One quarter of Myanmar’s estimated 55 million people live on less than $2 per day. The United Nations Development Programme Human Development Index ranked Myanmar as 149 out of 186 countries in 2013. The health sector has yet to catch up to the rapidly expanding economy. Total health spending from all sources is less than 2.5 percent of the Gross Domestic Product. However, matters are changing drastically; a market economy and broad government reforms are emerging since the 2011 transition to a civilian government.
PSI has operated in Myanmar since 1995 and is one of the largest NGOs in the country, delivering significant health impact in nearly all 331 townships. PSI/Myanmar is based in the country’s former capital and its commercial center, Yangon, with eight project offices nationwide.
Its work addresses the largest contributors to Myanmar’s burden of disease: HIV, tuberculosis, malaria, pneumonia, diarrhea, reproductive and maternal health. It also works in reproductive health matters.
PSI provides primary health services in 210 townships through its Sun Quality Health franchise network. The network is comprised of more than 1,500 private medical doctors that PSI/Myanmar trains and monitors on reproductive health services as well as treatment for malaria, tuberculosis, pneumonia, diarrhea, HIV and sexually transmitted infections. In addition, PSI supports the Sun Primary Health network of more than 2,000 village health workers.
PSI’s Targeted Outreach Program operates 17 drop-in centres nationwide, providing counseling and clinical services to populations most at risk of HIV, such as men who have sex with men and female sex workers.
Its nationwide network of private retail outlets distributes essential health products through social marketing techniques. These products include condoms, contraceptives, oral rehydration salts, water purifier products, and treatments for HIV, STIs, malaria, tuberculosis, and pneumonia.
PSI/Myanmar creates powerful campaigns based on evidence to motivate consumer behavior change. These campaigns are executed through mass media and interpersonal communications.
HIV and Sexually Transmitted Infections
PSI/Myanmar’s HIV and STI program is comprehensive, consisting of prevention, care and treatment, aimed at low-income, at-risk populations.
The Targeted Outreach Program, consisting of interpersonal communications conducted by peer outreach workers, is the largest community-led intervention in Myanmar. The project reached more than 40,000 female sex workers and 44,000 men who have sex with men in 2013, and performed more than 20,000 HIV tests for most-at-risk populations. The Targeted Outreach Program also operates 17 drop-in centers through Myanmar for female sex workers and men who have sex with men. The drop-in centers provide an extensive range of free clinical services for key affected populations in an integrated package of care, including sexually transmitted infection testing and treatment, HIV counseling and testing, antiretroviral treatment services (directly or through referrals), directly observed short-court treatment for tuberculosis, reproductive health services, cervical cancer screening and treatment, and opportunistic infection services.
PSI/Myanmar distributes eight condom types via social marketing under the brand name “Aphaw” (“companion” in the Myanmar language). In 2013, it sold more than 24 million condoms at subsidized prices through the private sector, accounting for 83 percent of the commercial condom market.
Through private providers involved in PSI/Myanmar’s social franchising network, the following are offered:
- Syndromic management of sexually transmitted infections,
- Provider-initiated testing and counseling targeted at bridging populations and tuberculosis patients, and
- Antiretroviral treatment for people living with HIV/AIDS.
PSI/Myanmar provides tuberculosis diagnosis and directly observed short-course treatment, the international standard of care for tuberculosis treatment. Tuberculosis drugs are available free of charge from select Sun Quality Health private providers clinics throughout Myanmar. To further promote active case detection, Sun Primary Health community health workers refer suspected cases to nearby Sun Quality Health clinics and serve as treatment adherence observers. PSI/Myanmar incorporates provider-initiated testing and counseling methods to increase the number of suspected and confirmed tuberculosis cases that are tested for HIV.
PSI/Myanmar also leverages the active case detection rate in urban slum areas through two innovative channels — interpersonal communications and pharmacies.
In 2013, more than 73,000 individuals with suspected tuberculosis were screened for the disease, and more than 22,000 cases were registered for treatment at Sun clinics. Altogether, PSI addressed 15 percent of the national burden.
A total of 17,000 individuals with suspected tuberculosis were also tested for HIV in 2013; the positivity rate among these clients was 7 percent.
