Country Report on Caring Societies in Myanmar

Transcription

1 Country Report on Caring Societies in Myanmar Dr. Kyi Soe, Director General, Department of Health Planning, U Maung Myint, Director, Department of Social Welfare, U Hla Myint, Director, Department of Social Welfare 1. Introduction Myanmar is one of the largest countries in South East Asia. Ethnically diverse, Myanmar is a nation of many races. Some 130 ethnic groups make up its population of 53 million. The majority of Myanmar's people are Bamars, but the Shan, Kachin, Kayin, Mon, Rakhine and others are also prominent throughout the country. Myanmar is a country with a large land area rich in natural resources. Accepting the view that agricultural sector can contribute to overall economic growth of the country the government has accorded top priority to agricultural development as the base for all round development of the country as well. Since adopting market oriented economy from centralized economy the government has carried out liberal economic reform to ensure participation of private sector in every sphere of economic activities. Myanmar is now in the process of implementing the five year economic plan from to Development of social sector has kept pace with economic development expansion of schools and institutions of higher education have been considerable especially in the States and Divisions. Adult literacy rate for the year 2003 was 91.9 percent with 94.8 percent for male and 89.4 percent for female. Expenditure for health and education have raised considerably, equity and access to health and education and social services has been ensured all over the country. Government has increased health spending on both current and capital yearly. Total government health expenditure increased form kyat million in to kyat million in The estimation of total national health expenditure for the year was estimated to be kyat million on equivalents to 2.5 percent of GDP. Myanmar possesses good technical capacity and can successfully undertaken major initiatives when there are clear objectives and high-level commitment and support, combined with national mobilization and adequate

2 2 resources. Examples of there are the National Sanitation Weeks, National Immunization Day (NIDs) and efforts to achieve Universal Salt Iodization and Vitamin A supplementation. With the strong political commitment of government and enthusiastic efforts by basic health services and disease control programme staff, leprosy was eliminated at national level in 2003 and polio was eradicated in Myanmar could make major achievements in reducing morbidity and prolonging the lives of the citizens through strengthening and expanding health services through out the country, expanding and upgrading infrastructures for health services delivery and enhancing the capacity of the human resources for health. Myanmar is also committed to working with all partners and will continue to sustain the partnership developed, nationally, regionally and globally. The Ministry of Health and the Ministry of Social Welfare, Relief and Resettlement mainly undertake services of people with disabilities (PWDs). The Health Department together with the Myanmar Maternal and child welfare association are implementing programs for pre-natal and natal care of mother and child with the aim of preventing disabilities and also for early detection and intervention. Polio eradication campaign and prevention of iodine deficiency are being carried out through out the country as National basic. Two Rehabilitation Hospitals, one in the capital (Yangon), and one in Mandalay, the second largest city in the country take care of the Medical Rehabilitation of PWDs. Township also have departments where rehabilitation services are provided. For different reasons, after being rehabilitated at the National Rehabilitation hospitals, the physically handicaped persons could either join the Vocational Training School for Adult disabled persons established by the Department of Social Welfare or join the Vocational Training Centre established by AAR (Japan) in collaboration with Department of Social Welfare (DSW) and School for Disabled Children run by DSW.

