POVERTY: MYANMAR: Rural healthcare "in crisis"

 Photo: Back Pack Health Worker Team
Most villages lack basic healthcare

YANGON, 28 January 2011 (IRIN) - Myanmar is one of 57 countries worldwide facing a critical shortage of medical staff, defined as fewer than 23 health workers per 10,000 people, the minimum needed to provide 80 percent coverage for births and measles immunizations, according to the UN World Health Organization (WHO).
At the agency's second forum on human resources for health in Bangkok from 25-29 January, experts are again asking how to attract and retain health workers in remote underserved areas.
Half the world's population live in rural areas, but fewer than 38 percent of nurses and 25 percent of doctors work there, according to the world health body.
For example, in rural Myanmar - where 70 percent of the country's 58 million people live - most villages lack basic healthcare. Patients travel hours - in some hilly regions nearly an entire day - to reach hospitals or clinics located only in towns.
Nationwide, there are 1,504 rural health centres covering more than 65,000 villages, according to a 2010 Health Ministry report.
"Due to [the] remoteness between their villages and towns, patients come to the hospital only when they cannot stand their deteriorating health conditions. While some arrive [at the hospital] in time, some arrive [too] late," said a local doctor working in the country's second-largest city, Mandalay, who gave only his last name, Htway.
"Due to a lack of healthcare services, there are normally just two options for many rural people: rely on local traditional remedies or seek treatments from untrained [health workers]," he added.
"Some people rely on quack doctors, though they know that is not a good choice. It's because they need not pay medical fees immediately; they can pay later after they reap their harvest or crops."
In an effort to fill the gap, a dozen health international NGOs are providing free medical care, but the demand far outstrips their capacity, according to one NGO.
Myanmar had an estimated 13 doctors and nurses/midwives per 10,000 residents, according to a WHO 2010 calculation. As of 2010, there were about 26,000 doctors, 23,800 nurses and 19,000 midwives nationwide, according to the government.

Learning gap
In Myanmar, medical students tend to come from wealthy urban families and are unwilling to "serve in poor... rural areas", said a local health worker.
There are 14 public (but no private universities) offering medical courses in Myanmar, which enrolled 3,780 students, split between medicine (2,400), dental, pharmacy and medical technology (300 each) and community health (180), according to a 2009 government survey.
"In rural areas, communication is unreliable, while transportation is uncomfortable. There is no medical journal or internet access for us to learn [the] latest medical science there," said another government health worker posted four hours south of Yangon in the Ayeyarwady region.
Health workers told IRIN that rural pay for doctors was not "respectable" and "discouraging".
Most health workers prefer working in cities where private hospitals and clinics pay higher salaries; others emigrate.
"While the government needs to give incentives to the health workers so they want to go and work in the poor rural areas, at the same time, the government needs to spend more [on the overall] health sector," said Htway.
The government spent 1.9 percent of its gross domestic product (GDP) on health in 2007, the lowest rate among countries for which WHO had data.
Participants at the human resources for health conference are reviewing a draft outcome statement that calls for "better financial management and monitoring mechanisms" to "foster accountability, and improve equity and efficiency".
In 2010, WHO published 16 recommendations to boost the odds of rural residents accessing lifesaving care, including recruiting medical students from rural areas, compulsory rural health service, improving living conditions and offering financial incentives to rural health workers.

