Conflict affected, parallel health systems: challenges to collaboration between ethnic and government health systems in Kayin State, Myanmar

Colette Pang Biesty,Barry Munslow,Aung Ja Brang

doi:10.1186/s13031-021-00396-z

Abstract

BackgroundMyanmar has had a long history of civil wars with its minority ethnic groups and is yet to see a sustainable peace accord. The conflicts have had a significant impact on health in Myanmar, with ethnic populations experiencing inequitable health outcomes. Consequently, to meet the health needs of ethnic people, Ethnic Health Organisations and Community-Based Health Organisations (EHO/CBHOs) created their own health system. The EHO/CBHO and Government health systems, provided by the Myanmar Ministry of Health and Sports (MoHS), remain parallel, despite both stakeholders discussing unification of the health systems within the context of ongoing but unresolved peace processes. EHO/CBHOs discuss the ‘convergence’ of health systems, whilst the MoHS discuss the integration of health providers under their National Health Plan.MethodsA qualitative study design was used to explore the challenges to collaboration between EHO/CBHOs and the MoHS in Kayin state, Myanmar. Twelve health workers from different levels of the Karen EHO/CBHO health system were interviewed. Semi-structured, in-depth interviews were digitally recorded, transcribed, and coded. Data was analysed thematically using the Framework method. Topic guides evolved in an iterative process, as themes emerged inductively from the transcripts. A literature review and observation methods were also utilised to increase validity of the data.ResultsThe challenges to collaboration were identified in the following five themes: (1) the current situation is not ‘post conflict’ (2) a lack of trust (3) centralised nature of the MoHS (4) lack of EHO/CBHO health worker accreditation (5) the NHP is not implemented in some ethnic areas.ConclusionsUltimately, all five challenges to collaboration stem from the lack of peace in Myanmar. The health systems cannot be ‘converged or ‘integrated’ until there is a peace accord which is acceptable to all actors. EHO/CBHOs want a federal political system, where the health system is devolved, equitable and accessible to all ethnic people. External donors should understand this context and remain neutral by supporting all health actors in a conflict sensitive manner.

Highlights

Myanmar has had a long history of civil wars with its minority ethnic groups and is yet to see a sustainable peace accord
Political background Myanmar has a long history of civil war between ethnic armed organisations (EAOs) and the Tatmadaw, the armed forces of Myanmar
There have been improvements in the relationship between health workers in the Ethnic and Government health system, challenges expressed in the interviews evidence deeper roots, all of which are related to the lack of peace in Myanmar

Summary

Introduction

Myanmar has had a long history of civil wars with its minority ethnic groups and is yet to see a sustainable peace accord. Civil war with the Karen National Union (KNU) non-state armed group in Kayin state is one of the oldest insurgencies in Myanmar [1]. This has had a severe impact on the provision of healthcare and other services in these politically contested territories [2] as 50 years of military dictatorship has left the provision of health services a low priority [3]. Continued conflict between EAO NCA signatories (EAONCA) and the Tatmadaw has led to absent or inaccessible Government health-services for some ethnicities, severely setting these regions back in reaching World Health Organisation’s (WHO) health outcome goals [5]

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