3 2. Maternal and Child Health and Community Support Health Care System in Myanmar Ministry of Health is the main organization of health care provision. It is organized into 7 departments Department of Health Planning, Department of Health, Department of Medical Science, Department of Medical Research (lower Myanmar), Department of Medical Research (Upper Myanmar), Department of Medical Research (Central Myanmar) and Department of Traditional Medicine each of which is headed by Director-General. Department of Health plays a major role in providing comprehensive health care through out the country including remote and hard to reach border areas. Various Types of health facilities exists at different levels. At the rural community level, there are Rural Health Center (RHC) staffed by a Health Assistant, Lady Health Visitor and Midwife and Sub-center run by Midwife and Public health Supervisor grade II (PHS II). In addition, there are basic voluntary health workers (Community Health Worker and Auxiliary Midwives) providing out reach services to village hamlets. At the first referral level, in urban areas are Township Hospitals with a Medical Officer (TMO) and allotted quota of health personnel. The Township Hospitals have 16, 25 or 50 beds depending on the population. Each Township has at least 1-2 Station Hospitals with one Medical Officer and other health staff and 4-7 Rural Health Centers under the jurisdiction. The second referral level is the District Hospitals which are equipped by specialist services.. At the tertiary referral level are the State/Division General Hospitals, and Teaching and Specialist Hospitals, which have all specialties, better facilities and more staff. To promote the sectoral collaboration and community participation in health development activities, the National Health Committee (NHC) was formed in The National Health Committee is a high-level inter-ministerial and policy making body, which provide leadership and guidance in implementation of systematic efficient health programmes. Recognizing the growing importance of the needs to involve all relevant sectors at all administrative levels and to mobilize the community more effectively in the health activities, Health Committees have been established in various administrative levels down to the wards and village tracts. These committees at each level are headed by the chairman or responsible person of the organs of

4 4 power concern and include heads of related government departments and representatives from the social organizations as members, heads of health departments are designated as secretaries of the committees. In line with the National Health Policy, NGOs such as Myanmar Nainggan Women Federation (MNWF), Myanmar Maternal and Child Welfare Association ( MMCWA), Myanmar Red Cross Society (MRCS), other Professional and Religious organizations are also taking some share of service provision and their roles also becoming important as the needs of collaborative actions for health become more prominent.

5 5 Health Care System in Myanmar STATE PEACE & DEVELOPMENT COUNCIL National Health Committee CABINET Ministry of Health NHP M & E Committee Department of Health Planning Department of Health Department of Medical Science Department of Medical Research (Lower) Department of Medical Research (Upper) Department of Medical Research (Central) Department of Traditional Medicine State/Division Peace and Development Council District Peace and Development Council Township Peace and Development Council State/Division Health Committee District Health Committee Township Health Committee State/Division Health Department District Health Department Township Health Department Station Hospital 1. Ministries 2. Union Solidarity & Development Association 3. Myanmar Women's Affairs Federation 4. Maternal & Child Welfare Association 5. Red Cross Society 6. Medical Association 7. Dental Association 8. Nurses Association 9. Health Assistant Association 10. Traditional Medicine Practitioners Association 11. Religious Organization 12. Parent-Teacher Association Ward/ Village Peace and Development Council Ward/ Village Tract Health Committee Rural Health Center Village Volunteers

6 2.2. Situation of Women and Children 6 Myanmar has a youthful population. Of an estimated total population of 53 million, around 23 million are children and adolescent under age of 18, and approximately 14 million are women of child bearing age. The children and women are from many different ethnic backgrounds and wide diversity of locations. The majority of people, 70 percent of population reside in rural areas, dependent upon agriculture of their live hood. The remaining 30 percent of population live in Yangon, Mandalay and other cities. During the past decade, much progress has been made in many aspects of situation of Myanmar's Children and Women. It was shown that nearly 80 children die before age 5, for every 1,000 live births (National Mortality Survey, CSO-1999) and it was found to be reduced to 66 per 1,000 live births in 2002 (Overall and Cause Specific Under Five Mortality Survey WCHD ). Similarly, Infant Mortality Rate (IMR) of 60 per 1,000 live births in 1999 (National Mortality Survey, CSO-1999) has been reduced to 50 per 1,000 live births in 2002 (Overall and Cause Specific Under Five Mortality Survey WCHD ). According to the National Mortality Survey (CSO 1999), the Maternal Mortality Ratio (MMR) was estimated at 2.55 per 1,000 live births (1.78 for urban and 2.81 for rural) in Collaboration of health services In Myanmar, over 60 percent of the total population constitutes with mother and children who are the most vulnerable group. Maternal and Child Health Care services are provided free of charge both in urban and rural setting and it is also a crucial component of National Health Plans. This traditional maternal and child health care, consisted of antenatal care, aseptic and safe delivery, postnatal care, under-one infant care, immunization, growth monitoring of under-three children, nutrition education, control of dirrhoeal diseases and management of acute respiratory infection has been provided by Basic Health Staff with assistance of voluntary health workers and community participation all over the country. Starting from the early 1950s, a Rural Health Center Scheme was established and MCH care for rural community has been provided through this

