One-quarter of Myanmar’s estimated 52 million people live on less than $2 per day. In 2013, the United Nations’ Human Development Index ranked Myanmar as 149 out of 186 countries. The health sector has yet to catch up to the rapidly expanding economy: total health spending from all sources is less than 2.5% of the gross domestic product. However, change is in process; 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 330 townships. PSI/Myanmar is based in the country’s former capital and its commercial center, Yangon, with eight project offices nationwide.
PSI/Myanmar works to address the largest contributors to Myanmar’s burden of disease: HIV, tuberculosis, malaria, pneumonia, diarrhea, reproductive and maternal health, nutrition, diabetes, and hypertension.
PSI provides primary health services in 220 townships through the Sun Quality Health franchise network. The network is comprised of more than 1,300 private medical doctors that PSI/Myanmar trains and monitors, ensuring that health services are provided in accordance with national guidelines and international quality standards. In addition, PSI supports more than 2,000 village health workers who also provide health products and services to communities in rural areas across Myanmar.
PSI’s Targeted Outreach Program (TOP) operates 18 drop-in centers nationwide, providing counseling and clinical services to populations most at risk of HIV, such as men who have sex with men (MSMs) and female sex workers (FSWs).
PSI’s nationwide network of private retail outlets distributes essential health products using social marketing techniques. These products include condoms, contraceptives, oral rehydration salts, water purifier products, and treatment for STIs and malaria.
PSI/Myanmar creates powerful campaigns utilizing in-depth knowledge of the communities we serve to motivate consumer behavior change. These campaigns are executed through mass media, digital media and interpersonal communication.
PSI/Myanmar estimates that in 2015, its products and services helped avert 451,995 DALYs, including, by health area:
- 62,937 Malaria DALYs
- 92,039 HIV DALYs
- 46,287 FP DALYs
- 143,365 MNCH DALYs
- 107,160 TB DALYs
- 157 WASH DALYs
- 50 NCD DALYs
PSI/Myanmar’s family planning programs also provided 553,885 couple-years of protection.
HIV and Sexually Transmitted Infections
PSI/Myanmar’s HIV and STI program is a comprehensive model that addresses the health and well-being of low-income populations that are at-risk of HIV/STI infection. It consists of a package of services for the prevention, care, treatment and support of HIV positive persons, as well as those at risk of HIV infection.
The Targeted Outreach Program (TOP), is the largest community-led intervention in Myanmar. The project reached more than 37,000 female sex workers and 45,000 men who have sex with men in 2016 and performed more than 31,000 HIV tests for most-at-risk populations. The program also operates 18 drop-in centers across 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, including counseling, testing and treatment for sexually transmitted infections, HIV, TB, other opportunistic infections, as well as reproductive health services.
PSI/Myanmar distributes eight condom types via social marketing under the brand name Aphaw (‘companion’ in the Myanmar language). In 2016, it sold more than 16 million condoms at subsidized prices through the private sector, accounting for 83%of the commercial condom market.
PSI/Myanmar provides TB 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 provider clinics throughout Myanmar. To further promote active case detection, 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 communication and pharmacies.
In 2015, more than 64,000 individuals with suspected tuberculosis were screened for the disease, and more than 18,000 cases were registered for treatment at Sun clinics. Altogether, PSI addressed 15% of the national burden.
A total of 9,000 individuals with suspected tuberculosis were also tested for HIV in 2015; the positivity rate among these clients was 4%.
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%. Private sector provision of family planning services at that time was very limited, with most services provided through public health centers and government extension workers – and only to married women in limited geographical areas. By 2015, contraceptive prevalence had increased to 51.3%. Now, PSI’s program provides millions of family planning products and more than 1.5 million reproductive health consultations annually.
In recognition of the rising mortality rate 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 five, 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. In order to address the high levels of undernutrition among children under five in Myanmar, PSI is also supporting the government and partners in the distribution of a 15-micronutrient powder, Sprinkles, to families in townships where undernutrition is highest.
