1.

INTRODUCTION

According to WHO, health refers to a state of complete physical, mental, and social
well-being and not merely the absence of disease. Every human being has the
fundamental right to enjoy the highest attainable standard of health without distinction
of race, religion, political belief, economic or social condition. The health of all
people is essential to the attainment of peace and security and is dependent on the
fullest cooperation of individuals and States. Unequal development in different
countries in the promotion of health and control of diseases, especially communicable
diseases, is a common danger. Informed opinion and active cooperation on the part of
the public are critical in the improvement of the health of the people (WHO, 2023).

A health care delivery system is a system of an organization that provides resources

and treatments that help people when they are sick or injured, and help them stay
healthy through preventive care. The purpose of the health care delivery system is to
provide preventive care to help keep people healthy and provide treatment to treat
diseases such as cancer or heart disease, illnesses such as colds or flu, or injuries. All
the people who provide care, and all the facilities where care is received, are included
in the healthcare delivery system (Anon, 2023).

A healthcare delivery system is composed of all the institutions, organizations,

people, and resources that help a particular group of people stay healthy. It includes
the policy, organizations, and regulations that promote health with direct and indirect
strategies. It is organized into four functional components: financing, insurance,
delivery, and payment. It can also be divided into four major components: service,
consumers, personnel (providers), and payment. In many countries, primary care
services are delivered in private solo, or group activities. On the other hand, outpatient
specialist care is frequently provided in outpatient departments of hospitals or clinics
(Anon, 2023).

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2. PROFILE OF COUNTRY
The Republic of the Union of Myanmar, located in South-East Asia, is surrounded by
Bangladesh, India, China, Laos, and Thailand on the landward side and the coastline.
It bounces 2200 kilometers from north to south and 925 kilometers from east-west at
its widest point. Myanmar covers an area of 676,578 square kilometers in 653,508
square kilometers of land and 23,070 square kilometers of water. The length of the
contiguous frontier is 3,828 miles (6,129 kilometers), sharing 1,370 miles with China,
1,310 miles with Thailand, 832 miles with India, 1,687 miles with Bangladesh, and
148 miles with Laos respectively. The country is divided administratively, into Nay
Pyi Taw Council Territory and 14 States and Regions. It consists of 74 districts, 330
villages, 398 cities, 3,065 parishes, 13,619 village structures, and 64,134 villages.
Myanmar enjoys a tropical climate with three distinct seasons, summer, rainy and
cold season (Ministry of Health, 2014).
The Republic of the Union of Myanmar organized its most recent census in
March/April 2014. This is more than 30 years after the last census in 1983. The
provisional results indicate that the population of Myanmar on the 29 th March 2014
was 51,419,420 persons 2014. Now, the United Nations (UN) estimated that
Myanmar’s population in 2019 was 54.34 million. The proportion of the population in
each state is Kachin (3.28%), Kayah (0.56%), Kayin (3.06%), Chin (0.93%), Bamar
(70.66%), Mon (3.99), Rakhine (6.20%) and Shan (11.31%). The census results show
that the population density in Myanmar is 76 persons per square kilometer. About 30
percent of the population resides in urban areas (Ministry of Immigration and
Population, 2014).

Myanmar is composed of 135 national races speaking over 100 languages and dialects
and the Myanmar language is the official language. Kachin (12 races), Kayah (9
races), Kayin (11 races), Chin (53 races), Bamar (9 races), Mon (1 race), Rakhine (7
races), and Shan (33 races) are the major ethnic groups. Religion in Myanmar spread
among Buddhists (87.9%), Christians (6.2%), Muslims (4.3%), Hindus (0.5 %)
Animists (0.8%), other (0.2%), and None (0.1%) of the population. (MoH, 2014).

