HEALTH SITUATION Myanmar is currently in demographic transition, moving slowly towards an ageing population. Myanmar is consistently endeavoring, with its limited resources, to attain its health objectives and maintain its trends in key health indicators. According to official sources IMR, U5MR, and MMR all declined between 1990 and 2015. Over the same period, life expectancy increased for both men and women. Despite making significant progress, Myanmar missed the targets of Millennium Development Goals 4 and 5 (child and maternal health, respectively). Thus, ending preventable deaths of mothers, newborn and children will require major efforts to meet the new Sustainable Development Goals – as recognized in the country’s National Health Plan 2017-2021, launched 31 March 2017. WHO and partners are supporting accelerated implementation of key interventions to improve maternal, newborn and child health. Among specific diseases, leading causes of death and illness are TB, HIV-AIDS and malaria. Myanmar has made remarkable progress in reducing malaria morbidity and mortality and achieved MDG targets in 2004, well ahead of its target year (2015). Malaria morbidity and mortality has declined by 77% and 95% respectively by 2016 compared to 2012. Country is moving forward as per the National Strategic Plan aiming for malaria elimination by 2030. The TB prevalence rate is three times higher than the global average and one of the highest in Asia. HIV-AIDS epidemic is considered to have stabilized nationally since 2000, with ‘hot spots’ of transmission in several locations. Estimated annual new HIV infections are significantly less than in 2000. Recent surveys indicate high levels of viral hepatitis in Myanmar, i.e. viral hepatitis B 6.5%, viral hepatitis C 2.7% in general population (2015). Viral hepatitis C infection among people injecting drugs varied from 74% to 84% (2014). Co-infection of HIV & HBV 2.2%, HIV & HCV is 20.1% and HIV, HBV and HCV is 20.7% respectively (Bio-behavioural survey, 2014). Antimicrobial Resistance is a big threat to the country revealing Pseudomonas species, Acinetobacter species and Enterobacteriaceae are found to be resistant to Carbapenem 27%, 21% and 14% respectively in 2016 according to National Health Laboratory. Myanmar is facing a double burden of communicable and noncommunicable diseases (NCDs). Chronic NCDs with shared, modifiable risk factors – tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol - include cardiovascular disease, diabetes mellitus, cancer and chronic respiratory disorders. Myanmar is prone to various natural hazards, some of which have the potential to impact large numbers of people. Since 2002, more than 13 million people have been affected by natural disasters. Furthermore, emerging or re-emerging infectious disease outbreaks do occur – for example H1N1 outbreak in 2017. Poverty is a principal constraint – perhaps the principal constraint - to improving health status. To address poverty, significant efforts are being undertaken to improve institutional capacity, building community capacity, moving towards socioeconomic growth with equity in the country, with increased domestic spending, including in health, and with the support of international assistance. HEALTH POLICIES AND SYSTEMS ‘Myanmar Health Vision 2030’ was drawn up in 2000 to meet future health challenges. Supporting this ambitious, long-term health development plan, The Government of Myanmar has recently launched Myanmar’s new five year National Health Plan (NHP) 2017-2021, providing a strategic vision for health in Myanmar. Universal health coverage by 2030 is referred to as key direction and aspiration. The NHP will be operationalized through five annual operational plans. An Essential Package of Health Services (EPHS) is being developed under the aegis of the $200m World Bank loan for UHC. Implementation of the EPHS is linked to the 5 year NHP cycle. WHO’s General Programme of Work, regional flagships and priorities are key for the CCS. Social developments emerging from the national reform process, and key health challenges and emergencies confronting the country, were carefully synthesized to update major focus areas. Close consideration was given to the contributions by other external partners in identifying challenges and gaps in health sector cooperation, as well as to lessons learnt from a review of WHO’s cooperation over the last CCS cycle. COOPERATION