http://www.irinnews.org/report.aspx?ReportID=91761

POVERTY:Back Pack Health Worker Team on Thai-Buma border

WORTHY OF SUPPORT
With fascinating slide show and video





Dr. Cynthia Maung,
Founder, Mae Tao Clinic and Chairperson, Back Pack Health Worker Team
When I was studying medicine at university in Burma, I undertook two clinical internships during 1980 – 1985, one at Mingaladone Military Hospital and the other at North Okkalar Civil Hospital. It was then that the problem for access to health care in Burma and in particular for the poor and rural populations first became apparent to me. At North Okkalar most of the patients came from the outskirts of the city and were poor; the hospital facilities were terribly inadequate and the staff overworked. There the staff struggled against many challenges, lack of medicine, lack of staff and also struggling to make ends meet for their own families. There were no preventive services and many patients arrived seriously ill. The differences between Okkalar and Mingaladone were striking in terms of the resources and who could access the services.
After I finished study, I was an intern at Moulmein Hospital, where the situation was very similar to North Okkalar, but so many of the patients had to travel 3 – 5 hours by bullock cart or boat to reach the facility. It became clear to me that for rural populations, preventive care was non existent and emergency services were not accessible. Government services were simply not accessible to all.
After I graduated, I went to work in the village of Eain Du in Karen State and there I realized the role of poor social and economic development on health as well as the affects of militarization. Young boys, called up for their “volunteer” work, to serve the army in building military camps or in carrying military supplies, returned to the village malnourished, injured and with untreated malaria. The fear of the military was pervasive, and villagers’ ability to work to raise enough for their own food and livelihood was severely impaired. The effect of militarization on the villagers was very clear.
The village was only 15 km from the State Hospital, but there was only public transport 2 times a day at night, or for emergencies, referral was really difficult. The hospital in Eain Du village had a 12 bed facility for a 20,000 – 25,000 population. During the 11 months that I stayed in Eain Du, a doctor was only available for 3 months. There was no medicine available. Nurses and midwives operated out of their houses, providing private medical services. Public services were barely provided. I soon knew that the Burmese health system had in fact collapsed.
When I fled to the border, we passed through the jungle, walking for 7 days. At that time I met with many villagers and internally displaced people who had never been able to access any government health care systems.
Since 1988, the health workers coming to the border have always been quick to identify and respond to the needs of the local villagers and internally displaced populations living along the border. Gradually mobile medical teams emerged and where possible, community health clinics were established. Most health work on the border started with medical services, but gradually expanded to public health, maternal and child services, school health programmes and basic trauma care. Through maternal and child health programmes and school health programmes, the community understanding of health issues and how to participate in their own health provision increased.
Each organization on the border was operating their own mobile medical teams, traveling for 3 – 6 months at a time. During 1996 and 1998, many ethnic areas fell under the control of the military regime; some clinics had to close down and the challenges in providing health care increased. In 1998, a series of meetings were held among different ethnic organizations and through these, the Back Pack Team model was developed. Through this effort, it was possible for standardization of service delivery and a great collaboration was initiated. Everyone involved was very proud of its establishment and it was so impressive that we were able to begin immediately with 38 teams in 1998.
Since the Back Pack Health Worker Team started 10 years ago, awareness of the health and human rights situation facing internally displaced people from Burma has increased and continues to grow.
http://www.backpackteam.org/

POVERTY: THAILAND-MYANMAR: Thousands still displaced along border

 Photo: Chandler Vandergrift/IRIN:
Thousands have fled fighting

BANGKOK, 25 January 2011 (IRIN) - About 10,000 people are displaced and in hiding along the Thai-Burmese border, having fled artillery fire in eastern Myanmar where fighting between the Burmese military and armed groups is expected to continue for several months, aid groups say.
The Back Pack Health Worker Team, a Mae Sot, Thailand-based, NGO that provides healthcare to conflict areas of Myanmar, said the displaced were on both sides of the border and the situation was "highly unstable".
"These people are in hiding sites rather than in officially recognized temporary shelters or holding centres. Large numbers of displaced civilians have now been sent back into Burma [Myanmar], often several times, by Thai authorities," said Back Pack in a report released on 24 January.
The displaced were scattered in about 28 different sites, including makeshift camps in the forest, along the banks of the Moei river that separates Thailand and Myanmar, as well as in villagers' homes, according to the Thailand Burma Border Consortium, an umbrella group of 12 humanitarian organizations working with Burmese refugees.
"People are trying to take shelter where they can," Sally Thompson, the TBBC's executive director, told IRIN. "When people first came across because of fighting, they did go into official centres [designated by Thai authorities]. As soon as that fighting stopped, people were sent back, so now people are reluctant to go into them because it's thought that people are being returned prematurely."

Ethnic conflict
Burmese troops have for decades waged war against armed ethnic groups, which have sought autonomy from the central government. The latest violence began after the 7 November elections, when tensions flared between government forces and armed ethnic groups that have refused to be incorporated into the country's centrally-controlled Border Guard Force.
After initial battles in the days after the election, there was sporadic conflict throughout December, according to a situation report from the Back Pack. Since 31 December, there have been almost daily skirmishes, it said.
"You've got different ceasefire groups being squeezed, and it's the Burmese attacking them, and they attack back, and until the border guard forces is resolved... we can expect to see these ongoing skirmishes, people coming across the border, back and forth, possibly through May," Thompson said.