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2. HEALTH STATUS OF MYANMAR

The life expectancy rate is one of the most important indicators of the health status of
a country. Improving healthcare systems and increasing health expenditures have
raised life expectancy at birth in Southeast Asian regions throughout recent years.
Singapore was the highest life expectancy at birth of all the Southeast Asian countries
in 2021 with an average of 82.8 years old. Interestingly, Singapore is included in the
top ten countries with the highest life expectancy worldwide. In Myanmar, the life
expectancy rate is 67 age years old at birth as of 2020 (Statista, 2023). The life
expectancy rate is increasing between 1980-2020 in Myanmar (55 years in 1980, 61.9
years in 2000, 64 years in 2011, and 67 years in 2020). But, Myanmar’s life
expectancy is lower when compared with other countries in Southeast Asia.
Another indicator of health status is the crude death rate or mortality rate. The crude
death rate of Myanmar is the highest among Southeast Asian countries with 8.3 deaths
per thousand population in 2021. On the other hand, Brunei had the lowest crude
death rate with 4.8 deaths per population. In Myanmar, tuberculosis is one of the main
causes of death among communicable diseases. The number of deaths from
tuberculosis is 51 deaths per hundred thousand population in 2017 (Statista, 2023).
Other main causes of death in Myanmar are lower respiratory infection, HIV/AIDS,
diarrheal diseases, and stroke (health system review, 2014). In 2019, approximately
240 thousand Myanmar people were living with HIV/AIDS which showed an increase
from 2000 with an estimated number of approximately 150 thousand people with
HIV/AIDS (Statista, 2023).
Moreover, immunization coverage is an indicator that shows the health status of the
respective country. In Myanmar, one million of children had no access to vaccination
against communicable diseases in 2021 due to multiple challenges including political
crisis, escalating conflict and violence, the ongoing COVID-19 pandemic, climate-
related disasters, increasing poverty, and the collapse of public services (UNICEF,
2022). Only 44 percent of children in the age groups of 12 to 30 months were
immunized against measles and it was the lowest number in Myanmar (Statista,
2023).

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4. REVIEWING THE HEALTHCARE SYSTEM OF MYANMAR and
PHILIPPINES

A health system is composed of organizations, institutions, resources, and people and

primarily aims to improve health. It consists of efforts for influencing determinants of
health and direct health-improvement activities. The health system combines both
public health activities as well as the pyramid of healthcare facilities that deliver
personal health care to provide preventive, promotive, curative, and rehabilitative
care. The health system should treat people respectably with responsive and
financially fair actions. The health system requires staff, funds, information, supplies,
transport, communication, and overall guidance and direction to function. It should
address key constraints in each of these areas to strengthen the health system (World
Health Organization, 2010).

The health system is multifaced in nature and this is the spread of direct and indirect
responsibilities across multiple sectors. Thus, this has challenges in monitoring health
system performance. There are key indicators and effective methods and measures of
health system capacity, including inputs, processes, and outputs to monitor and
evaluate the health system. There exist many strategic frameworks for the health
system. WHO framework for health system assessment includes the World Bank
control knobs framework and the WHO buildings blocks framework (World Health
Organization, 2010).

The WHO framework describes health systems including six core components or
building blocks: service delivery, health workforce, health information systems,
access to essential medicines, financing, and leadership and governance. These
building blocks integrate into the strengthening of health systems in different ways.
Some blocks such as health information systems and leadership/governance offer the
basis for the overall policy and regulation of all other health system blocks. Financing
and the health workforce are key input components to the health system. The
immediate outputs of the health systems consist of medical products and technologies
and service delivery (World Health Organization, 2010).

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4.1. Health Service Delivery

Strengthening health service delivery is essential to achieve the health-related

Sustainable Development Goals (SDGs) including the delivery of interventions to
reduce child mortality, maternal mortality, and the burden of tuberculosis, HIV/AIDS,
and malaria. The key functions of a health system are to ensure the availability of
health services that meet a minimum quality standard and secure access to them. To
monitor the progress in strengthening health systems, there are eight key
characteristics of good service delivery including comprehensiveness, accessibility,
coverage, continuity, quality, person-centeredness, coordination, accountability, and
efficiency (World Health Organization, 2010).

