Providing essential lifesaving services during humanitarian crisis in Myanmar

Following the military takeover of the legislative, judicial and executive powers of Myanmar on 1 February 2021, the situation in Myanmar changed dramatically. Protests against the military regime took place across the country. Security forces cracked down on unarmed people, a curfew was put in place from 20:00 until 04:00 the next morning nationwide, and martial law was imposed in many townships. Considerable disruption was encountered with internet connectivity, electricity, and financial services. Even worse was the disruption of services for essential and emergency services at public health facilities due in part to health care workers participating in the civil disobedience movement and in part by the on-going conflict.

In response to the COVID-19 pandemic, in parallel with the military takeover and subsequent political turmoil, the WHO Country Office in Myanmar designed and developed a strategic purchasing of services model, engaging with three partners (a national professional association, the national red cross, and a private hospital entity) to ensure that lifesaving essential health services were provided for people in dire need. 

How did Myanmar do it, and how did the WHO Secretariat support Myanmar?

In Kalay Township in the Sagaing Region, the WHO Country Office contracted with a tertiary care hospital to provide COVID-19 treatments when the third wave of COVID-19 started in Chin State. For primary care services, the WHO Country Office partnered with the Myanmar Medical Association and the Myanmar Red Cross Society to act as a strategic purchasing entity to coordinate provision of lifesaving essential reproductive, maternal, newborn, child, and adolescent health services and emergency referral services in selected townships of the Yangon Region targeting the urban poor. For secondary and tertiary care, together with Wesley Private Hospital, WHO purchased essential reproductive, maternal, newborn, child, and adolescent health services and emergency services as well as services to treat severe and very severe cases of COVID-19. A total of 2568 patients benefited by the strategic purchasing programme in the initial six months.

Further details of the intervention include:

• The average cost was 123 664 Myanmar Kyat (roughly 70 US dollars) per patient and the average volume of patients per day was seven, ranging from three to 18 patients per day based on the type of facility and services provided.
• The costing information by type of service supported was also calculated. The average cost for antenatal care was 33 647 Myanmar Kyat (19 US dollars) for new visits and 13 898 Myanmar Kyat (8 US dollars), for follow up antenatal care, 2589 Myanmar Kyat (1.4 US dollars) for child care, 384 956 Myanmar Kyat (215 US dollars) for caesarean delivery, 17 050 Myanmar Kyat (9.5 US dollars) for medical emergencies, and 185 035 Myanmar Kyat (103 US dollars) for normal vaginal delivery.
• Two-thirds of the patients were female, among which nearly 40% were in the reproductive age group, and received support in reproductive, antenatal and maternal care as well as emergency obstetric services.
• Fifteen per cent of the served population were children under-five who received childcare, neonatal care and emergency referral services.

Highlights from the strategic purchasing programme include:

• Particularly in the initial six months of the pandemic, it was observed that low utilization of health services led to missing planned targets of the population accessing contracted services.
• The applicable prices differed significantly across health facilities.
• The contracted purchasers were not experienced in strategic purchasing and outcomes-based performance payment mechanisms. Capacity issues with human resources and data information systems were reported. Claim processing might be a bottleneck when considering scaling up the programme.
• Addressing the quality dimension, Wesley Private Hospital programme included patient satisfaction (patient experience) surveys. Five percent of all cases were interviewed. Volunteers conducted exit interviews and, based on analysis of the results, over 75% of respondents responded positively to dimensions of patient satisfaction including infrastructure, responsiveness discrimination, affordability, knowledge of provider, respectful care and looking forward, were reported.

Numerous challenges were found during implementation. For instance, different purchaser organizations reported different volumes of cases. Health providers struggled to report data using the required format. The medical record system is not strong in private clinics and some private hospitals partnered with the Myanmar Medical Association to collect data and report to WHO which in turn delayed the submission of the data to WHO for analysis. In addition, low compliance was noted regarding data security and confidentiality issues in reporting and sharing data. These challenging issues on data quality and timely reporting, as well as cashflow transfer on banking services hindered programme implementation. Further, there was no proper monitoring system to track patient claims on treatment, neither for the established provider payment mechanisms nor for performance payment. Human resource shortages negatively impacted the allocation of designated staff for data monitoring and reporting. Such challenges will need to be addressed prior to rolling the programme out on a national basis.

Effective partnership with local organizations and collaborative teamwork within the WHO Country Office under guidance from the senior management team ensured success of the programme to deliver lifesaving services to thousands of beneficiaries during an acute humanitarian crisis. Based on lessons learned from this initiative, gaps and challenges will be addressed for a more efficient purchasing strategy with harmonized costing moving forward. An exchange of knowledge has been gained from these strategic purchasing programmes which has been shared with development partners. Such an innovative approach in providing essential services should be customized to address public-private partnerships.

Photo Credit: © WHO / Myanmar Red Cross Society

Photo Caption: Myanmar Red Cross Society volunteer helped referral of a patient in labour to hospital around curfew hour.