Section A: Governance
What are the main national sources of health financing?
The main health financing sources in Myanmar are the government, out-of-pocket payment, non-profit institutions and pre-payments including mandatory social security or voluntary health insurance contributions. Out-of-pocket payments account for the greatest share of Current Health Expenditure (CHE), at 76.48%, followed by the government at 17% and non-profits and pre-payments.
The government-funded Ministry of Health and Sports (MOHS) is the largest provider of health services and is responsible for preventive, curative and rehabilitative services.
Myanmar’s Social Health Insurance covers only 3% of the population as of 2021 (1.6 million beneficiaries).
What is the main national Strategic Purchasing unit for healthcare?
There is no main strategic purchasing unit for health.
As part of the National Health Plan (NHP) 2017-2021, “the groundwork for implementation of greater risk pooling and strategic purchasing will already be laid.” This is to include the accreditation of providers, the contracting of providers and the definition of provider payment mechanisms. However, there are no reports on whether and how this has been achieved.
A pilot strategic purchasing project was launched by Population Services International, a non-profit that runs a franchise of General Practitioners (GPs) in Myanmar. Lessons from this pilot have been published by USAID‘s Health Finance and Governance (HFG) project, intended to inform broader implementations of strategic purchasing. The aim was to transfer skills from this pilot to a new semi-autonomous body for purchasing, channeling development and government funds. This has not been implemented as of 2022.
What agencies/institutions are involved in healthcare purchasing nationally?
Medicines and vaccines (national level):
Ministry of Health and Sports – Department of Medical Services (Procurement unit)
Medicines and vaccines (subnational level):
Regional/township hospitals
Regional/township health departments
Development partners/donors
Medical equipment and consumables (national level):
Ministry of Health and Sports – Department of Medical Services (Procurement unit)
Medical equipment and consumables (subnational level):
Regional/township hospitals
Regional/township health departments
Development partners/donors
Healthcare services:
Ministry of Health and Sports (MOHS)
Development partners/donors: fund some healthcare providers (e.g. Ethnic Health Organisations, Non-Governmental Health Organisations)
Healthcare support services
Township hospitals
Township health departments
What is the market structure of healthcare purchaser(s) nationally?
Most payments for healthcare services are done out-of-pocket. Some healthcare providers (e.g. Ethnic Health Organisations, Non-Governmental Health Organisations) are funded by international development partners.
Public health facilities at the regional and township level are allocated budgets by the Ministry of Health and Sports (MOHS) yearly and are responsible for implementing this budget.
The MOHS, regional/township health authorities and hospitals at different levels are all involved in conducting procurement. There is no centralised procurement mechanism.
Is healthcare purchasing conducted in a decentralised manner or universally across the health system?
Purchasing for healthcare goods is both centralised and decentralised. The Ministry of Health and Sports (MOHS) has a Procurement unit, but regional/township hospitals and health authorities can also procure healthcare goods within their allocated budgets as they are responsible for health budget implementation.
Purchasing of healthcare services comes mainly from out-of-pocket payments and various development partners.
If purchasing is conducted in a decentralised manner, are there any plans for integration?
There are plans to establish a centralised procurement system for public healthcare but this has not yet been implemented.
What are the top five agencies/institutions involved in purchasing health goods and services nationally?
No information was found on the top agencies involved in purchasing for health.
What criteria do the main healthcare purchasers use to determine what to buy?
Budgets prepared by subnational health units and approved by the Ministry of Planning, Finance and Industry (MoPFI) are prepared based on historic allocations, rather than health needs and priorities. The health sector (including the health workforce) is thus continually underfunded.
As part of the National Health Plan 2017-2021, some townships will be prioritised for investment from the Ministry of Health and Sports (MOHS) based on set criteria such as need and fiscal space availability. These criteria have yet to be published. Currently, facilities are paid within a line-item budget system.
At the subnational level, townships themselves will be responsible for identifying gaps and planning resource distribution at the local level.
How do the main healthcare purchasers govern their use of funds?
No information was found on the governance of funds.
Who are the main stakeholders involved in decision-making on health financing and the health system?
The central government retains most fiscal responsibilities and the oversight of budget processes, as led by the Ministry of Planning, Finance and Industry (MoPFI). Budgets are allocated centrally to ministries (including the Ministry of Health and Sports) and regions, with little flexibility even in the case of emergencies.