7 7 centers. Until before 1988, the health system focused only on the conventional maternal and child care. After that, in accordance with the changing social and economic policies, it calls for introduction of wider concept of comprehensive reproductive health care in life cycle approach with emphasis on safe motherhood into the health care delivery systems. Myanmar formally introduced reproductive health activities into the National Health Plan of , and started the Family health Care Project. Conventional maternal and child health care was incorporated into the broader concept of reproductive health in 1996 and the program was renamed the Reproductive Health Care Project. Various activities are conducted in conjunction with local and international organizations. UNFPA has been involved in birth spacing activities since The main priorities for reproductive health are reducing infant, child and maternal mortality and improving the quality and accessibility of birth spacing services. Ministry of Health uses two categories of reproductive health packages: essential and comprehensive. Essential reproductive health care covers the reproductive age group and the priority programs: safe motherhood, birth spacing, prevention and management of abortion and its complications, reproductive tract infections, sexually transmitted diseases (STDs) including HIV/AIDS, infertility, and adolescent reproductive health issues, including unwanted pregnancies, unsafe abortions. The comprehensive reproductive health care package adds covers violence, infertility, and the entire life span, including elderly and osteoporosis health matters. Myanmar Reproductive Health Policy was formulated in The policy interventions have been carried out with the high lightened interest on safe motherhood activities. The policy aims to provide comprehensive reproductive services covering adolescence to old age. The policy contains 11 elements covering political commitment, quality of health care services, accessibility and affordability, partnership development, an improved referral system, gender equality and equity, and other statements. Essential reproductive care has been implemented as one of the activities of the National Health Plans. Promotion of Community awareness on the knowledge about pregnancy and childbirth, danger signs, role of family and community in birth preparation and transportation in case of emergency was the major gainful achievement to the safe motherhood activities at community level.

8 8 Despite the advances, the progress has been uneven in some areas and there are much more rooms for improvement in reduction of maternal and neonated morbidity. The UNICEF has provided special programmes on maternal and child health care through Child Survival Project ( ), Integrated Management of Maternal and Childhood Illness (IMMCI) ( ) and Women and Child Health Development (WCHD) (2001-aonwards). UNFPA and UNDP have also provided maternal care through strengthening of birth spacing programmes in project townships. National NGOs such as Myanmar Maternal and Child Welfare Association (MMCWA) plays an enourmous role in the provision of maternal and child health care services through voluntarism. The Ministry of Health has put emphasis on achieving the Millennium Development Goals (MDGs) by 2015 in its own capacity with available resources. At country level, the Ministry of Health has been developed and implementing the Five-Year Strategic Plan for Reproductive Health ( ) and the Fiveyear strategic plan for Child Health Development ( ) with multi-sectional support and contribution. In line with the Nation's commitment to attaining MDGs, Special emphasis has put to implement the Making Pregnancy Safer Initiative, as a high priority component of reproductive health strategy, which also included the introduction of Voluntary Counseling and Testing for PMCT in routine AN care. The collaboration between reproductive health programmes and other related key public health programmes such as immunization (utilization of safe delivery kits, improving TT2), nutrition (management of anemia in pregnancy) has been strengthened. Although there are on going programs and projects that impact on maternal and child health development, more investments and well coordinated evidence-based actions are needed to further improve the status of women and children's health in the country. Implementation of maternal and obstetric services is constrained by a number of factors. Scarcity of supplies, equipment, live-saving drugs, and jobaids at the peripheral level is the most pressing constraint. The cost of referral services and frequently delayed referral of clients poses a challenge to the delivery of emergency obstetric services. Inconsistencies in collection of routine