To address under-nutrition, PSI/Myanmar is implementing a behavior change program with women of reproductive age on the benefits of exclusive breastfeeding, as well as providing a maternal vitamin tablet to pregnant and lactating women to address nutrient deficiencies during this critical period.
PSI is at the forefront of Myanmar’s national malaria elimination effort. Targeting populations most vulnerable to malaria, PSI provides quality case management, behavior change communication, applied operational research, and innovative surveillance solutions.
Health impact and quality malaria case management is primarily achieved through four channels:
- A formal network of general practitioners providing health care through their own pre-existing clinics.
- A network of village-level primary health workers who are trained, supervised and directly supplied by PSI.
- A diffuse network of non-formal providers, such as pharmacies, itinerant drug vendors and general retail stores. These non-formal private sector outlets are supplied with subsidized treatment by major pharmaceutical distributors with extensive reach across Myanmar.
- A network of worksite programs. Volunteers are providing an integrated basket of health products, including malaria test and treat services, to the workers. The worksite program was launched in 2015 with a mapping survey to locate all worksites across the country in order to assess the number of workers and the availability of health services onsite. PSI trains and stocks a permanent worker at each site. Worksites that attract mobile-migrant workers include rubber plantations, mines and dams.
In 2016, through PSI/Myanmar’s comprehensive network of malaria health providers, 658,484 febrile cases have been tested and 11,544 confirmed cases have been treated.
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 to 2016, approximately 2 million treatments were delivered through this innovative subsidy mechanism, and 249,000 cases of Plasmodium 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 have informed a nationwide, rapid diagnostic test (RDT) scale-up among informal outlets. The scale-up is expected to reduce drug waste, alleviate drug resistance risk to artemisinin-based combination therapy (the gold standard for malaria treatment) and improve overall case management practices. From 2015 to 2016, the availability of RDTs among informal outlets has greatly increased from 13.4% in 2015 to 36.5% in 2016.
- UK Department for International Development (DfID)
- The Global Fund To Fight AIDS, Tuberculosis and Malaria
- Bill & Melinda Gates Foundation (BMGF)
- Three Millennium Development Goal Fund
- U.S. Agency for International Development (USAID)
- Livelihoods and Food Security Trust Fund
- United Nations Population Fund (UNFPA)
- Danish International Development Agency (Danida)
- Soa Aids
- Procter & Gamble
- Good Ventures
- The Joint United Nations Programme on HIV/AIDS (UNAIDS)
- United Nations Children’s Fund (UNICEF)
- United Nations Office for Project Services (UNOPS)
- Marie Stopes International
- World Vision
- Save the Children
- FHI 360
- Management Sciences for Health
- Malteser International
- Médecins sans Frontières (Holland)
- Medecins du Monde
- The University of Maryland, Baltimore
- Private sector partners: Telenor, Ooreedo, AA Group Limited, PolyGold
- Myanmar Strategic Purchasing Brief Series #2: Calculating a Capitation Payment
This is the second in a series of briefs examining practical considerations in the design and implementation of a strategic purchasing pilot project among private general practitioners (GPs) in Myanmar.
- Myanmar Strategic Purchasing Brief Series #1: Package of Services
This is the first in a series of briefs examining practical considerations in the design and implementation of a strategic purchasing pilot project among private general practitioners (GPs) in Myanmar.
- Malaria Elimination: Who is Really at Risk?
This document presents an alternative approach to thinking and talking about malaria risk factors affecting mobile and migrant populations in the Greater Mekong Subregion, and how this can be translated into strategy and action.
- The GEMS Program: Greater Mekong Subregion Elimination of Malaria through Surveillance
In 2016, PSI launched GMS Elimination of Malaria through Surveillance (GEMS) in Cambodia, Lao PDR, Myanmar and Vietnam to strengthen case management and surveillance in the private sector to accelerate malaria elimination. This project brief describes each component of GEMS project in detail.
- Making Data Work for Malaria Elimination: Surveillance in the Private Sector
This two-page brief describes the importance and usefulness of the Malaria Case Surveillance App and provides a case study of how it has been used in Cambodia.
- 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.