Township hospitals and township health departments are in charge of implementing their assigned budgets to achieve health goals. While such subnational units prepare paper-based budget proposals, these do not significantly influence budget allocations done centrally.
In 2018, the Ministry of Health and Sports (MOHS) declared an intention to implement more comprehensive health financing to achieve the Universal Health Coverage goals. This is currently in development by MOHS.
Who are the main stakeholders involved in decision-making on strategic health purchasing?
There are no specific stakeholders involved in strategic purchasing for health.
However, a National Supply Chain Task Force (NSCTF) was establised to provide leadership for public sector supply chain and support the Ministry of Health and Sports (MOHS)’s health supply chain strategy.
Section B: Legal and Policy Landscape
What laws/regulations define the mandates and roles of healthcare purchasers and providers?
The Social Security Law of 2012 established the Social Security Board (SSB) of Myanmar as the operator of the social security scheme and of three hospitals, 91 clinics and 42 enterprise clinics. In the Law, health provisions and entitlement benefits are explained. The SSB was also mandated to reimburse member bills incurred outside these facilities.
The Myanmar Medical Council Law of 2015 describes the roles and responsibilities of the Myanmar Medical Council, and sets down guidelines and a code of conduct for medical practitioners and professionals. The Myanmar Medical Council is a regulatory body overseeing good medical practice, ethics, and accreditation of medical schools and institutions.
The Private Health Care Services Law of 2017 established a Central Body to give guidance and supervise licensing for private healthcare institutions, and outlines minimum criteria that private hospitals and clinics must fulfil to be allowed to operate (e.g. land space, facilities, manpower).
The National Health Plan 2017 – 2021 outlines the government’s strategy, and the Ministry of Health and Sports (MOHS)’ mandate, to increase access to a yet-to-be-defined essential benefits package for the entire population by gradually expanding coverage by 2030. This plan involves coordination between the MOHS, the private sector, the SSB and other stakeholders.
What policies/regulations are in place surrounding healthcare purchasing?
The National Medicine Policy 2018 and its corresponding Implementation Plan was developed in support of Universal Health Coverage (UHC) and the strengthening of primary care through access and responsible use of essential medicines. This policy outlines goals to increase access to essential medicines through enhanced selection, procurement, regulation and pharmacovigilance.
The Ministry of Health and Sports (MOH)’s National Health Supply Chain Strategy for Medicines, Medical Supplies and Equipment (2015-2020) was developed to strengthen public sector procurement. The strategy includes the development of a centralised procurement system for the public sector, the computerisation of logistics management systems and performance incentives for the pharmaceutical sector.
What laws/regulations govern public finances and public spending?
The 2008 Constitution of Myanmar gives the basic structure of the government and outlines the duties of sectors like the Finance and Planning Sector.
The Regulations on Financial Management of Myanmar (2017) delineates the responsibilities of financial units including the Ministry of Planning and Finance, the Budget Department, the Treasury Department, the Regioner State Government, the Office of the Auditor General of the Union, and the Office of the Auditor General of the respective Regions or States. It codifies the laws on spending public funds and major financial activities of the Republic of the Union of Myanmar.
The Public Financial Management Reform Strategy (2018) is a strategic framework for economic and social reform that organises ongoing and future reform policies and activities. The goal of the framework is to modernise the public financial management of Myanmar.
The 2020-2021 Union Budget Law lists the rules on expenditure for the Union Ministries and Departments and gives a budget for every entity.
What government procurement & tendering processes are in place?
The Procurement Directive No.1 (2017) outlines laws regarding government procurement and tendering processes. It also establishes the Tender Committee, which manages the construction, procurement, lease and sales of services.
The tendering process is declared as follows:
(a) Screening whether there is permitted budget
(b) Making a purchasing plan and obtaining confirmation
(c) Developing tender documents including the documents related to the contract
(d) Calling and announcing the tender
(e) Screening and accepting the tender
(f) Notifying the reports which shall include suggestions for the contents of the contract and an evaluation of the tender
(g) Announcing the tender winner
(h) Concluding the contract and amending the contract
(i) Managing the contract, including payment methods
What healthcare-specific procurement & tendering processes are in place?
The Procurement Guidelines of the Ministry of Health and Sports provides rules on procurement contracts, tender documents and communication between procuring entities and suppliers. In accordance with these guidelines, each procuring entity appoints a Procurement Committee to oversee procurement. Procurement entities must prepare an Annual Procurement Plan in advance.
