□Develop a community-based essential drug cost recovery scheme that is affordable, replicable and sustainable

□Reduce disparities and inequities in access to primary health care by supporting provision of universally accessible basic preventive and clinical services

□Promote the development of national policies on essential drugs that will ensure the availability and affordability of essential drugs and their continuous replenishment at the community level

□Strengthen and/or revitalize primary health care (PHC) services, thereby increasing their use by communities

□Promote and enhance community participation and empowerment by developing and implementing community cost sharing and co-management schemes for basic health services

□Reduce morbidity and mortality of population, with emphasis on women, mothers and children

□Intensify coverage and quality of care through advocacy, training and provision of essential drugs to basic health staff, local administrative authorities and communities

□Sustain project activities through proper monitoring, supervision and evaluation

□With the support of WHO, the Myanmar Essential Drugs Programme (MEDP) was initiated in Bago Division in 1989. Its first undertaking was the production of training manuals covering the essential drugs concept, rational drug use, estimation of drug requirements and systematic store management.

□Under the guidance of the National Health Committee and UNICEF, the Ministry of Health introduced a pilot community cost sharing project in 1993 in Taikkyi township of the Yangon Division that imposes user fees.

□With assistance from The Nippon Foundation and UNICEF, the Community Health Management and Financing Project was implemented in 1994 in five divisions (BAGO, Yangon, Magway, Mandalay and Ayeyarwaddy), five townships of Mon State and one township of Shan State. Plans are in place to extend the project into 25 more townships in various states and divisions in the current year.

□Health care utilization has increased substantially in rural health sub-centers and rural health centers in Taikkyi.

□(See Table, p.66)

□When bilateral assistance was granted, the government understood its role to be simply to order drugs as needed for the primary health care system. When the drugs arrived in Myanmar, a clause was attached stating that they should be used on a cost recovery basis. After considerable discussion within the Department of Health, the Ministry of Health decided that the public division concerned with PHC activities, called Basic Health Services (BHS), should manage the project.

□The drugs ordered did not fully meet the needs of PHC activities based on estimates of the Myanmar Essential Drugs Programme. A request has been submitted to The Nippon Foundation for a complementary supply for the 41 Phase I project townships. To avoid this problem in the future, the next request for drugs will be based on the method of quantification used by MEDP.

□Since drugs arrived prior to completion of preparatory activities, the training period for township medical officers (TMOs) and basic health staff (BHS) was too short. As a result, cost recovery schemes were not fully understood. An intensive refresher course was conducted for TMOs and BHS. This training was made possible because a medical officer from the MEDP was recruited to assist the project manager.

□Much work has been done on cost recovery in Myanmar. Supervisory Health Committee members in villages have sustained rural health centers by purchasing drugs locally and by fixing prices for treatment despite recent formalization of cost recovery as national policy. However, basic principals of the Bamako Initiative, including the empowerment of communities to manage health care, are still new to the country.

□There is a lack of expertise in health economics within the Ministry of Health, itself. There are only three persons who have backgrounds in health care financing. These persons are assigned to other divisions in the Department of Health. Only recently has a task force been formed to review health care financing strategies to be implemented in Myanmar.

□Since the concept is new to the country, authorities working on the project do not have enough knowledge of the role of economics and its implications. UNICEF has recruited a consultant to assist in these matters.

□Although authorities acknowledge the importance of empowering communities to co-manage health care financing, this approach does not accord with current financial rules for the social sector.

□Lack of expertise in health economics has created difficulties in pricing drugs. The roles of exchange and inflation rates have not been considered in this procedure.

□The recent introduction of market reforms has encouraged the establishment of many new pharmacies in this country. In addition, many drugs enter the country through the border trade. The lack of quality and trade control in the private sector is a critical issue.

□Although a Food and Drug Administration Division has been established in the Department of Health, there is no means of enforcing relevant laws and regulations.

□Because the project attempts to achieve equity in primary health care services, exemption criteria are a major issue. In a recent evaluation, exemption criteria practiced in various townships were summarized and documented. Most exemptions practiced do not have standardized criteria.

□Providing preventive health care to communities is a major role of Rural Health Sub-Centers and Rural Health Centers. However, there is a shortage of such facilities in many areas. Thus, many people seek health care in the private sector. In the long run, this problem may weaken the health care financing system.

□High turnover among township medical officers undermines the momentum of the project. When untrained TMOs are assigned to project areas, retraining must be provided.

□The people of Myanmar have enjoyed free medical services for decades. Although people are willing to pay for services in the private sector, they are unaccustomed to doing so in the public sector. In addition, the acute shortage of drugs in the public sector has undermined confidence in the system. It is therefore critical to inform and mobilize the public to create social acceptance of cost recovery schemes.

□Midwives play a leading role in delivering primary health care services through Rural Health Sub-Centers. Thus, they perform most project activities. Because the project adds tasks to a midwife's heavy workload, it is necessary to provide incentives of some kind, or to redeploy health workers in a way that will reduce their burden.

□The extension of the project to remote areas of the country where transport is difficult can create problems with regard to monitoring and supervision. Moreover, the shortage of human resources at all levels will constrain expansion of the project.

□In the health policy adopted in 1993, the government encouraged implementation of cost sharing activities. However, because the government dose not wish to burden rural communities, implementation of the scheme has been widely endorsed only at the township level. Meanwhile cost sharing happens de facto at all PHC levels.

□Though communities are willing to pay fees, particularly for curative care, they are less inclined to join insurance schemes or purchase health care cards. Myanmar people are known for their generous donations to common services, such as capital costs for health and education. However, they must be educated about the key role they can play in co-managing health care by making donations for current costs.

□At present, communities are not actively involved in the management of health services. Though committees have been established in communities, their role in such management should be established more firmly.

□Extension of the project throughout the country will require close supervision and monitoring. Because travel allowances are not adequate and inflation has elevated prices, relevant officers in the states and sivisions have few incentives to undertake supervisory visits to the field. Budgetary allocations of US$9,000 per year for supervision and monitoring should be considered. One or two national monitoring officers could be hired for the full year to ensure regular monitoring at the field level. This will cost US$12,000 per officer per year.

□Myanmar has a pharmaceutical industry in the public sector. A consultant should be recruited to explore means for enhancing the capacity of the industry to meet the demand for essential drugs. A two-month consultancy will cost approximately US$25,000.

□Project managers and township medical officers should be sent on field visits in other countries to gain more knowledge about cost recovery schemes.

□There is a shortage of relevant technical publications, but such literature (including newsletters) should be widely distributed in Myanmar and in other countries.

□Countries should receive support to conduct operational research on health care financing, and the findings should be published and distributed with the assistance of The Nippon Foundation.

□Outside assistance should be phase out gradually to allow adequate time for scaling up the project and for the ensurance of sustainability.

□The Nippon Foundation, in consultation with UNICEF, should establish priorities and guidelines for the use of additional funds for complementary activities supporting essential drug provision.