Myanmar has one of the most serious HIV epidemics in Asia. Contrary to many perceptions, the response to the epidemic is expanding. Funding for the response has gradually increased over recent years. However, coverage remains unacceptably low, donors seem largely unwilling to inject the resources needed to meet health needs and the government itself significantly under-invests in health.
The National Strategic Plan on AIDS 20062010 issued by the Ministry of Health provides the reference framework for the response. Despite what might be expected given the environment, the Plan was developed in a participatory fashion, is multi-sectoral and up to date and prioritises service provision for the most at-risk populations. It is supported by a government-led, inclusive technical coordination group. However, significant barriers to service provision exist. These include constraining administrative procedures, controlled access, limited research and a highly politicised context. Nevertheless, the results demonstrate that persistent negotiation can yield agreements resulting in increased services for those in need. Nearly 40 international and national NGOs are implementing successful activities in Myanmar, alongside government efforts and with UN support.
Present estimates of people needing services
In August 2007, government staff, the UN and NGO stakeholders held a workshop to apply international tools to estimate the extent of the HIV epidemic in Myanmar. The results were that 242,000 adults and children would be living with HIV at the end of 2007 (or 0.67% of the population, within a range of 0.5% to 0.9%), and that the epidemic peaked in 2000. Some NGO providers of anti-retroviral treatment (ART), calculating backwards using estimated population numbers, have raised concerns that prevalence might be higher, and this question requires more research. Prevalence remains high amongst sex workers and injecting drug users, and is believed to be high among men who have sex with men. As elsewhere in Asia, a significant number of married women are thought to be infected from their husbands, amounting to approximately one-third of those living with HIV in Myanmar.
Expanding service delivery
The number of people in Myanmar accessing HIV services has increased significantly since the beginning of the decade. The number of patients receiving ART quadrupled, from roughly 2,500 in 2005 to 10,500 in 2007; the number of sex workers, drug users and men who have sex with men reached by outreach or peer education services has increased, to the levels presented in Table 1. In many areas of HIV work, the number of townships where programmes have been initiated is growing: 132 townships with prevention of mother-to-child transmission services (2008), 273 townships with sex worker outreach or peer education programmes (2005), 24 townships with HIV programmes for drug users (2006) and 170 townships with government-promoted 100% Targeted Condom Programmes (2006). A growing number of self-help groups of people living with HIV are emerging across the country, and they are beginning to organise themselves into State/Division-level networks. Most partners are able to undertake service provision using participatory approaches at community level, through techniques emphasising peer education and support for community-based organisations.
Most of this service expansion has been delivered by NGOs, especially for peer education work for vulnerable groups, community-oriented prevention, care and support activities and anti-retroviral treatment. The government, with international assistance, is also providing services, including anti-retroviral treatment (roughly 1,800 patients), treatment of sexually transmitted infections, targeted condom promotion, prevention of mother-to-child transmission, some support for harm reduction activities and life-skills education in schools.
However, even for those services where expansion has been possible, the reach is still alarmingly low. Currently roughly only 15% of people living with HIV (PLHIV) who need ART receive it. On the paediatric side, in 2006 only 317 HIV-positive children received ART out of 1,495 estimated to be in need. An estimated 20,000 people die of AIDS-related causes each year. These deaths are preventable, but doing so requires significantly expanded support from the international community, and increased capacity among NGOs and within the public health sector to deliver services. The low coverage in other priority, active areas is presented in Table 1.
Gaps and constraints
In addition to insufficient coverage of those services which are at least being delivered to some extent, there are other major gaps in the HIV response. For example, programmes in closed settings such as prisons are nearly non-existent. The authorities seem unwilling to have the police engaged in HIV programmes in a large-scale manner; programmes for uniformed services are minimal and, if they occur at all, are undertaken in isolation. The situation of orphans and vulnerable children is precarious and insufficiently addressed. There is ineffective use of mass media for advocacy. While many globally promoted strategies for these and other areas are accepted in the National Strategic Plan, and have been helpfully highlighted in reviews such as the external review of the National AIDS Programme of 2006, the review of the 100% Targeted Condom Promotion programme (2005) or the review of the prevention of mother to child transmission programme in 2007, gaps remain. It is negligent and contrary to the interests of those who might benefit from services not to advocate and negotiate with the authorities to expand services, delivered both by NGOs and by the public health sector so that these gaps are filled.
Programmes must operate in a highly constrained environment, characterised by high transaction costs and long delays. International NGOs must negotiate their memorandums of understanding (MOU) every year and in considerable detail, down to specific activities in individual townships. International staff visiting project sites must obtain prior approval and be accompanied by a government official. Obtaining approval for importing commodities is a slow process. Procurement delays, compounded by a lack of predictable funding, at times seriously curtail programme implementation. International organisations face limitations in geographical access, particularly to sensitive areas, which include border areas and some critical mining sites. More importantly in the long run, Myanmar organisations themselves face constraints in establishing the legal footing necessary to operate, facing a protracted and unclear process to obtain approvals at multiple administrative levels. And there is a high level of unpredictability. Formal guidelines, written letters and informal oral instructions are uncertain, irregular and variable in practice. The requirement for case by case negotiation, often township by township, is the only constant.