In Myanmar, the Ministry of Health takes the role of main responsibility for health
which is comprised of six departments. Among these six departments, the Department
of Public Health and the Department of Medical Services are key players to deliver
health services. Public health services are provided to communities by rural health
centers (RHCs) and sub-rural health centers (Sub-RHCs) through the corresponding
township, district, regional, and state health departments. For tuberculosis, malaria,
HIV/AIDS, leprosy, and prevention of blindness, campaigns and implementation of
specific national programs are systematically provided at all levels. Together with
nutrition promotion, health education, and environmental sanitation services, maternal
and child health (MCH) services are provided in the community through the expanded
program on immunization. Primary ambulatory care is usually delivered by all
outpatient departments at the hospitals, urban health centers, MCH centers, school
health teams, RHCs, and Sub-RHCs. Hospitals at all levels handle emergency,
specialized ambulatory, and specialized inpatient care. specialized inpatient care is
provided by both public tertiary hospitals and private specialist clinics and hospitals.
An elderly health care project is implemented by opening a weekly clinic for the care
of the elderly at the RHC level. Dental care is delivered through oral health programs
in schools for schoolchildren (MOH,2014).

The health services provided in Myanmar are public; primary/ambulatory care;

specialized ambulatory care, inpatient and specialized inpatient care; emergency care;
pharmaceutical care; rehabilitation/intermediate care; long-term care, palliative care;
mental health care; dental care, and complementary and alternative medicine. These

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services had been well delivered to people in Myanmar until 2019. Beyond 2019, two
main factors the Covid-19 pandemic and the political crisis severely affect the health
system Of Myanmar. During this period, public health services are not more well
implemented than inpatient care services. Moreover, 70 % of the population lives in
rural areas and thus coverage of health services in rural areas is critical to improving
the health status of Myanmar. Therefore, health inequities in Myanmar remain despite
the presence of policy regarding health-sector decentralization.

Also, in the Philippines, health services delivery has challenges, and fragmentation of
the delivery system severely hampers consisting of an under-resourced public
component serving the poor majority and an over-resourced public component for the
rich minority. Further fragments of government service delivery are caused by
dividing responsibilities between the national, provincial, and municipal government
units. There is practically non-existent a formal referral system to move clients
between each of the different levels of service. To encourage referral mechanisms,
and strengthens delivery mechanisms, the universal health care program of the
government includes provisions to facilitate the achievement of the Millennium
Development Goals. Moreover, the lives of the poorest of the poor are improved by
the conditional cash transfer (CCT) program of the government. Immunization for
children and regular checkups for pregnant women are essential services including the
conditions for the covered families to receive cash subsidies (Alberto Romualdez et
al., 2012).

4.2. Health Workforce

The knowledge, skills, motivation, and deployment of the people responsible for
organizing and delivering health services have a large impact on the ability of a
country to meet its health goals. There is a direct and positive relationship between
the number of health workers and the health outcomes of the population. The
definition of a health workforce is “all people engaged in actions whose primary
intent is to enhance health”. Human resources for health include nine occupational
categories including physicians, nursing and midwifery personnel, dentistry
personnel, pharmaceutical personnel, laboratory health workers, environmental and
public health workers, community and traditional health workers, other health service
providers, and health management and support workers described in the WHO Global

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atlas of the health workforce. A shortage of health workers is an important issue that
faces many countries worldwide. Some factors influencing the shortage of health
workers are the inadequate numbers and skills mix of people being trained or
maldistribution of their deployment and losses due to death, retirement, career change,
or out-migration. If the country has fewer than 23 physicians, nurses, and midwives
per 10000 population, it has been estimated that it generally fails to achieve adequate
coverage rates for selected primary healthcare interventions (World Health
Organization, 2010).

Myanmar had about 13 health workers (doctors, nurses and midwives) per 10000
population in 2016. This data represents inadequate human resources in health care
system. the Department of Human Resources for Health is the key player in the health
workforce. Under the Department of Human Resources for Health, 16 universities and
53 nursing and midwifery training schools produce health professionals. In 2019, the
numbers of healthcare professionals are approximately 12.4 thousand doctors and
22.3 thousand nurses a significant decrease compared with the number of 32.6
thousand nurses in 2015. Then, the number of midwives in 2019 was approximately
14.31 thousand with marked a slight decrease from the previous year. The highest
number of healthcare professionals is in the Yangon region which is one of the major
urban areas. On the opposite side, the lowest number of healthcare professionals
occupies Kayah State, a predominantly rural state. In this fact, urban areas have more
opportunities for access to health services than rural areas. Therefore, the equity of
health services in both urban and rural areas is essential to achieve universal health
coverage (Statista, 2023).

