This is by no means an official or comprehensive guide to the healthcare system here, but just some of the information I’ve gathered in my time here.
My main exposure has obviously been in the setting I am in day to day. I’ve been with a NGO with many healthcare programs across Myanmar. I have been involved in their 3 clinics around Yangon, which have HIV and primary healthcare services. Everything is free for the patients, including most of the drugs (relatively small formulary). For primary healthcare (or ‘general’) patients we can offer some basic bedside tests like blood glucose, haemoglobin %, urinalysis, sputum screening for TB and drugs such as common antibiotics, enalapril, metformin, deworming, paracetamol, ibuprofen, scabies treatment, tb treatment. HIV patients have the same plus they will have some more tests and drugs for tb and other opportunistic infections, plus a wider range of tests as long as HIV related (otherwise they have to pay for the tests, though we can give financial support if needed). Patients come for HIV care from all over the country – travelling for hours on the bus.
There is otherwise no free state provided healthcare. I have observed that very occasionally a poor patient will go to a government hospital, be unable to pay for their care, and the fee gets waived. But there doesn’t seem to be a pattern or specific threshold for this. So, in general, poor people (which is most people) will either just not go to hospital. Or they will go when they’re really very, very sick, when it may be too late. The reason they don’t go is partly financial but also there is general fear of what might happen.
Fees are slightly cheaper in government hospitals than in private hospitals. It costs about $6 for a chest x ray or abdominal ultrasound, for example. An over night stay on a general ward costs around $20, more if you want a private room. Putting this in context, a lot of patients I’ve seen in our clinics earn at most $4 per day, if they have employment, to sustain their whole families.
Doctors consultation (ie consultant) fees vary. Most doctors who work in the government setting will have private practice that begins in the evenings. A lot of elective private surgery happens overnight as a result (in contrast to at home, where surgery overnight is only ever done if it’s an absolute emergency).
In many hospital settings, the junior doctors clerk the patients but will carry out a plan given by their consultant and they won’t construct their own or deviate from the plan they’ve been given. In our clinics, as the junior doctors have more ownership of the patients and more autonomy, they’re more confident in managing patients and thinking up their own plans, which Ned noted when he visited.
We don’t have inpatient facilities, so if a patient is too sick to go home or needs more intensive therapy that we can’t perform, then we have no option but to refer to hospital. We can give some gentle advice as to what we think needs to be done, but generally the hospital doctors will assess and do their own plan. When they are discharged, it can be difficult to ascertain what has happened from the patients’ file; they write in English but often the details are scanty. If the patient dies in hospital, so far, I’ve never been able to figure out what has happened, which is a shame, as you can’t then try to learn from it and you wonder if there’s something you missed or should have done differently.
Those that are not so sick, but need a specialist opinion and tests, we can refer on. For example, a HIV patient who happens to have unrelated cardiac problems. The patient will have to fund this, however, as we can only cover the costs of HIV related treatment. So, even if we can treat their HIV and optimise them from that point of view, without the support of other health services, sometimes it can be very difficult.
The other difficulty I’ve encountered, is the treatment of HIV patients by other doctors. For example, a patient we had with well controlled HIV on treatment, CD4 850, with nearly two years history of diarrhoea. Many courses of antibiotics tried, stool tests done, trial of loperamide etc. What this patient needs is a colonoscopy and given that he now weighs 29kg, we might even be able to justify helping to pay for a colonoscopy for this patient. However the problem is, clinicians are reluctant to do it as the patient is known to be HIV positive.
Traditional medicine is pretty common in Myanmar. We have to inform patients that we don’t know what they contain and they could interact with HIV drugs or cause liver or kidney problems. Often they contain aspirin, so people with fever will have a response (aspirin being antipyretic). Worryingly there have been reports of Reye’s syndrome (potentially fatal) when children have been given traditional medicine containing aspirin. My other big issue with traditional medicine is that patients are spending money on this, money that could be spend on their food and decent housing, and it might not be doing anything. We had a patient who had a low CD4 (around 50) and was sent to the traditional medicine practitioner by her parents and was lost to follow up for three months. The treatments cost around $25 per go, quite expensive for them. She then chose to return to our clinic as she was feeling so awful and as a consequence was disowned by her parents. By this point her CD4 was 10 and she weighed 24kg, we did all we could but I know that she has since passed away.
On a positive note, there are people here trying to improve things. Myanmar doctors and foreign doctors. Myanmar junior doctors are so keen and willing to learn and improve their skills. They value every bit of training they can get. I’m hopeful.
Lastly, I love the NHS.