FOR HEALTH Myanmar has applied many principles to improve harmonization and alignment. This includes in- country mechanisms to meet objectives of the Paris Declaration on Aid Effectiveness, the Accra and Busan Calls for action and IHP+ Global Compact. Political commitment by the Naypyidaw Accord, at Myanmar’s first Development Cooperation Forum, followed. Joint UN efforts: Joint UN efforts have been initiated with active involvement of WHO. For example, in the development of Myanmar’s first UNDAF, development of Humanitarian Response Plan 2018, nationwide Japanese Encephalitis campaign. In addition, as at March 2018, a strategic framework for international engagement in Rakhine state is currently underway with the purpose of a common vision for a Peaceful, Fair, and Prosperous Future for the People of Rakhine. The draft is being considered and debated among different constituencies, including and beyond UN Myanmar country team. A further example of collaboration with multi-partner in improving health security was accomplishment of the Joint External Evaluation of the International Health Regulation (IHR) in 2017. Myanmar http:// www.who.int/countries/en/ W HO Region South-East Asia W orld Bank income group 1 Lower-middle- income Child health Infants exclusively breastfed for the first six months of life 2 (%) (2015) 51 Diphtheria tetanus toxoid and pertussis (DTP3) immunization coverage among 1-year-olds 3 (%) (2016) 90 Demographic and socioeconomic statistics Life expectancy at birth 3 (years) (2015) 64.6 (Male) 66.6 (Both sexes) 68.5 (Female) Population 3 (in thousands) total (2015) 53897.2 % Population under 15 3 (2015) 27.6 % Population over 60 3 (2015) 8.9 Poverty headcount ratio at $1.25 a day (PPP) 4 (% of population) (2015) 6.5 Percentage of the population 15 years and over achieving at least a fixed level of proficiency in functional literacy 5 (%) (2015) 89.6 Gender Inequality Index rank 6 (2015) 80 Human Development Index rank 6 (2015) 145 Health systems Total expenditure on health as a percentage of gross domestic product 7 (2014) 2.28 Private expenditure on health as a percentage of total expenditure on health 7 (2014) 54.09 General government expenditure on health as a percentage of total government expenditure 7 (2014) 3.59 Physicians density 3 (per 1000 population) (2012) 0.568 Nursing and midwifery personnel density 3 (per 1000 population) (2012) 0.93 Mortality and global health estimates Neonatal mortality rate 3 (per 1000 live births) (2016) 24.5 [18.0-32.2] Under-five mortality rate 3 (probability of dying by age 5 per 1000 live births) (2016) 50.8 [39.2-64.2] Maternal mortality ratio 3 (per 100 000 live births) (2015) 178 [ 121 - 284] Births attended by skilled health personnel 3 (%) (2015) 60.2 Public health and environment Proportion of population using improved drinking water sources 5 (%) (2015) 80.6 Proportion of population using improved sanitation 5 (%) (2015) 79.5 Sources of data: 1 World Bank Country and Lending Groups. Country Classification. 2 Ministry of Health and Sports and ICF. 2017. Myanmar Demographic and Health Survey 2015-2016. 3 World Health Organization. Global Health Observatory Data Repository. 2 April 2018. 4 World Bank. World Development Indicators. (https://data.worldbank.org/indicator) 2 April 2018 5 Central Statistical Organization and United Nations Development Programme. 2017. Measuring Myanmar’s Starting Point for the Sustainable Development Goals: SDG Indicator Baseline Report. 6 United Nations Development Programme. 2016. Human Development Report 2016. 7 World Health Organization. Global Health Expenditure Database 2 April 2018. (http://apps.who.int/nha/database/ViewData/Indicators/en) WHO COUNTRY COOPERATION STRATEGIC AGENDA (2014–2018) Strategic Priorities Main Focus Areas for WHO Cooperation STRATEGIC PRIORITY 1: Strengthening the health system Support expanded coverage of , and improved access to, quality health care Strengthen implementation of the National Health Plan through support for its operationalization for universal health coverage Technical support for national strategic plan on human resources for health , for Health Information System and for options related to health care finance Support national health authorities to promote essential, traditional and herbal medicines STRATEGIC PRIORITY 2: Enhancing the achievement of communicable disease control targets Attain 80% coverage of people