In nursing, the annual number of nurses produced by two nursing universities,

Yangon and Mandalay is nearly 400 graduate nurses. Nursing training schools
produce annually about 2200 nurses and midwives. However, the number of nurses
produced by universities and training schools markedly decreases due to the Covid-19
pandemic and political crisis. Therefore, the total number of registered nurses reduces
from 30000 to 8000. The nursing shortage is an issue in the health system not only in
Myanmar but also in other countries. Therefore, the Department of Human Resources
for Health introduced nurse-aid training to cover the nursing shortage in hospitals as a
function of task shifting. Moreover, a key challenge in human resource management
is the gap between production and deployment of health workers. Finally, human

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resource challenges outlined by The Health Workforce Strategic Plan (2012-2017)
included shortages of human resources, inappropriate balance and mix of skills,
inequitable distribution, and difficulties in rural retention.
In the Philippines, one issue for human resources is an irrational deployment
demonstrated by the oversupply of nurses in the country following the increased
demand in the united states and other countries. There are thousands of unemployed
nurses in the Philippines and thus many hospitals have accepted them as volunteers
and they have an opportunity to undergo ‘on-the-job training’ that they had to pay for.
In 2011, the government presented ‘RN Heals’ to deploy nurses to underserved
communities as part of community health teams. To fill the needs of a future universal
healthcare system, it needs to update the Health Human Resource Master Plan.
Moreover, it needs to compensate healthcare professionals well to prevent its
experienced and skilled people from being pirated by other countries. Finally, it
should review all policies related to health workforce production, deployment, and
management and revise existing legislation (Alberto Romualdez et al., 2012).

4.3. Health Information Systems

The foundation of decision-making is sound and reliable information across all health
system building blocks. It plays an essential role in health system policy development
and implementation, governance and regulation, health research, human resources
development, health education and training, service delivery, and financing. The
health information system includes four main functions; data generation, compilation,
analysis and synthesis, and communication and use. It aims to provide an alert and
early warning capability, supporting patient and health facility management, enabling
planning, underpinning and stimulating research, permitting health situation and
trends analyses, orienting global reporting, and reinforcing communication of health
challenges to diverse users. Core indicators of health information systems are health
surveys, civil registration, census, facility reporting, and health system resource
tracking (World Health Organization, 2010).

In Myanmar, the health information system started with Medical Record System
including morbidity and mortality situations in public hospitals. In 1978, a system
using a standard format was introduced to record, register and report service activities
along with formulating and implementing PHPs. For public health information, Basic

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Health Staff (BHS) collect data manually using standardized forms on monthly,
quarterly, and annual bases. For hospital information, data is collected monthly from
all public hospitals and disseminated through annual hospital statistics reports. In
1995, Health Management Information System (HMIS) was introduced and reviewed,
and revised in 2005, 2012, and 2019. In 2014, hard copy was updated to soft copy
based on District Health Information Software (DHIS). HMIS includes public health
information and hospital information. Public health information consists of data
including twenty-one projects. In 2019, data quality assessment was added to HMIS.
According to data resulting from HMIS, public health services cover only 10-20 % of
primary health but projects such as antenatal care, immunization, and nutrition are
more covered in public health. And there is weak data on school health because of
one-time data collection per year per school. Now fieldwork about health information
is not continued according to the situation. Therefore, the health information system
needs to be strengthened in Myanmar (MOH, 2014).

In the Philippines, the health information system was the system of paper and pencil
data collection at the periphery. Thus, data were highly susceptible to human error
and manipulation and the system was the uncoordinated and non-standardized use of
modern information and communication technology. Therefore, the government
recognized the importance of a sufficient and accurate information system and
introduced the universal health care program including modern data collection and the
adoption of common technology to improve coordination among the various parts of
the health system (Alberto Romualdez et al., 2012).

