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Burma - the challenge providing access to reproductive health

Thursday, September 19, 2013

At the end of July Meg led a group of UK Parliamentarians to Burma to study reproductive health services her account follows.

Over the last few months Burma has been much in the news. In July the President and former General, Thein Sein was welcomed on a visit to the UK, and last November Aung San Suu Kyi, the leader of the National League for Democracy, addressed both Houses of Parliament. These developments have solidified the sustained movement toward democracy in the Burma from what was initially seen to be a sham democracy.

Many political prisoners have been released and there is a commitment to release all in the near future. Cease fires have been achieved with most of the many ethnic groups, and the media is beginning to open up. Indeed criticism of the Government is allowed, and the respected and often critical current affairs magazine, The Irrawaddy, has returned to the country after twenty years in exile.

For a week at the end of July I led a delegation of UK parliamentarians from the All-Party Parliamentary Group on Population, Development and Reproductive Rights on a study visit. Organised and supported by Marie Stopes International, we visited a range of health care facilities from small private general practice clinics in urban areas, to larger clinics in rural areas and including both small and large hospitals.

Burma is amongst the lowest spending countries on health in the world and is expected to fail to meet the Millennium Development Goals related to maternal and child welfare. The country was spending around 1% of total Government expenditure on health, equivalent to about $17 per capita. We were told that this has recently been increased by four times, but it remains a very low amount to cater for the obvious need. While the economy suffered from international sanctions there has still been funds to build large buildings, wide roads, a state-of-the-art airport and support lavish life styles for generals turned politicians in the new capital Naypyitaw.

The health of babies continues to be a big issue with the most common health problem being diarrhoea - too many people with no access to clean water. We saw for ourselves the impact of dengue fever, with one hospital ward full of young children suffering from the disease. Symptoms include fever, headache, muscle and joint pains, and a characteristic skin rash that is similar to measles.

Even in the largest teaching hospital in Rangoon there was only meagre equipment and not everything works. I saw a baby who was destined to die but who would have survived in the UK. Most doctors have the relevant skills many trained in the UK. But there are not enough of them for the population, meaning that many are overworked. Over the last 20 years education standards have been poor, leaving fewer younger people able to become qualified as doctors.

Most worryingly, the Ministry of Health does not seem to have a clear vision of the health service it wants to develop. Changes are being made but not as part of an overall strategy. The current system has a mix of public and private, with non-governmental organisations playing a role too. Tensions are emerging between those who see the benefits of further investment and development of primary care services, and those who would opt for a higher tech approach with brand new hospitals.

The provision of medical supplies has also been a major issue, with patients’ families generally expected to buy what is needed. Most hospitals will not accept admissions of people on their own for this reason. This problem was recently eased with a large capital investment from the Government, leading to them being available for free in the public sector. However no-one knows whether that will continue or whether it was a one off.

Still in place from British rule, the health services have systems of regulation and registration of health professionals. In every setting we met midwives with their distinctive red skirts, along with assistant midwives and nurses. Midwives are trained for a total of two years, rather than this specialised training being additional to a nursing qualification. Improving the quality of midwife training could dramatically improve child and maternal welfare, as the ability to identify early problems can be crucial. Even when problems are identified transport is a major issue in rural areas - poor roads and few vehicles means transporting a woman on a bullock cart.

A strong campaign of disinvestment meant many companies left Burma and international organisations, including non-governmental organisations, were generally unwelcome. By keeping its head down and concentrating solely on service delivery Marie Stopes International has been able to keep working from 1997. It has delivered vital services from family planning to HIV testing and sexual health education. With the opening up of the political situation there is now an opportunity for the organisation to move more into advocacy.

There is no shortage of issues on which it could advocate. In this primarily Buddhist country there is a strong belief in the importance of marriage with most births within marriage. Abortion is illegal, yet the hospitals see the results everyday of what is termed unsafe abortion. Just as in the UK before legalised abortion, women continue to die from what we would call back street abortionists.

The official birth rate is surprisingly low for a developing country at around 2 children. However the high number of women aged between 20 and 40 who remain unmarried means that family size is generally larger than the birth rate would suggest. In a rural clinic villagers told us that their families have 3 - 4 children. Contraceptive advice is welcomed by most women who wish to control the number of children they have. Depo injections are the most popular, but IUDs or coils are often unavailable as medical staff do not receive training in their use.

The Burmese people welcomed us wherever we went. In hospitals, medical centres and doctors surgery’s the whole medical staff turned out to see us, and at one rural clinic all the mothers with young children turned up even though it was a Saturday and the clinic was not open. Our delegation had to get clearance from the Ministry of Health before our visits. Nevertheless we saw a wide range of facilities, far below western standards but invariably clean with dedicated and knowledgeable staff. The concept of privacy was certainly not the same. Beds in hospitals are close together with no optional curtains or screens. No-one batted an eyelid when we met a group of villagers and one woman told us about the contraception she uses and the help she had received.

Burma is in many ways a surprising country. The repression that had kept the country under military rule for so long may be evident in the compliant attitudes of the population, but pictures of Aung San Suu Kyi and her assassinated father are everywhere. Politically no-one really knows what will happen next national elections are due in 2015. What is clear is the need for huge investment into public services to lift the people out of poverty and help them realise their potential.


Originally published on the website of the All-Party Parliamentary Group on Population, Development and Reproductive Health - http://www.appg-popdevrh.org.uk/index.html

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