needing antiretroviral therapy (ART) under national guidelines and minimize HIV transmission from infected mothers Further reduce TB prevalence and mortality to achieve the TB impact targets Intensify malaria control in high transmission areas and along international borders; and accelerate elimination in low transmission areas; and control and eliminate neglected tropical diseases Strengthen immunization systems to achieve at least 90% DTP coverage nationally and 80% in all townships; and expand planning and implementation of other VPD programmes . STRATEGIC PRIORITY 3: Controlling the growth of noncommunicable disease burden Support the national health authorities to expand activities for promoting practices of healthy lifestyles and health literacy in the community, including tobacco control Multisectoral support to expand national efforts for prevention of injury, violence and disability Support to strengthen the prevention and control of noncommunicable diseases including multi - sectoral plan in this regard. STRATEGIC PRIORITY 4: Promoting health throughout the life course Develop a comprehensive, integrated package of interventions for family planning and maternal, newborn and child health, particularly child nutrition and growth monitoring Improve sexual and reproductive health including adolescent and women’s health and health care for elderly Support the national authorities to enhance safe water supply, water quality control, improved sanitation and personal hygiene, and links with health literacy promotion. STRATEGIC PRIORITY 5: Strengthening capacity for health emergency preparedness and response Enhance preparedness, surveillance and response for disasters and health emergencies Joint External Evaluation of International Health Regulations and National Action Plan for Health Security Develop and enhance pandemic preparedness Strengthen health cluster coordination in collaboration with Ministry of Health & Sports Please note that the 3rd generation CCS 2014-20g finalize © W orld Health Organization 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. This publication does not necessarily represent the decisions or policies of WHO. WHO/CCU/18.02/Myanmar Updated May 2018
HEALTH SITUATION Myanmar is currently in demographic transition, moving slowly towards an ageing population. Myanmar is consistently endeavoring, with its limited resources, to attain its health objectives and maintain its trends in key health indicators. According to official sources IMR, U5MR, and MMR all declined between 1990 and 2015. Over the same period, life expectancy increased for both men and women. Despite making significant progress, Myanmar missed the targets of Millennium Development Goals 4 and 5 (child and maternal health, respectively). Thus, ending preventable deaths of mothers, newborn and children will require major efforts to meet the new Sustainable Development Goals – as recognized in the country’s National Health Plan 2017-2021, launched 31 March 2017. WHO and partners are supporting accelerated implementation of key interventions to improve maternal, newborn and child health. Among specific diseases, leading causes of death and illness are TB, HIV-AIDS and malaria. Myanmar has made remarkable progress in reducing malaria morbidity and mortality and achieved MDG targets in 2004, well ahead of its target year (2015). Malaria morbidity and mortality has declined by 77% and 95% respectively by 2016 compared to 2012. Country is moving forward as per the National Strategic Plan aiming for malaria elimination by 2030. The TB prevalence rate is three times higher than the global average and one of the highest in Asia. HIV-AIDS epidemic is considered to have stabilized nationally since 2000, with ‘hot spots’ of transmission in several locations. Estimated annual new HIV infections are significantly less than in 2000. Recent surveys indicate high levels of viral hepatitis in Myanmar, i.e. viral hepatitis B 6.5%, viral hepatitis C 2.7% in general population (2015). Viral hepatitis C infection among people injecting drugs varied from 74% to 84% (2014). Co-infection of HIV & HBV 2.2%, HIV & HCV is 20.1% and HIV, HBV and HCV is 20.7% respectively (Bio-behavioural survey, 2014). Antimicrobial Resistance is a big threat to the country revealing Pseudomonas species, Acinetobacter species and Enterobacteriaceae are found to be resistant to Carbapenem 27%, 21% and 14% respectively