Although improving, both national and international organisations lack sufficient opportunities for dialogue with the government about programmes, and in an environment where mistrust and miscommunication are already significant obstacles the governments physical move from Yangon to Nay Pyi Taw has only increased these barriers. Research is tightly controlled (in principle any research to be disseminated in-country should have prior governmental approval), inhibiting advocacy and discussion about social issues and programme strategies. The public health infrastructure, upon which all partners depend to varying degrees, is weak due to chronic under-funding both by the government itself and by donors unwilling to invest in health systems in Myanmar.
The highly politicised context raises the political risks for potential donors, and thus discourages investment. Grants are closely scrutinised by political actors inside and outside the country, who in other circumstances might not pay attention to details of HIV funding. The Global Fund Round 3 AIDS grant, terminated in 2005, provides an example of such a failed large-scale effort. The newer Three Diseases Fund, which was carefully negotiated with partners inside and outside of the country during its design and is now entering its second year, has so far proved more stable. Partners in-country are cautiously optimistic that, learning from these experiences, a new effort to access the Global Fund will be successful.
The operating environment is on the whole highly constraining, yet far from being entirely prohibitive. While negotiations are often protracted, once organisations have an agreement they are generally able to implement projects and permission to implement programmes is rarely permanently withdrawn.
Coordination and planning
Accompanying the expansion in service delivery, structures for coordination, participative planning and monitoring have likewise moved forward. Early efforts provided opportunities for partners to experiment with ways to engage despite the politicised environment. Such efforts included the early entry into the country of a few NGOs, the first Global Fund proposal process and the initial experience of organising a Country Coordinating Mechanism, and the UNs Joint Programme on AIDS 20032005, with the accompanying multi-donor Fund for HIV/AIDS in Myanmar.
In 2006, the Ministry of Health developed a multi-sectoral strategy using a more participatory process than previously. The Myanmar National Strategic Plan on AIDS 20062010 is a targeted and prioritised plan for the totality of HIV work by actors in the response, supported by a budgeted Operational Plan. Its development involved the government, the UN, NGOs and representatives of affected communities. Advances include a basis for greater multi-sectoral involvement (for example prisons, the police, the uniformed services, the transport sector and the judicial sector); a focus on the most at-risk populations, including sex workers and clients, drug users and men who have sex with men; a participatory coordination structure; and explicit references to human rights. In addition to the exclusively governmental National AIDS Committee (which has not met in several years), the Minister of Health now also chairs a more inclusive Coordinating Body for AIDS, Tuberculosis and Malaria, and the Department of Health chairs Technical and Strategy Groups (TSGs) for AIDS, tuberculosis and malaria, for which UN agencies serve as the secretariats. The TSG for AIDS has 25 members including representatives from the government, the UN, national and international NGOs and people living with HIV.
These structures have already led to some improvements. A forum at least now exists for international and national partners, including nascent networks of people living with HIV, to raise issues, even if the meetings are not as frequent or as efficient as might be hoped. Planning and reporting documents are now prepared in a more participatory way, such as national Progress Reports for 2005 and 2006 (issued by the National AIDS Programme but reflective of inputs and outputs from all partners). In 2007, the TSG produced the first agreed set of priority townships (forthcoming) for sex work, drug use, mobility and burden of care. The Operational Plan 20062008 is being updated using the TSG and inclusive working group structure, and is trying to establish credible but ambitious targets to raise funds to increase service delivery. These structures and activities represent an important rehearsal of participatory practice which could serve as a basis for a revitalised Country Coordinating Mechanism providing harmonised coordination efforts for the whole national response in the fight against AIDS, TB and malaria.
Sufficient and predictable resource flows are critical for planning and service delivery. In 2006, $27.2 million were spent on the national response to AIDS. For 2008, the expected available funds have risen to $35m (Figure 1). For 2008, while there are gaps for both prevention and care and treatment components, expected resources fall seriously short of what is needed to provide life-saving treatment.
Myanmar does not currently access resources from the Global Fund, the World Bank or the Asian Development Bank. The contribution of the government of Myanmar to the national response to AIDS is estimated at approximately $0.2m per year. Government health expenditures in 2005 were reported to be $0.37 per person, which is grossly insufficient and disproportionate to the wealth of the country. The Three Diseases Fund (3DF) provides roughly 40% of the available funding, and while this finances critical services, the 3DF has insufficient funds currently to fuel the needed scaling-up.
Considering its development profile, Myanmar receives a very low level of financial support from the international community. With roughly comparable epidemics, the people of Cambodia receive nearly eight times more funding per capita for AIDS than the people of Myanmar (Figure 2). Cambodia receives more assistance per capita for AIDS than the people of Myanmar receive for all development assistance combined (Figure 3).
Despite the politicised atmosphere, actors both inside and outside the country have demonstrated that negotiated agreements on HIV programming and corresponding delivery of services are possible. HIV services have expanded as a result of advocacy by internal and external actors, increased recognition of HIV by the Ministry of Health, incremental increases in international funding and the establishment and expansion of services by NGOs, the UN and the government. The National Strategic Plan reflects international best practice, highlights the most at-risk populations and was developed in a more participatory manner than any preceding plan. Funding and expenditures have slowly increased each year. Programme output data demonstrates that increased resources and policy engagement can result in increased services for people in need and facilitate the evolution of HIV policies. International donors should recognise the evidence of increased coverage possibilities by increasing commitments. Without more investment from the Myanmar government and international sources, the road to universal access to HIV prevention and care will be long, preventable deaths will occur and individuals rights to health care will remain unmet.
* The UN Joint Team on AIDS in Myanmar comprises UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, ILO, WHO, IOM, FAO, UNIC, UNOPS and UNAIDS.