4.4. Access to Essential Medicines

The health system needs to be well-function to ensure equitable access to essential

medical products, vaccine, and technologies of assured quality, safety, efficacy, and
cost-effectiveness, and their scientifically sound and cost-effective use. Two building
blocks such as service delivery and governance closely relate to monitoring access to
essential medicines. For the functioning of the health system at all times, essential
medicines should be available in adequate amounts, in the appropriate dosage, with
assured quality, and at a price that individuals and the community can afford. The
Global core list of medicines in WHO surveys include 14 medicines. Core indicators
for access to essential medicines are average availability and median consumer price

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ratio of 14 selected essential medicines in public and private health facilities.
Regarding treatment access in low- and middle-income countries, key impediments
are low availability, high prices, and poor affordability (World Health Organization,
2010).

In Myanmar, the national list of essential medicines has been developed and revised
by the Myanmar essential drugs program since 1979. The Essential Medicines List
can be used as the basis for the procurement and distribution of medicines and for
developing National and Hospital Formularies. It can also be applied to identify
product areas for selective support to the National Pharmaceutical Industry for
targeted quality assurance. CMSD is located in Yangon with two sub-depots, one in
Mandalay and the other in Taunggyi. It has the responsibility for procurement of all
medical supplies and medical equipment for all health care facilities with the
government budget; supplies of the various projects with WHO, UNICEF, United
Nations Population Fund (UNPF) and Japan International Cooperation Agency
(JICA), and supplies received from national and international donors; and installation
and maintenance of hospital equipment. A subset of 92 medicines from the essential
medicine list in 2010 was procured by the Central Medical Store Depot (CMSD) 2010
but enough funds were not provided by the Ministry of Finance to procure all the
needed essential medicine MOH, 2014).

In the Philippines, the regulatory infrastructure for health is viewed as supply-side

dominated with conditions mainly dictated by the regulated groups (pharmaceutical
companies, doctors and other professionals, and other suppliers of goods and
services). As a result, the market force that jeopardizes the health of the poor and the
weak is imbalanced. Therefore, new laws are designed to improve the technical
competence of regulatory agencies. To implement these laws, needs political will to
defend these technical units against the strong lobby groups that benefit from a weak
regulatory environment health (Alberto Romualdez et al., 2012).

4.5. Health Systems Financing

Health financing is defined as the function of a health system concerned with the
mobilization, accumulation, and allocation of money to cover the health needs of the
people, individually and collectively in the health system. It aims at raising sufficient
funds, providing financial risk protection, and ensuring efficiency in resource use.

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Health financing is essential for the health system to maintain and improve human
welfare. Health workers would not be employed, medicines would not be available
and health promotion and prevention would not take place without the necessary
funds. Three interrelated functions of health system financing are revenue collection,
fund pooling, and purchasing/provision of services. The best source of information
about health expenditure is from NHA. The core indicators for the availability of
funds and the extent of financial risk protection include total expenditure on health;
general government expenditure on health as a proportion of general government
expenditure (GGE); the ratio of household out-of-pocket payments for health to total
expenditure on health (World Health Organization, 2010).

In Myanmar, total health expenditure is 2.0-2.4% of its GDP between 2001 and 2011.
General government health expenditure increased significantly to 0.76% of GDP and
3.14% of GGE respectively. However, this level of health investment remains in low
compared to the demand for health care. High out-of-pocket payments by households
resulted from inadequate government expenditure on health care over the past decade
and became the dominant source for financing for health care accounting for 79 % of
total health expenditure. In the late 1990s, aid flows increased and peaked in 2009 and
2010 in response to Cyclone Nargis. A health system review in Myanmar stated that
interventions about OOP and financial protection for the poor were not successful due
to many reasons (MOH, 2014). In 2019, the health expenditure increased to 4.68% of
its GDP but it is still low under 5% compared with the global average. In Myanmar,
the government spends most of GGE on defense but is still low in spending on health.
Therefore, strengthening financial protection needs a significant increase in
government spending on health.

In the Philippines, the country’s health care financing relied on out-of-pocket

payments with an estimated 57% of total health expenditure in 2007. This condition is
unsuitable for the country because the majority of the population is too poor to afford
to pay even partially for the costs of effective care. the major determinants of access
to life-saving interventions are economic barriers. Therefore, a new National Health
Insurance Program is introduced for coverage among the country’s poorest groups.
Preventive outpatient procedures are included in broadening the benefit packages of
the program. Moreover, the government has plans to address the pressing issues of

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poor utilization of benefits and public facilities by poor income groups (Alberto
Romualdez et al., 2012).