For more than a decade, PSI has provided a wide range of family planning products and services to women in Myanmar through its network of private health providers, village health workers and pharmacies. In partnership with the government and local organizations, PSI continues to increase access to quality short- and long-term contraceptive methods to women in need and to build the capacity of the private sector to offer related products in more than 200 townships in Myanmar. In 2001, when PSI started its Sun social franchise network, the contraceptive prevalence rate in Myanmar was 37 percent. Private sector provision of family planning services at that time was highly limited, with most services provided through public health centers and government extension workers – and only to married women in limited geographical areas. By 2009, contraceptive prevalence had increased to 46 percent, in large part due to PSI’s program that provides millions of family planning products and more than 1.5 million reproductive health consultations annually.
In recognition of the rising mortality rate of women in Myanmar from cervical cancer, PSI has piloted a cervical cancer prevention program whereby women of reproductive age can be screened using a low-cost but highly effective method known as visual inspection with acetic acid. Those with pre-cancerous lesions are referred for appropriate treatment and follow-up.
For children younger than age 5 in Myanmar, PSI/Myanmar addresses the top two causes of death: pneumonia and diarrhea. PSI provides treatment to children for both illnesses through its network of skilled providers. It implements communications campaigns targeting caregivers on the symptoms of pneumonia and diarrhea and the need to seek appropriate care. PSI also socially markets related products, namely antibiotics for pneumonia and oral rehydration salts and zinc for diarrhea in children.
To reduce diarrhea among children, PSI/Myanmar has begun a household water treatment program and a hand-washing program.
To address under-nutrition, PSI/Myanmar implements a behaviour change program with women of reproductive age on the benefits of exclusive breastfeeding.
PSI is at the forefront of global efforts to contain antimalarial drug resistance, recently indicated on the Thailand/Myanmar border. As a major implementing partner of the Myanmar Artemisinin Resistance Containment framework, PSI delivers appropriate interventions at national scale in the private sector, contributing more to reducing malaria-related disease burden than any other non-governmental organization in the country.
Health impact and resistance containment is primarily achieved through two private sector channels: a formal network of general practitioners and village-level primary health workers who are trained, supervised and directly supplied by PSI, and a diffuse network of informal providers, such as pharmacies, itinerant drug vendors and general retail stores. These private sector agents are supplied with subsidized treatment by major pharmaceutical distributors with extensive reach across Myanmar.
The formal Sun social franchise network supported by PSI/Myanmar contributes to a general reduction in disease burden through qualified practitioners. In 2013, the Sun franchise tested approximately 350,000 suspected malaria cases and treated an estimated 50,000 confirmed cases.
The mono-therapy replacement project in the informal private sector has driven a rapid change in quality combination treatment access. From the start of the intervention in October 2012 through 2013, approximately 1.3 million treatments were delivered through this innovative subsidy mechanism and more than 200,000 cases ofPlasmodium falciparum malaria were treated.
In 2013 PSI/Myanmar conducted a pilot in six townships to determine the plausibility of utilizing rapid diagnostic tests in the private sector to diagnose malaria. The results of this pilot are informing a nationwide rapid diagnostic test scale-up that is expected to reduce drug wastage, alleviate drug resistance risk to artemisinin-based combination therapy (the gold standard for malaria treatment) partner drugs, and improve overall case management practices.
- United Kingdom Department for International Development
- The Global Fund To Fight AIDS, Tuberculosis and Malaria
- Bill and Melinda Gates Foundation
- Three Millennium Development Goal Fund
- U.S. Agency for International Development
- Livelihoods and Food Security Trust Fund
- United Nations Population Fund
- Procter & Gamble
- Good Ventures
- Marie Stopes International
- World Vision
- Save the Children
- FHI 360
- Management Sciences for Health
- Malteser International
- Medecins sans Frontieres (Holland)
- Medecins du Monde
- Private sector partners: Telenor, Ooreedo, AA Group Limited, PolyGold
- Towards Subsidized Malaria Rapid Diagnostic Tests. Lessons Learned from Programmes to Subsidise Artemisinin-Based Combination Therapies in the Private Sector: a Review
Private sector subsidy programmes of ACTs have been effective in increasing availability of ACTs in the private sector and driving down average prices but struggled to crowd out antimalarial monotherapies. A subsidy of rapid diagnostic tests (RDTs) in the private sector has been recommended by governments and international donors to cope with over-treatment with ACTs and to delay the emergence of resistance to artemisinin. In order to improve the cost-effectiveness of co-paid RDTs, we should build on the lessons we learned from almost 10 years of private sector subsidy programmes of ACTs in malaria-endemic countries.
