Progress towards universal health coverage in Myanmar

The Article by Su Myat Han and colleagues in The Lancet Global Health is, perhaps, the first public, quantitative analysis of national health care and health financing indicators in Myanmar and provides a valuable starting point for further analysis of the country's health system and health policies. This cross-sectional study was based on data from surveys done in 2010 and 2016, provides a potential baseline for further monitoring and measurement of progress, and identifies priority areas that need to be addressed. To provide context for the analysis and interpretation of these data, the authors have included a brief update on country-level health financing and health service capacity indicators. However, further descriptive information about the policy and institutional framework for universal health coverage (UHC) in Myanmar would strengthen the analysis.

The authors used the broad framework for monitoring of UHC proposed by WHO, and addressed the three key areas of service coverage, financial protection, and equity. They developed their own set of indicators to measure these areas and thus did not use the effective service coverage indicator developed by WHO and the World Bank,, although that indicator was possibly released after completion of their study. Han and colleagues used a broader set of indicators for service coverage, which covered the same areas of prevention and treatment services used in the global indicator. However, the two measures cannot be directly compared. Furthermore, the calculations for the financial protection indicators were based on the measures proposed in the latest global UHC indicators, but the authors used the national poverty line rather than an international line for calculation of impoverishment.

Nonetheless, the estimates for Myanmar country-level indicators in the Global Monitoring Report for 2017 provide data for comparison with Han and colleagues' study. In terms of overall service coverage, the composite index was 60 (out of 100) in the Global Monitoring Report, whereas the composite coverage index in Han and colleagues' study was 71·2%. The use of different indicators to derive the composite index makes comparison difficult, but notably the Global Monitoring Report includes data for HIV and tuberculosis treatment, blood pressure, and blood glucose. Those data were not available to Han and colleagues. Conversely, Han and colleagues calculated indicators for financial protection, albeit on the basis of data from 2009–10, whereas data for financial protection were unavailable for Myanmar in the Global Monitoring Report.

The main strength of Han and colleagues' work is the equity analyses, which address both service coverage and financial protection and include logistic regression models exploring the factors contributing to inequalities. In particular, the authors identified substantial subnational inequities, with regions of conflict being the most disadvantaged. Equity analyses in the Global Monitoring Report were limited by data availability to indicators of maternal and child health only, and were based on socioeconomic data for the whole population. Equity analysis at a subnational level is a key area in which country-level studies will be of most use, and most relevance to policy makers, noting the high level of political attention often given to subnational differences.

These comparisons between country-level and global-level assessments of progress towards UHC in Myanmar suggest that both levels are needed and offer different—although complementary—perspectives. At the global level, the focus is on comparability and use of standardised measures, whereas at a country level, the focus is on specificity and in-depth assessment with a variety of measures—to explore equity particularly. These differences in perspective are shown by comments on Myanmar's progress. Hogan and colleagues note that Myanmar is one of the countries achieving a health service coverage index 10 points higher than would be predicted on the basis of gross national income per person. By contrast, Han and colleagues conclude that achievement of UHC will be challenging because of low levels of service coverage and government investment in health. Furthermore, they identified priority areas requiring policy attention, particularly in relation to subnational inequities and financial protection, which will be of value to government policy makers.

Both Han's and Hogan's papers also showed the need for greater investment in data collection and analysis to monitor progress towards UHC, and especially the need for contemporaneous collection of data for household expenditure and health service usage (as recommended by Hogan and investigators).

I declare no competing interests.


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