4.6. Leadership and Governance

In building a health system, leadership, and governance involve to ensure that
strategic policy frameworks exist and are combined with effective oversight,
coalition-building, regulation, attention to system design, and accountability. There
are two types of indicators for measuring health system governance: rule-based and
outcome-based. The rules-based indicator includes 10 rules-based indicators and
measures whether countries have appropriate policies, strategies, and codified
approaches for health system governance. Outcome-based indicators provide
information on whether rules and procedures are being effectively implemented or
enforced, based on the experience of relevant stakeholders. Leadership and
governance remain inadequately monitored and evaluated despite the importance of
improving health outcomes (World Health Organization, 2010).

In Myanmar, the National Health Policy formed the direction of the National Health
Plans, which were formulated every five years. The current National Health Policy
was introduced in 1993 and includes 15 items. Now, NHP 2021-2026 is
implementing. National Health Plans are developed to achieve Universal Health
Coverage (UHC). UHC refers to receiving the health services all people need without
suffering financial hardship. All UN Member States have agreed to strive to achieve
UHC by 2030 under the Sustainable development goals (SDGs). UHC’s goals
integrated Myanmar’s road to sustainable growth and poverty reduction. NHP
includes 11 programs: communicable disease control program; non-communicable
disease control program; RMCH+ program; improving hospital care; traditional
medicine; human resource for health; promoting health research; addressing
determinants of health; nutrition promotion; strengthening health system; and rural,
peri-urban and border health (MOHS, 2016).

According to the NHP’s programs, Myanmar’s health system has up-to-date health
policies and strategies including programs for tuberculosis, HIV/AIDS, malaria, and
maternal and child health as rules-based indicators. However, Myanmar’s health
status is still low among countries in South-East Regions because it may assume that
it is weak in the implementation of developed health policies and strategies timely.

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Therefore, leaders in health need to emphasize whether health services are well
provided in both urban and rural areas regarding health policies and strategies.

Moreover, Health sector decentralization has been introduced with the formation of
the Regional Health Department in 1965. However, centralization in health services
remains a health issue that influences the health status of Myanmar. The process of
decentralization is not always smooth and so patience, among other requirements, is
needed. Challenges to be overcome are inadequate managerial capacity and the more
reactive mindset to be smooth and effective in the process of decentralization.

Also, in the Philippines, there was a lack of consensus among stakeholders about a
common definition of equity in health and the parameters that will determine whether
universal health care is achieved. In addition, there was mainly top-down in the
processes for policy and decision-making. This kind of policy refers to the health
governance dependent on the political landscape and the six-year cycle of each
presidency. Thus, it needed to develop new mechanisms of stakeholder consultations
at different levels. Such mechanisms might be evolved from market-research
techniques that are employed by private enterprises to promote their products. To
develop these capabilities, the country began some health agencies such as PhilHealth
and the Department of Health (Alberto Romualdez et al., 2012).

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5. CONCLUSION
The healthcare delivery system is complex in nature and multisectoral approach in an
organization. To strengthen the healthcare system, it needs to well-functioning in
every sector in the healthcare system. As a result, it is difficult to effectively cover
multisector even in developed countries. However, every country in the world
develops and implements various health policies and strategies to strengthen the
healthcare system. In 2013, it stated eleven global health issues such as long Covid,
mental health, diabetes, and so on.

Myanmar is also one country that faces these global issues. It includes developing and
low-income countries. Moreover, the health status of Myanmar is low among South-
East Asia countries. Thus, Myanmar is one country that needs to develop a
multisectoral approach to strengthening the health care system. Health inequities are
one of the major issues in Myanmar’s healthcare system. Policymakers in health care
therefore should emphasize the process of decentralization to achieve health equity
for all the people in the country. Besides, healthcare providers at all levels need to be
a reactive and proactive mindset. Finally, Myanmar’s health care system may improve
if it effectively overcomes health issues in the future.

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