in 2016 according to National Health Laboratory. Myanmar is facing a double burden of communicable and noncommunicable diseases (NCDs). Chronic NCDs with shared, modifiable risk factors – tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol - include cardiovascular disease, diabetes mellitus, cancer and chronic respiratory disorders. Myanmar is prone to various natural hazards, some of which have the potential to impact large numbers of people. Since 2002, more than 13 million people have been affected by natural disasters. Furthermore, emerging or re-emerging infectious disease outbreaks do occur – for example H1N1 outbreak in 2017. Poverty is a principal constraint – perhaps the principal constraint - to improving health status. To address poverty, significant efforts are being undertaken to improve institutional capacity, building community capacity, moving towards socioeconomic growth with equity in the country, with increased domestic spending, including in health, and with the support of international assistance. HEALTH POLICIES AND SYSTEMS ‘Myanmar Health Vision 2030’ was drawn up in 2000 to meet future health challenges. Supporting this ambitious, long-term health development plan, The Government of Myanmar has recently launched Myanmar’s new five year National Health Plan (NHP) 2017-2021, providing a strategic vision for health in Myanmar. Universal health coverage by 2030 is referred to as key direction and aspiration. The NHP will be operationalized through five annual operational plans. An Essential Package of Health Services (EPHS) is being developed under the aegis of the $200m World Bank loan for UHC. Implementation of the EPHS is linked to the 5 year NHP cycle. WHO’s General Programme of Work, regional flagships and priorities are key for the CCS. Social developments emerging from the national reform process, and key health challenges and emergencies confronting the country, were carefully synthesized to update major focus areas. Close consideration was given to the contributions by other external partners in identifying challenges and gaps in health sector cooperation, as well as to lessons learnt from a review of WHO’s cooperation over the last CCS cycle. COOPERATION FOR HEALTH Myanmar has applied many principles to improve harmonization and alignment. This includes in- country mechanisms to meet objectives of the Paris Declaration on Aid Effectiveness, the Accra and Busan Calls for action and IHP+ Global Compact. Political commitment by the Naypyidaw Accord, at Myanmar’s first Development Cooperation Forum, followed. Joint UN efforts: Joint UN efforts have been initiated with active involvement of WHO. For example, in the development of Myanmar’s first UNDAF, development of Humanitarian Response Plan 2018, nationwide Japanese Encephalitis campaign. In addition, as at March 2018, a strategic framework for international engagement in Rakhine state is currently underway with the purpose of a common vision for a Peaceful, Fair, and Prosperous Future for the People of Rakhine. The draft is being considered and debated among different constituencies, including and beyond UN Myanmar country team. A further example of collaboration with multi-partner in improving health security was accomplishment of the Joint External Evaluation of the International Health Regulation (IHR) in 2017. Myanmar http:// www.who.int/countries/en/ W HO Region South-East Asia W orld Bank income group 1 Lower-middle- income Child health Infants exclusively breastfed for the first six months of life 2 (%) (2015) 51 Diphtheria tetanus toxoid and pertussis (DTP3) immunization coverage among 1-year-olds 3 (%) (2016) 90 Demographic and socioeconomic statistics Life expectancy at birth 3 (years) (2015) 64.6 (Male) 66.6 (Both sexes) 68.5 (Female) Population 3 (in thousands) total (2015) 53897.2 % Population under 15 3 (2015) 27.6 % Population over 60 3 (2015) 8.9 Poverty headcount ratio at $1.25 a day (PPP) 4 (% of population) (2015) 6.5 Percentage of the population 15 years and over achieving at least a fixed level of proficiency in functional literacy 5 (%) (2015) 89.6 Gender Inequality Index rank 6 (2015) 80 Human Development Index rank 6 (2015) 145 Health systems Total expenditure on health as a percentage of gross domestic product 7 (2014) 2.28 Private expenditure on health as a percentage of total expenditure on health 7 (2014) 54.09 General government expenditure on health