9 9 data and other relevant information, turnover of basic health staff, and dropout and quality of voluntary health workers, are also challenges to provision of consistent quality services. One of the major problems in providing adequate services for maternal and child health is that most people are in rural areas and transportation is often limited. A second problem is that midwives are currently overburdened with an average coverage areas of 4500 people, which makes it difficult for them to reach all the women and children in need services. Third, the referral system is not function at an optimal level, patients delay in reaching to higher level health facilities because of people do not recognize early warning signs. The reproductive health programme has obtained growing interest by donor agencies, decision-makers and implementers. Better cooperation and coordination by national NGOs have been developed in line with the strong political commitment to ICPD goals and MDGs. Since the nation's health system has been set up with a very strong infrastructure, implementation of new clientcentered approach would be successful through better orientation of health workers. However, to certain extent cultural and traditional system may restraint some aspects of reproductive and sexual health services. There need to be excited tactfully. Financial and human resource constraints are also important issues requiring serious attention. Given the diversity of opinions among stake holder, there is also a need for better cooperation and coordination among the partners. Coordinated and sustained resource commitment needs to be considered. 2.4 Partnership between public and private sector The National Health Policy calls for close Collaboration between ministries, NGOs, private sector, and community in implementation of health activities. Thus, apart from MOH, there are other health related ministries, international agencies including UN agencies, bilateral agencies, at least 27 international NGOs and 9 national NGOs, involved in health care activities. Local NGOs include the Myanmar Maternal and Child Welfare Association (MMCWA), and Myanmar Red Cross Society (MRCS) who have vast network of volunteer/ member who support the delivery of health services at grassroots level.

10 10 There are also private formal and informal health care providers. According the changing political and economic system, the number of private poly-clinics, hospitals and pharmaceutical market/ drug stores expanded rapidly after Private sector is growing and about 75-80% of ambulatory care is still provided by different types of providers in private sector. The private general practitioners are active in most urban areas. There are many private drug shops in urban areas and even in rural areas. Small shops often sell a limited range of drugs. Traditional medicine practitioners and informal healthcare providers also serve the population. Key areas being addressed by government and its partners that have direct or indirect impact on reproductive health, adolescent health, newborn care, IMMCI, Nutrition, EPI, disease control (malaria, dengue, filariasis, soil transmitted helminthiasin, TB, HIV/AIDS), early child development and Psycho-social development, prevention and management of child abuse and care of children with special needs. Recent analysis of stakeholders in health in Myanmar showed more partners working on reproductive health. The people themselves individually, collectively or through health committees are partners in health care, including National Immunization Campaigns, National Sanitation Weeks, and other health development activities. The private sector is an important source of birth spacing services in all townships, with contraceptive readily available at drug shops and private clinic. The Myanmar Medical Association (MMA) has trained general practitioners in selected townships in birth-spacing service provision. The national NGOs, Myanmar Maternal and Child Welfare Association (MMCWA), provides information on birth spacing and supplies in some townships. Birth spacing services and support is provided by number of international NGOs. A large proportion of maternal health services are provided by the public sector. Virtually all antenatal care, many deliveries, and most treatment of obstetrical and abortion-related complications are provided by public-sector. However, the role of the private sector is expanding, and those who can afford it often prefer private practitioners. Trained Traditional Birth Attendants (TTBA) continue to provide assistance at a significant proportion of deliveries. In large urban areas, private maternity homes and hospices are available. The MMCWA has 94 maternity homes throughout the country. A number of organizations are supporting the provision of maternal health services through supplies and training activities.

11 11 Growing community awareness regarding maternal health issues can be built by expanding and strengthening ongoing activities. Since most women attend public sector services one or more times during pregnancy, this is a good opportunity to provide women with essential knowledge and information as well as services. ` However, a number of challenges to provision of contraceptive services remain. In relation to supplies, insufficient public sector quantities and private sector commodity quality are of concern, as are difficulties of logistics management. The low client-load at public health facilities poses a challenge. Evidence suggests the families can significantly improve the survival, growth and development of their children by carrying out a limited set of practices such as antenatal care, breastfeeding, nutrition and immunization. Community need to be strengthened and supported to provide the necessary care to improve child survival, growth and development. To provide this care, families need knowledge, skills, motivation and support. They need to know what to do in specific circumstances and as the child grows and develops. They need skills to provide appropriate care and to solve problems. They need to be motivated to try and to sustain new practices. They need social and material support from the community. And finally, families need support from the health system, in the form of accessible clinics and responsive services, and health workers able to give effective advice, drugs and more complex treatments when necessary. In this regard, community empowerment will be pursued vigorously. Moreover, aside from strengthening the public health system, partnership between different sectors / stakeholders will be established and sustained to help ensure broad participation and harmonized actions to improve child health situation in the country. 2.5 Human resources development The Department of medical Science is concerned with the production of all categories of health personnel with the aims to strengthen the development of human resources for health and equip them with advanced technologies. The type of health personnel produced are doctors, dental surgeons, nurses (including speciality nurses) paramedics, pharmacists, dental technicians