- Oral Artemisinin Monotherapy Market Still Maintains a Foothold in Myanmar, 2015
A 2015 outlet survey was conducted in the private sector within 4 domains: intervention and comparison areas in eastern/central Myanmar for the Artemisinin Monotherapy Replacement Project (AMTR) in operation since 2012; western border areas with India; and the Bangladesh border / Rakhine region. Availability and distribution of oral AMT is a serious problem throughout Myanmar, with particularly urgent need to address this problem in India border areas. It’s distribution, especially at sub-optimal dosing is likely to further exacerbate the spread of artemisinin resistance in Myanmar. There is urgent need for rapid national scale-up and strengthening of strategies, including those used by the private sector AMTR program, to rid oral AMT from the market, and increase access to QA ACT. Policy changes that ban the full import, distribution, and sale of oral AMT would create a far more conducive environment for the support of these activities.
- Who Continues to Stock Oral Artemisinin Monotherapy? Results of a Provider Survey in Myanmar
This study attempts to quantify the characteristics of outlet providers who continue to stock oral artemisinin monotherapy (AMT) for the treatment of malaria despite national efforts to replace oral AMT with quality-assured artemisinin-based combination therapies (ACTs) in Myanmar.
- Oral artemisinin monotherapy removal from the private sector in Eastern Myanmar between 2012 and 2014
The aim of this paper is to examine changes over time in the private sector anti-malarial landscape and to illustrate the value of complementary interventions in the context of a national ACT subsidy.
- Trusted yet Troubled: The Role of the Health Provider in Responding to Gender-Based Violence in Myanmar
GBV has significant reproductive health outcomes. After decades of isolation, Myanmar is opening up and rapidly changing. Recent research with survivors in two cities demonstrated that GBV is pervasive and patterned. This study asks how the knowledge, experiences, and perceptions of GBV among Sun Quality Health providers and clients can inform the design of an effective health sector response to GBV in Myanmar.
- Leading mHealth into the Smartphone Age in Myanmar
Prior to the start of its democratic transition in 2012, Myanmar was known as one of the last “un-phoned” countries. In 2014, SIM card prices dropped from $250 USD to $1.50, driving Myanmar to leap-frog over feature phones and computers directly to smart phones. PSI/Myanmar (PSI/M) has launched two digital interventions – a Facebook page and mobile app – to capitalize on this advancement and make Reproductive Health (RH) and Maternal Child Health (MCH) information more readily available to women of reproductive age (WRA).
- Improving Provider Behavior Change Communication and IPC: Best Practices from the Women’s Health Project
This brief describes the challenges faced, strategies developed, and lessons learned by the Women's Health Project. It also proposes a set of best practices for improving productivity of interpersonal communications (IPC) agents and increasing providers' skills and motivation.
- A Total Market Approach for Condoms in Myanmar
This article in Health Policy and Planning presents research from Myanmar, where a total market approach was proposed in order to improve efficiency in the market for condoms.
- Improving Uptake and Use of Malaria Rapid Diagnostic Tests in the Context of Artemisinin Drug Resistance Containment in Eastern Myanmar: an Evaluation of Incentive Schemes among Informal Private Healthcare Providers
This study tested different incentives to increase RDT use and improve the quality of care among informal private healthcare providers in Myanmar.
- Cases Supplement on the Total Market Approach
PSI sponsored two articles in a special supplement on the total market approach (TMA) in the Cases in Public Health Communications and Marketing journal. The first recounts PSI's experience in the markets for male condoms in Myanmar and Vietnam, and the second proposes a universal set of indicators to measure the success of TMA initiatives.