as a percentage of total government expenditure 7 (2014) 3.59 Physicians density 3 (per 1000 population) (2012) 0.568 Nursing and midwifery personnel density 3 (per 1000 population) (2012) 0.93 Mortality and global health estimates Neonatal mortality rate 3 (per 1000 live births) (2016) 24.5 [18.0-32.2] Under-five mortality rate 3 (probability of dying by age 5 per 1000 live births) (2016) 50.8 [39.2-64.2] Maternal mortality ratio 3 (per 100 000 live births) (2015) 178 [ 121 - 284] Births attended by skilled health personnel 3 (%) (2015) 60.2 Public health and environment Proportion of population using improved drinking water sources 5 (%) (2015) 80.6 Proportion of population using improved sanitation 5 (%) (2015) 79.5 Sources of data: 1 World Bank Country and Lending Groups. Country Classification. 2 Ministry of Health and Sports and ICF. 2017. Myanmar Demographic and Health Survey 2015-2016. 3 World Health Organization. Global Health Observatory Data Repository. 2 April 2018. 4 World Bank. World Development Indicators. (https://data.worldbank.org/indicator) 2 April 2018 5 Central Statistical Organization and United Nations Development Programme. 2017. Measuring Myanmar’s Starting Point for the Sustainable Development Goals: SDG Indicator Baseline Report. 6 United Nations Development Programme. 2016. Human Development Report 2016. 7 World Health Organization. Global Health Expenditure Database 2 April 2018. (http://apps.who.int/nha/database/ViewData/Indicators/en) WHO COUNTRY COOPERATION STRATEGIC AGENDA (2014–2018) Strategic Priorities Main Focus Areas for WHO Cooperation STRATEGIC PRIORITY 1: Strengthening the health system Support expanded coverage of , and improved access to, quality health care Strengthen implementation of the National Health Plan through support for its operationalization for universal health coverage Technical support for national strategic plan on human resources for health , for Health Information System and for options related to health care finance Support national health authorities to promote essential, traditional and herbal medicines STRATEGIC PRIORITY 2: Enhancing the achievement of communicable disease control targets Attain 80% coverage of people needing antiretroviral therapy (ART) under national guidelines and minimize HIV transmission from infected mothers Further reduce TB prevalence and mortality to achieve the TB impact targets Intensify malaria control in high transmission areas and along international borders; and accelerate elimination in low transmission areas; and control and eliminate neglected tropical diseases Strengthen immunization systems to achieve at least 90% DTP coverage nationally and 80% in all townships; and expand planning and implementation of other VPD programmes . STRATEGIC PRIORITY 3: Controlling the growth of noncommunicable disease burden Support the national health authorities to expand activities for promoting practices of healthy lifestyles and health literacy in the community, including tobacco control Multisectoral support to expand national efforts for prevention of injury, violence and disability Support to strengthen the prevention and control of noncommunicable diseases including multi - sectoral plan in this regard. STRATEGIC PRIORITY 4: Promoting health throughout the life course Develop a comprehensive, integrated package of interventions for family planning and maternal, newborn and child health, particularly child nutrition and growth monitoring Improve sexual and reproductive health including adolescent and women’s health and health care for elderly Support the national authorities to enhance safe water supply, water quality control, improved sanitation and personal hygiene, and links with health literacy promotion. STRATEGIC PRIORITY 5: Strengthening capacity for health emergency preparedness and response Enhance preparedness, surveillance and response for disasters and health emergencies Joint External Evaluation of International Health Regulations and National Action Plan for Health Security Develop and enhance pandemic preparedness Strengthen health cluster coordination in collaboration with Ministry of Health & Sports Please note that the 3rd generation CCS 2014-20g finalize © W orld Health Organization 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. This publication does not necessarily represent the decisions or policies of WHO. WHO/CCU/18.02/Myanmar Updated May 2018