12 12 and basic health workers such as health assistants, public health supervisor grade I and II, lady health visitors and midwives who are the cornerstone for the implementation of rural health development programme. In total, the country has 17,564 doctors (6,473 in the public sector and 11,091 in the private sector) 1,365 dental surgeons, 17,864 nurses, 1,767 health assistants, 1,702 lady health visitors, 16,245 midwives, 529 public health supervisors grade I and 1,339 public health supervisors grade II. For maternal and child health services in urban areas, 86 Urban Health Centers and 348 Maternal and Child Health Centers have provided while 1452 Rural Health Centers and 5628 Sub-centers are providing necessary care to rural community. There are 243 medical doctors, 195 nurses, 459 lady health visitors and 1150 midwives in urban areas. For rural areas, 1564 health assistants, 1199 lady health visitors and 7358 midwives are providing maternal and child health care. At present the ratio of midwifery skilled providers (including Auxiliary Midwives) to villages is 1:2 while the national target is at least one midwifery skilled person to every village. Thus manpower production and allocation has been focused especially to rural and remote areas by enhancing the recruitment of Auxiliary Midwives (AMW). During 2004, around 500 new AMW were trained to increase the strength of skilled birth attendants. At the same time institutional delivery has also been enhanced among the community through upgrading and promoting of rural health center with attachment of labour rooms. In the light of Rural Health Development scheme, health sector development was implemented throughout the nation. It has been planned to expand of Rural Health Centers every year to provide effective primary medical care and to cover the increasing population to enable to reduce the health problems among the children, mothers and the community. Skilled health staff are critical for delivery of quality health care to mothers and children. As not all necessary tools are available to support training and on going development of health worker skills, it will be necessary to development and adapt technical training materials, guidelines, and standards already existing at the international level. A training course is currently being developed for the integrated management of pregnancy and childbirth at primary health care level,

13 13 which will teach the use of the job-aid on Pregnancy, Childbirth, Postpartum, and Newborn care (WHO et al 2004). Training on the use of job-aid will supplemented, at the rural health center level and above, by using the WHO midwifery modules (WHO 1996). Other areas where training courses need to be developed or adapted include training methodologies, township level management, manual vacuum aspiration, use of magnesium sulphate, anaesthesiology for essential and emergency obstetric care procedures, performance of caesarean sections, emergency contraception and counseling for the provision of reproductive health services. It also need to be develop training programme on simplification of job-aid for auxiliary midwives and trained traditional birth attendants. 3. Welfare and Health Services Delivery for People including Children with Disabilities 3.1 Inter-sector collaboration in Health and Welfare Services for the people with disabilities The Department of Social Welfare stands as a key provider of social welfare services in the country. The department also encouraged voluntary organizations to establish community based child care centers and day-care centers to care for the needy children. At the Vocational Training School for Adult Disabled, inmates are provided training such as hairdressing, tailoring, silk screening printing, photography, radio TV repairing and computer training. At school for Disabled children (Physically and Mentally Retarded), children are provided with special education and daily living activities. People with disabilities (PWDs)such as the Blind and the Deaf, after medical treatment at the relevant hospitals can join special schools established by GO and NGOs. Schools for different types of disabilities are established under DSW. In school for the blind, a modern teaching approach, computer software are provided to teach the blind effectively and also provided vocational trainings such as massage, canework and astrology. Moreover formed education and vocational trainings such as computer training, silk-screen printing and embroidery are effectively provided at the school for the deaf.

