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The dream of universal healthcare in Myanmar becomes a nightmare

Jim Brockbank has retired from General Practice. He continues in his role as a GP Appraiser and as an International RCGP Trainer for Myanmar. He also works with the human rights organisation The Helen Bamber Foundation.

The Caravan of Hope

Myanmar (formerly known as Burma) has been a nation at the crossroads for more than ten years.1 The caravan of hope set off following the release of Aung San Suu Kyi in 2010, picking up speed after the release of political prisoners and the commencement of some democratic reforms in 2011. The journey out of darkness continued with visits from Hillary Clinton, USA Secretary of State, in 2011 and President Barack Obama in 2012. In 2015 Aung San Suu Kyi won a supermajority of the seats for the National League for Democracy (NLD) and a combined national parliament was formed with 25% predetermined seats for the military.

Her victory raised the hopes of the youth of the nation towards a brighter future. The onward journey has been bumpy with many setbacks under this fragile democratic arrangement. Despite these challenges, the NLD again won the parliamentary elections in November 2020 in a landslide victory. Then on the 1st February 2021 the Tatmadaw (the armed forces) blocked the road ahead and the caravan ground to a halt.

[Aung San Suu Kyi’s] victory raised the hopes of the youth of the nation towards a brighter future.

A host of travellers were on board, including healthcare. Progress, albeit a bit slow, towards Universal Healthcare (UHC) was being made.The WONCA conference Asia Pacific region had been due to take place in April 2021 in Yangon with a focus on the pivotal role of primary care in UHC. This decision had been greeted with a holler of delight from the normally reserved Myanmar GPs who had made the application to WONCA, the World Organisation of Family Doctors.

I clambered onboard this caravan in January 2018 when I made my first visit to Myanmar for the start of the RCGP – Myanmar GP Society Quality Improvement project. My fellow travellers were three colleagues, all UK GPs, two of whom were originally from Myanmar.

Of course you can’t just turn up and hitch a ride. Work to support the development of family medicine as a specialty had been going on since 2013 in close liaison with the Myanmar GP Society and the Myanmar Medical Association. Discussions had also been held with the Health Minister.

The Road to Mandalay

The project was to take place in the Mandalay region of Myanmar, in the city of Meiktila, population 150,000, and in Mandalay the second largest city in Myanmar, population 600,000, some 450 miles from Yangon. We could have taken the Yangon to Mandalay Expressway but we took the old road to Mandalay along with freight traffic that is not allowed on the Expressway. This was of course slower but offered a glimpse of towns, pagodas, local festivals, markets and other slices of life, including two wheel road haulage and bullock cart racing!

Stepping Out on The Road to Universal Healthcare

We were in Myanmar to support progress towards the recognition of General Practice as a specialty that would meet the challenges of developing UHC.This was to be a year long Quality Improvement (QI) project involving 64 practices in 16 Townships covering a population of approximately 2.5 million. 30% of practices were in urban areas, the rest were in small towns and large villages.

In Myanmar most GP surgeries are single-handed practitioners working in a small room with patients waiting outside. Many GPs work in professional isolation and there is no requirement for postgraduate qualifications or training in primary care. The majority of care provided in Myanmar GP practices are for acute episodes of illness, despite the burden of chronic diseases such as diabetes and hypertension. The majority of patients who see GPs as their first point of access to health care are the poorest people in Myanmar, this is especially so in rural areas. The better off usually access specialist healthcare directly. Continuing Medical Education (CME) is provided by secondary care, the topics and didactic style of teaching do not cater to a GP’s learning needs. Does this ring any bells for the state of General Practice in the UK in the years immediately preceding and following the birth of the NHS in 1948 (the same year that Burma regained independence)?

A New National Health Plan for Myanmar 2017 -21 was launched in March 2017 by Aung San Suu Kyi.2 The goal was Universal Healthcare (UHC) for the entire population of Myanmar by 2030. The foundation of this plan was to be primary care. However despite the importance of General Practice in the new National Health Plan, it was not recognised as a medical specialty. There was no comprehensive General Practice activity nor quality data. There are parallels here with early UK General Practice which was vital to the functioning of the new NHS but failing. In response to this the RCGP was founded in 1952 to support good standards of practice, education and research and develop General Practice as a specialty. In Myanmar The Quality Improvement Project was conceived and funded in response to their goal of UHC.