An open tendering process is used for the procurement of goods and works. The guidelines outline the process: “A procurement notice is published and sealed tenders are opened in public for transparency. The contract is awarded to the best value tender on the basis of quality, price and any other criteria stated in the tender document.” Restricted tendering can be used in special circumstances.
The Department of Food and Drug Administration under the Ministry of Health and Sports controls licenses for manufacturing, distributing and selling drugs. The National Drug Law (1992) is the only legislation in effect for the purchasing of medicines, and does not cover medical devices.
Who is responsible for enforcing contracts with healthcare providers and suppliers, and how is this done?
No information was found on contract enforcement.
Section C: Performance Monitoring
What regulations or accountability frameworks are in place for healthcare purchasers and providers?
The National Health Plan (NHP) 2017-2021 aims to increase access to an essential package of health services for the entire population while maintaining financial risk protection. The NHP’s Implementation Monitoring Unit (NIMU) is a unit under the Ministry of Health and Sports (MOHS) that monitors progress towards the NHP and guides its implementation.
The NIMU’s Monitoring & Evaluation framework document mentions various key performance outputs for all health authorities. These include “minimum standards of care met by all providers” and “availability of essential drugs and supplies”. Implementation of these is the direct responsibility of health authorities/stakeholders and not of NIMU.
Are there performance-based incentives in place for healthcare providers and suppliers?
No performance-based incentives are in place. Budget is allocated based on historic utilisation rates.
Population Services International (PSI)’s strategic purchasing pilot project included some performance-based incentives. Various performance indicators, quantifiable targets and means of verification were developed, and three final indicators were selected. Providers exceeding the selected output targets were rewarded through financial incentives.
What systems are in place to assess the performance of healthcare providers and suppliers?
The NHP Implementation Monitoring Unit (NIMU) released a set of indicators to track implementation of the National Health Plan 2017 – 2021. This was initially done using basic indices on inputs and outputs. The Health Input Scoring Index (HISI) measures townships’ infrastructure and workforce development, while the Health Output Scoring Index (HOSI) covers key indicators on health and poverty outcomes.
The intended method of verification of these outputs is through available public/private sector data and regular facility surveys. However, the extent to which actual assessments are conducted is unclear. More sophisticated assessment systems with a common methodology across townships and sectors will need to be developed.
What mechanisms are in place to provide feedback to healthcare providers and suppliers?
No information was found on providing feedback to proivders and suppliers.
What processes are in place to assess health system performance (utilisation, financial protection, quality, efficiency)?
The National Health Plan (NHP) 2017-2021 is a framework for implementing Universal Health Care and strengthening the national health system. The NHP Results Chain is a guide for determining outcomes and impacts based on specific indicators. The NHP Monitoring Unit (NIMU) is in charge of monitoring the NHP at the national level through a Monitoring and Evaluation Framework. Impact, outcome and output indicators analysing service quality, utilisation, financial protection and efficiency are mentioned. NIMU is also responsible for coordinating implementation research and following up with information dissemination.
State/regional bodies are to be established with similar responsibilities on implementation research, as well as providing support and feedback to townships. At the township level, Township Health Working Groups — composed of representatives of several stakeholders like Township Medical Officer (chair), Civil Society Organizations, NGOs, and the Private Sector — are to communicate with state/regional bodies and NIMU, and conduct monitoring and implementation research.
The Ministry of Health and Sports (MoHS) leads health facility and administrative data collection and coordinates data quality assessments. Performance reviews of Health Management Information System data are facilitated by the entity responsible for HIS under the MoHS.
What data and information management systems are used to monitor health system performance?
The Health Management and Information System (HMIS) of Myanmar is one of the planned programs under the National Health Plan 2017-2021. The HMIS is planned to encompass hospital information, public health information, human resource information, logistics information and information communication technology development.
While the HMIS was planned for the period of 2017-2021, as of 2021, reporting data formats and channels were yet to be developed. Broader health information policies and strategic plans to guide implementation were also yet to be developed.
How are findings on health system performance used to inform purchasing decisions?
Health system performance is not consistently tracked and related information is not used to inform purchasing decisions. Decisions on budgeting and procurement are made based on historic utilisation rates.
What health & operational indicators are used to monitor and evaluate health purchasing decisions?
Purchasing decisions are not regularly monitored. As such, no information was found on monitoring criteria.