14 14 Myanmar Disabled Persons Organization (MDPO) was formed in 2004, as a National level. MDPO is working with the collaboration of the Department of Social Welfare the Department of Education and the Department of Health. With the collaboration and cooperation of Department of Education, DSW is implementing inclusive education for the disabled persons especially for the Blind and the Deaf. The inclusive education workshops attended by the school teachers by the Department of Education and the staffs of DSW were held throughout the country. Myanmar has recently joined the Special Olympic International which create an opportunity of Mentally Retarded children to develop physically and mentally through the implementation of this program. 3.2 Community Services With regard to self help organizations Yangon Deaf Association and Mandalay Deaf Association have been formed. Moreover the disabled persons who have been trained at AAR training centre have formed Self-Help Group to stand on their own feet, to raise up PWDs development groups, which has over 60 disabled persons. AAR planned and support the graduates economically, morally and socially (Eg. Setting up a business net working with other graduates to exchange knowledge and experiences.) The emergence of Self-Help Organizations (SHOs) and Self-Help Groups (SHGs) empowered PWDs to help each other and be independent. These has encouraged many PWDs organize themselves into different groups according to their type of disabilities, some (SHGs) with cross disabilities and help each other. For disabled female persons, the Zion centre for the development of disabled women was established and it is located on the outskirts of Yangon. It is focused on providing employment for the disabled women. In addition to employment, this centre brings disable individual from the community together socially, providing the opportunities for them to support and encourage each other who face the same straggles. At present World Vision International together with the Health Department is trying to develop CBR (Community Based Rehabilitation) projects. CBR program conducted by Health involve the community at the grass roots level

15 15 recruiting local voluntary Health workers for the implementation of the programs. Apart from that Eden Handicap Service Center (NGO) started a CBR project in The Department of Social Welfare is trying to raise awareness to the general public regarding disability issues. 3.3 Partnership between government and Non-government organizations including foreign NGOs in health and welfare services for the disabilities Various NGOs who have takes an interest in the welfare of PWDs have emerged and initial steps are taken towards improving the quality of life in Myanmar disabled population. There has been considerable improvement in recent years and at present there are NGOs catering for the PWDs for male as well as female. Income generating programs for the disabled are also established by the initiative of the disabled live independently. Each NGOs is oriented towards special kinds of disabilities or needs. DSW provides grants in AIDS in cash and kind to Blind and Deaf Schools run by NGOs. Eden Handicap Service Centre also net working with DSW in disability issues. The foreign NGO AAR (Japan) have signed a MOA with DSW working for PWDs, offers hairstyling and tailoring training courses. The training centre is located in Yangon, and PWDs students come all over the country. APCD has conducted (Training of Initiators for Self-Help Groups for Persons with Disabilities towards Right-based and sustainable community development and sponsored Myanmar trainers. As the Department of Social Welfare a focal point has a continuous good relationship with the APCD, it is hoped that the linkage between our Government and APCD activities need to more strengthen to make the services for more effective. INGOs such as E.M.D.H New Humanity (FO), LDSC, SC (UK), World Vision, collaborate and Cooperate in the rehabilitation services for the PWDs in Myanmar. 4. Conclusion Effective public health interventions such as increase access to primary health care services, and good immunization coverage have reduced maternal

16 16 and infant mortality to some extent. However, it is considered that death rates among mother, infants and neonates are still high. Evidence -based interventions, including reproductive health and Child care, are crucial for the survival and well-being being of mothers and infants. Although there are on going programs and projects that impact on maternal and child health development, more investments and well coordinated evidence-based actions are needed to further improve the status of maternal and child health in the country, sustain the gains and contribute to the achievement of Millennium Development Goals by In collaboration and co-operation with INGOs and NGOs the Department of Social Welfare will implement to fulfill the disability issues in Inclusive Education, Institutional Care and Community Based Rehabilitation. Myanmar will try her utmost to achieve the healthy and wellbeing of all women and children. This is not only the commitment but also to fulfill the responsibility for development of the people.