There are parallels here with early UK General Practice


The Quality Improvement (QI) Project

Just to remind ourselves, QI is about achieving best performance with the available resources. In the U.K. we have become familiar with methods that include audit, case review, significant event analysis and the identification of our learning needs through the appraisal process. But imagine hearing about this for the first time.

Data was collected on structure and process from all the GP practices at the commencement of the project and at the end. The RCGP Team visited GP practices to discuss and advise on quality indicators, professional / practice development (PDP), and to provide encouragement and moral support. Three days of workshops were carried out each lasting four hours, topics included the principles of Quality Improvement and the technical skills required . Lunch was included to accommodate the pattern of morning and evening surgeries seven days a week. Many of the doctors travelled a significant distance to attend.

The main areas for practice development were improving medical records, proper clinical waste disposal, and infection control, including hand washing and cleaning of premises. PDPs included plans to take the MRCGP International, targeted CME that was relevant to local GPs, and to learn about group practice. One of the desired outcomes of the one-year QI Project was that the GPs would continue to meet in small groups of 8-10 (Quality Circles) to learn together as a way of creating collaborative improvement in primary care.

Four visits to Myanmar by volunteer RCGP trainers were undertaken and six Myanmar GPs visited the UK at the end of the project to observe quality improvement in UK GP surgeries.

What Did We Find?

This was a rich and rewarding experience. The welcoming attitude of the GPs to new ideas and ways of learning was a major strength of the project. Group work was popular and the doctors were keen to contribute and share learning. Among the GPs in Mandalay and Meiktila who completed the RCGP QI Training we found significant improvement in infection control, and in medical records, which allowed 64% of doctors to carry out an audit of chronic disease management (CDM). 63% of doctors keep a record of their learning, and 70% have a PDP.3

100% of doctors who completed the training belong to Quality Circles, which have become an established method of collaborative learning. They have reduced professional isolation and increased the confidence to learn in peer groups. The shared development of medical records which included colour coding for CDM, the development of a register for CDM and the basic development of electronic medical records are a reminder of the pre-digital age in UK General Practice.

The Covid Pandemic

Digital technology came to the rescue when the Covid pandemic arrived in March 2020. The programme was adapted to remote working to ensure achievement of the long-term project objectives of improving quality in Myanmar General Practice, alongside the short-term objectives of preparing for COVID-19. The revised remote QI training programme included small group-training for those new to quality improvement, and small-group training to support graduates of the 2018 project to become Quality Champions, charged with promoting quality improvement within Myanmar. Additional elements included Webinars for GPs from all over Myanmar to facilitate sharing of learning and experiences during COVID and a Facebook Group between Myanmar and UK GPs. The necessity of remote teaching has had some advantages. Training in areas that are not geographically close has become possible. For example were due to start training in Sittwe the capital of the troubled Rakhine state, and Quality Champions from Mandalay and Meiktila have been involved in remote teaching of QI to GPs in other localities in Myanmar.

Other linked RCGP projects have included GPs trained as trainers; supporting the five non military universities of medicine in assessment techniques for use within their new integrated undergraduate curriculum, and the development of a new Masters degree in family medicine. Family medicine was arriving as a specialty in Myanmar.

The coup in the early hours of 1st February has halted all the progress made so far along the road to Universal Healthcare and the development of family medicine as a specialty in Myanmar.

The Nightmare

“All medical professionals including general practitioners and other health care workers in Myanmar should be able to deliver medical care to anyone in need of their help, without fear of intimidation, attack or arrest”.4

Human rights activists, and least of all the people of Myanmar, will not be surprised at the violation of medical neutrality in contravention of international humanitarian law.