 :Photo: Courtesy of Backpack Health Worker Team
A scene inside Karen State where scores are displaced

Aid challenges
Because most of the internally displaced persons (IDPs) are in hiding, it has been challenging for aid organizations to help those in need.
Furthermore, humanitarian groups are facing increasing restrictions and pressure has been mounting for the Karen civilians not to seek refuge in Thailand, Back Pack said.
"It's difficult to find where people are staying. We cannot register every person to find and provide them with assistance," said Mahn Mahn, secretary of Back Pack. "All the assistance needs to go through the Thai provincial and township level, but they do not want to allow civil [society] or NGOs to go through."
According to Thompson, most people are living in "very temporary" shelters, with only the basics for survival, including food and water, from local villagers, friends and local community-based organizations.
"At the moment, the understanding is that basic assistance is getting through to them," she said.
Meanwhile, Back Pack is calling on the authorities to allow the displaced to remain in Thailand for the moment.
"We request that civilians having fled the conflict on to Thai soil be allowed to remain in temporary shelters in Thai territory until it has been proven that it is safe for them to return... civilians fleeing armed conflict should not be returned to Burma unless this return is of a voluntary nature and an impartial assessment has determined that it is safe for them to return," a statement by the group said.
According to the UN Refugee Agency (UNHCR), Thailand hosts 96,800 refugees from Myanmar who have been registered, and an estimated 53,000 who have not, in nine government-run camps along the border.
http://www.irinnews.org/report.aspx?ReportID=91724

MALARIA: MYANMAR: Bullets not the main killer in conflict area

  Photo: Steve Sandford/IRIN Saw Kwe, a medical officer with the Democratic Karen Buddhist Army

MUN RU SHAI, 24 December 2010 (IRIN) - Saw Kwe, a medical officer with the Democratic Karen Buddhist Army, pulls out a cardboard box full of Artesunate from among the rolls of gauze and drugs used for clotting war wounds.
The 15-year veteran, who has been shot and nearly blown up in past fighting, says the most common killers of civilians are found off the battlefields - not on them.
"The most deadly is malaria," says Saw Kwe, as he hands a packet of pills to a young mother in the Burmese border village of Mun Ru Shai. "We often use up our supplies of Paracetamol to help relieve fever and pain for the sick."
The drugs are much in demand for the steady stream of displaced civilians who have hiked - sometimes for weeks - to border areas in eastern Myanmar to escape the escalating fighting between government troops and ethnic armies following the 7 November elections, the country's first poll in two decades.
In Karen state, conflict and death have become a part of life in fighting that began more than 60 years ago, but deaths from military clashes account for only 2.3 percent of mortality, according to a recent report, Diagnosis: Critical.
The indirect health impacts of the conflict are much more severe, with preventable loss of life accounting for 59.1 percent of all deaths and malaria alone responsible for 24.7 percent, according to the report, compiled by the Mae Tao Clinic.
Often, the villagers caught up in the battle zones are forced to flee with little more than the clothes on their backs and a few bits of food.
Without proper shelter and lacking clean water and food, the most vulnerable - the young and old - become susceptible to preventable illness such as pneumonia and diarrhoea, which can prove fatal if left untreated.
In fact, malaria was responsible for nearly a third of deaths in children under five, while diarrhoea was responsible for 17 percent of fatalities in this age group, states the report.

Caught on the border
Hundreds of families remain displaced and in hiding on both sides of the border, afraid to go home but unable to seek protection in Thailand.
"Right now, there are no official camps for those displaced so it is very difficult to provide even clean water and proper sanitation," says Man Nah, director-general of Backpacker Health Care Workers (BPHCW), a mobile medical unit that travels across the border to provide medical care.
According to recent estimates by BPHCW, nearly 4,000 people regularly flee to Thailand from Karen State areas opposite Kanchanburi and Tak provinces, where government attacks have escalated in recent weeks.


  Photo: Steve Sandford/IRIN: Thousands of ethnic Karen are regularly displaced by the fighting, many of them children

The mobile medical teams have set up three emergency clinics providing medical assistance to civilians having sought shelter in Thailand, particularly the more vulnerable, such as pregnant women, children and the elderly.
The increase in internally displaced persons has exacerbated an already hazardous situation in eastern Myanmar where nearly half a million people are on the run, according to the Thailand Burma Border Consortium.
In cases where the patient is in a serious condition, they will be often transported across the border to the Mae Tao clinic in Thailand, which offers free basic healthcare for refugees, migrant workers and others needing medical aid.
For more complicated cases, arrangements are made between NGOs and provincial hospitals in the region.

Over-crowding
In the bustling emergency ward of the Mae Sot hospital, the burden is all too clear.
Some patients lie on makeshift beds and benches erected in the crowded hallways, an all too common scene that hospital director Ronnatrai Rueangweerayut says will continue as long as there is conflict in the neighbouring country.
"Mae Sot hospital is a government hospital that is [a] non-profit organization," Ronnatrai said. "As you know, if you have no money, you can do nothing. It means that we have to arrange the budget as well as possible so we can treat all the patients in the same manner."
http://www.irinnews.org/report.aspx?ReportID=91440