From Fragmentation to Collaboration: Fighting COVID-19 in Myanmar

In the initial months of the pandemic, Myanmar reported few COVID-19 cases, likely as a result of comparatively low numbers of international travelers and very limited testing capacity. In recent weeks, however, the virus has spread primarily in the commercial capital of Yangon, and the country now faces challenges in disease containment unique to lower-middle-income countries.  While moderate isolation and movement restrictions have been implemented, socioeconomic realities make social distancing nearly impossible for much of the population.  The government has responded with an assertive case-contact and quarantine policy, meaning on a nightly basis apartment buildings, hotels, hospitals, and neighborhoods are placed under government-enforced total movement restrictions. 

FRAGMENTED HEALTH SYSTEM
The COVID-19 response in Myanmar is further complicated by the lack of primary health care integration between the public and private sectors.  The country has a fairly traditional hospital-based public health system augmented with limited primary health care facilities, largely focused on RMNCH and maternity care.  To provide the majority of other routine primary health care services in Myanmar, the population relies on approximately 15,000 general practitioners (GPs) in the private sector.  Due to this reality, the delivery of primary care in Myanmar is starkly fractured along a public/private divide. 

Though private sector GPs provide 60% of primary care service delivery in Myanmar, they have historically received minimal technical support or clinical capacity building from the governmental Ministry of Health and Sports (MOHS).  While infectious disease hospitals for treating COVID-19 patients have been established by the government, there has been minimal effort to integrate private sector GPs into COVID-19 prevention, testing, or treatment.  Protocols and guidelines for pandemic operation of private GP clinics and management of symptomatic and asymptomatic patients remain largely absent.  Furthermore, private GPs risk having their clinics forcibly shut down should they see a COVID-positive patient- intentionally or not.

INNOVATIVE COVID-19 RESPONSE SOLUTIONS 
Private sector GPs have shown resiliency in finding innovative ways to participate in community health care even when government support is lacking.  The Myanmar Academy of Family Physicians, together with the General Practitioners’ Society have launched a virtual Continuing Medical Education program designed to allow primary care doctors to contribute to the nation’s health system.  Educational and strategic health care delivery modules reviewing COVID-19 symptoms and transmission, personal protective equipment usage, psychological impact, and the practical implementation of telemedicine in the local context are being delivered to hundreds of GPs.  Additional education materials are being distributed to promote safe health behaviors and support the role of doctors in the community. 

Most importantly, GPs are finding ways to make an impact in supporting the government’s efforts in COVID-19.  For instance, a local GP recounts being contacted by one of her longtime patients experiencing new fever and cough, concerned about COVID.  Without making face-to-face contact or engaging in diagnostic evaluation, the GP explained by telephone the COVID-19 illness course, the implications for her patient’s family unit, the options for testing, and the likely duration of hospitalization while waiting for the test result.  Using this patient-centered approach, the GP was able to help the patient optimize decision-making despite the lack of clear public health guidelines, and she provided medical and psychological support despite not being part of the government team making the diagnosis.

COLLABORATING FOR CHANGE

Myanmar’s COVID-19 response suggests future collaboration between private and public medical practitioners can be possible.  The establishment of the ‘Fever Clinics’,  - designated locations for COVID-19 symptomatic patients to be evaluated - are a prime example of the benefits of the private and public sector working together.  Recognizing that many primary care clinics will be closed and that people often hesitate to visit government hospitals in Myanmar, private sector GPs lobbied the government to transform public health department buildings into COVID-19 evaluation centers with proper safety mechanisms.  The Ministry of Health has worked with the private sector to approve the opening of these clinics, and they are now largely staffed by volunteer local primary care doctors.  Hospitals and the public are thus spared unnecessary medical evaluation burden, and community doctors are able to contribute to the country’s response to COVID-19.

As the global community continues to struggle with the pandemic, we hope the Ministry of Health and Sports in Myanmar – and all other countries - will provide access for private GPs to the same guidance and resources given to national health service public employees.  In addition, the private sector and affiliated civil society organizations should be empowered to innovate in providing essential health services during a pandemic, while simultaneously supporting COVID-specific efforts.  Most importantly, as countries like Myanmar eventually shift to a recovery phase, it will be essential that government hospitals and universities strengthen their alliances with health workforce civil society organizations to ensure formal curricula on comprehensive primary health care service delivery are in place to ensure all frontline providers have the competencies necessary to both identify and fight the next pandemic and continue to offer the routine health services necessary to minimize deaths from non-COVID causes.

By Dr. Kyaw Thu, Program Director, Myanmar Academy of Family Physicians and Dr. Christoph Gelsdorf, Regional Director, Global Health Collaborative at Boston University Dept of Family Medicine

The views expressed in this blog are those of the author and do not necessarily reflect the views of PHCPI , WONCA, AfroPHC, or their members and partners.