Following the coup, Myanmar military and police forces have indiscriminately barraged crowds of peaceful demonstrators and volunteer medics with tear gas, rubber bullets and even military grade weapons. Scores of doctors, clearly distinguishable by the signature red cross on their clothes, have braved such dangers to treat injured protestors but have not been immune to the violence that sweeps Myanmar. Some doctors do not return to their homes at night.

The image of a medical student beaten unconscious by five helmeted men with truncheons, his apparently lifeless body dragged across the street, is a shocking distillation of the brutality and ‘otherness’ of the junta. If by chance he survived what medical care would be available?

We have clear photographic evidence from colleagues in Myanmar which shows a Doctor at gunpoint (above, right), a doctor arrested, destruction of a COVID centre and medical equipment taken away, a doctor’s request to complete suturing of an extensive head wound denied, civilians carrying injured patient on a wooden cart as an ambulance not allowed access (see the picture at the top of this article), paramedics from a charity clinic beaten, a paramedic trying to control severe bleeding from rubber bullet injury and the blood stained white coats of medical students after protest.

The information from Amnesty International is that the security forces in Myanmar are using shotguns loaded with rubber bullets (see left*), and the circumstances are that people are being shot at close range e.g. when fallen to the ground and surrounded by a group of the military. The intention appears to be to seriously harm, not simply disperse. This has been described by Amnesty as “contentious crowd control methods”. 5

The military and police forces occupy non-military hospitals and emergency services as their bases, life support machinery and equipment has been removed, facilities vandalised, and healthcare professionals threatened.

All of this is an attempt to undermine the civil disobedience movement. Doctors as citizens of Myanmar are balancing their right to protest against the coup with their public duty to provide medical care.

Civil disobedience can be justified when used to protest a high stakes political decision that will affect many, not just for this generation but future generations”.6

Successive regimes in Myanmar have an appalling record on healthcare. Until the democratic reforms the spend on healthcare was less than 2% of GDP, under limited democracy that rose to 4.5%. The price of the coup, particularly in the midst of a pandemic will be the lives of ordinary people denied the healthcare that the military provides for its own.7

Empathy is incomplete when it does not lead to action, an attempt to help”.8

Bearing witness, for our colleagues in Myanmar, as so many of us do for our patients, is powerful, but it is not enough. Colleagues in Myanmar want us to be their advocates, hear their stories, condemn the violation of medical neutrality, provide remote clinical guidance, especially on trauma medicine and communicate with them safely. It’s the least we can do.

What Next For Myanmar?

We are writing this new chapter with our own hands
Generation Z. Myanmar.

The protesters are not backing down, the street cannot easily be silenced. The impact of democracy over the last 10 years, however flawed, has diminished the suffocating influence of the junta.

The sunset in Myanmar from Inle Lake in the Shan Hills to the Shwedagon Pagoda in Yangon, is a natural masterpiece. Let us hope that the sun will rise on a new chapter of peace, democracy, prosperity and of course, universal healthcare for the people of this beautiful country.

References

  1. Rogers. B. Burma. A Nation at The Cross Roads’. Penguin Random House, [2015].
  2. Myanmar National Health Plan 2017 – 2021 Ministry of Health and Sports. mohs.gov.mm. [2017]
  3. RCGP Myanmar GP Society Quality Improvement Project Report. [September 2020.]
  4. Myanmar – UK GP Health Action. [March 2021]
  5. https://www.amnesty.org/en/latest/news/2021/03/myanmar-arsenal-troops-deployed-crackdown/ and personal communication
  6. Aung.S. Personal communication. [February 2021]
  7. Williams V.N. and Williams. T.I. Personal communication [March 2021]
  8. Coulehan.J.’“Let me see if I have this right”: Words that help build empathy’, Annals of Internal Medicine, Volume 135, p 221 [2001]

see also:

MYANMAR DOCTORS UNDER A MILITARY COUP IN THE MIDST OF THE PANDEMIC in BJGP Life,

and the Myanmar UK GP Health Action Group’s letter to the BMJ, which explains the endorsement by The Academy of Medical Royal Colleges:

All featured photos from the author. * Patient photo published with patient’s consent.

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