. He therefore recommended blood tests and serology[169] and constant surveillance so that when cases were found they could be contained. He said:

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He told us that, although overall incidence of drug resistant parasites was still low, the amount was growing quite rapidly on the borders.

140. Burma has developed a containment strategy in line with the World Health Organisation's Global Plan for Artemisinin Resistance Containment. The key component of the plan is to replace resistance-creating oral artemisinin monotherapy drugs with quality-assured artemisinin combination therapy drugs. We visited a private clinic run by Population Services International where the combination drugs were being made available.

141. In the conflict-affected areas in the east of the country the 3MDG Fund supports NGOs to provide health services and private businesses to prevent and treat malaria amongst their vulnerable and migrant workers.

142. Drug resistant malaria in Burma is of international importance. If it is not tackled it would have a devastating impact on the ability to treat malaria elsewhere, particularly in sub-Saharan Africa. Addressing this issue in Burma should be a high priority. We recommend that surveillance be stepped up in Burma, in particular in the border areas and amongst the migrant population.

HEALTH SYSTEM STRENGTHENING

143. There is an alarming shortage of skilled health workers in Burma, particularly at the local levels. Pact, the longest serving NGO in Burma which works to develop the capacity of local communities, believed that health system strengthening was of key importance to improving health outcomes. It said there was a lack of available services in many areas along with long distances and quality concerns between those available services.[171]

144. Charles Nelson of the Malaria Consortium explained that there had been a good plan for the health system in place since 1972 but the people and processes were not available to make it function for example in creating a supply chain that delivered equipment and for people to know how to clinically use it.[172]

145. Fiona Campbell told us that the World Bank, through the 3 MDG Fund, was working with the Burmese Ministry of Health and others to look at a future roadmap for the health system and that there was a new technical co-ordination group under the Health Sector Co-ordination Committee which was looking specifically at system strengthening.[173] Mark Foster thought DFID had an important role in influencing getting the right foundations in place on which to build the health system; for example, the right data and a clear idea of what the current landscape was including the role of the private sector. He also thought DFID needed to make sure the Ministry of Health "sets the bar at the right level" in terms of what in reality was achievable in Burma.[174]

Improvements to Rangoon General Hospital and medical education

146. Rangoon General Hospital was built by the British in 1905 and had a tradition of providing free healthcare. There are 1,500 beds and it is the main teaching hospital of the country's premier medical school. Unfortunately the buildings have not changed much in the last 110 years and the poor standard of medical care has meant only the poorest Burmese use the hospital.

147. Aung San Suu Kyi asked Hamish Ogston CBE to assist a project to upgrade Rangoon General Hospital. He informed us:

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After discussions with seven British universities he narrowed the field to University College London (UCL) Medical School, who have submitted an outline proposal.

The Director of UCL Medical School told us:

UCL Medical School has just submitted a bid, with colleagues in Myanmar, to a joint initiative by the ESRC, MRC, UK-aid and the Wellcome Trust, to conduct a piece of qualitative educational research to look at local educational needs. If funded, this would provide a clearer picture of the local medical education situation, and would provide evidence for redevelopment. However, these research funds rarely fund educational research, so the bid may not be successful.

I suggest that investment in the local medical education system, with support from the UK to provide context specific education and training is likely to pave the way for more sustainable improvements in the health system in resource poor countries, and in particular, in Myanmar. My understanding from local Myanmar medical colleagues is that this would be positively received, both by the local doctors, the Universities, and the Ministry of Health.

148. Better medical education would bring many benefits and Burmese medics are keen to form a partnership with the UK. Such partnerships will be an increasingly important feature of development in future. We recommend that DFID carefully examine the proposals for University College London, Royal College of Physicians' and others to improve medical education with a view to providing the relatively small amount of funding they require, either from DFID Burma funds or central funds. We appreciate that DFID does not have the funds to rebuild Rangoon hospital, concentrating rightly on building community health services, but it should consider how it can facilitate the process.

139 Q148 Back

140 ICAI Report 25, DFID's Health Programmes in Burma, July 2013 Back

141 Fiona Campbell (BUR 0052) Back

142 ICAI Report 25, DFID's Health Programmes in Burma, July 2013 Back

143 ICAI Report 25, DFID's Health Programmes in Burma, July 2013 Back

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145 ICAI Report 25, DFID's Health Programmes in Burma, July 2013 Back

146 DFID has made a commitment of up to £80m for the 3MDG Fund to 2016. Most of this was expected to be spent within the Operational Plan period but over £30m of this will now fall into later years. This is due in part to slower than expected expenditure by the 3MDG Fund. DFID supplementary submission. Back

147 3 MDG Fund Where we work Back

148 The Three Diseases Fund was instigated following the Global Fund withdrawing from Burma in 2005 due to restrictions on travel which as a consequence meant projects could not be sufficiently monitored Back

149 The Burnet Institution, Documenting the Lessons Learnt from the Joint Initiative on Maternal Neonatal & Child Health (JIMNCH) Back

150 Q150 Back