Khin Win Myint
INTRODUCTION
Myanmar is located in South East Asia Region, on the bay of Bengal and shares borders with Bangladesh, India, China, Laos and Thailand. It has total land areas of 676,577.5 square kilometers. It is divided into 7 States & 7 Divisions, 55 Districts, 320 Townships, 13577 village-tracts and 61 666 villages.
Of the total population of 44.74 millions (1995/96), male population was 22.22 millions (49.66%) & female population was 22.52 million (50.34%) with average annual population growth rate of I .87010. Population density is approximately 63 persons per square kilometer.
The proportion of population under I 5 years has declined from 38.28 percent in I 985/86 to 33.60 percent Jn I 995/96, while the proportion of working age-group between I 5-59 years increased from 55.6% to 58.87010 and the proportion of 60 years and above increased from 6.12ª/o to 7.53010. Due to the increase in population of the working age group during the period of 1985/86 to 1995/96, the dependency ratio has fallen from 7. 9.860/0 to 69.86%.
Crude birth rate was 28. I per I ,OOO population for urban area and 30 per I ,OOO population for rural area. Crude death rate was 8.7 per I ,OOO population population for urban area and 9.9 per I ,OOO population for rural area.
The expectation of life at birth derived from I 991 Population Changes and Fertility Survey (PCFS) for period of 1990-95 was 59.1 years for males and 62.58 years for females. Infant Mortality rate (IMR) is still moderately high with 94 per thousand live births as observed in 1991 PCFS but it reduces to 47.4 per thous~nd live births in 1993.
Literacy campaigns had been launched in Myanmar since 1965 up till I 988. By 1990, 297 out of the total 320 townships all over the country had been covered by the Literacy campaigns. The adult literacy rate was 86% & women literacy rate was 63%.
The overall economic situation of the country has been gradually improving after the inception of market oriented economic system in I 988/89. The Gross somestic product per capita was 1116 kyats in 1989/90 and increasing to I350 kyats in l994/95 .
Health status of the Myanmar Children
The future of a country belongs to and largely depends upon the younger generations, especially children who are infant valuable potential of the State.
Health programme for women and children are being implemented as outlined in the National Health Plan (NHP) (1993-96) an in accordance with the National Health Policies laid down by the National Health Committee, calling for " raising the level of health of the country and promoting physical and mental well being of the people with the objective of a achieving Health for all by the year. 2000, using the primary health care approach.
According health services are provided in an integrated manner and in line with the principles of primary health care, particular attention being given to the vulnerable groups in the population, especially women & children.
Indicators of the health status of this most vulnerable portion of the population were as follows.
The crude birth rate was 28.1 per I ,OOO population for urban area and 30 per l ,OOO population for rural area. Infant Mortality rate was 47.4 per I ,OOO Iive births in urban area and 49.8 per I ,OOO Iive births in rural area. Maternal Mortality rate was l per 1,000 Iive births in urban area & 1.8 per 1,000 Iive births in rural area.Perinatal mortality rate was 25.35 per I ,OOO Iive births for both genders down from 25.8 per 1,000 Iive births in 1988. Also, Under Five mortality rate was 72.72 per 1,000 Iive births for both genders down from 81 .60 for both genders in 1984.
The National Health Plan (NHP) exercise identified a total of 39 health problems by means of objective criteria. subjective criteria, and weighted score.
Top ten diseases in the priority ranking are malaria, tuberculosis, AIDS, diarrhoeal diseases, protein energy malnutrition, sexually transmitted diseases, drug abuse, Ieprosy, abortion and anaemia.
Most of our children being faced with Acute respiratory infection, diarrhoeal diseases, protein energy malnutrition, dengue haemorrhagic fever, malaria, Iow birth weight, EPI target diseases (TB, Diptheria, Whooping cough, Tetanus, Poliomyelitis, & Measles) and some sexually transmitted diseases (like congenital syphilis & AIDS).
Acute Respiratory Infection
Information revealed from 410 hospitals reportcd during I 981-82 that in children under 5 years,. ARI especially pneumonia was respossible for 20% of all admission (30010 of all hospital deaths). Out of 456 deaths from ARI at YCl, 272 (600/0) of children died within 24 hours of admission and 335 (73010) within 48 hours and more than 90010 of ARI deaths were due to pneumonia. Twenty percent of all deaths of children under five were due to pneumonia. ARI episodes in rural area was 2 episodes per child per year and in urban area was more than 2. ARI controlled programme in Myanmar directed towards reduction of pneumonia morbidity and mortality.
Diarrhoeal Diseases
According to 1993 report, diarrhea incidence was 299.45 per 100,000 population with case fatality raie of 0.38%.
There was 368 deaths in 2768 diarrhoeal cases who were admitted to Yangon Children's Hospital in 1991 and CFR was 13.290/0.In 1995, there was 91 deaths in 4470 cases and CFR was 2.04 in YCH.
Nutritional Diseases
Protein Energy Malnutrition (PEM) Malnutrition as a whole can be defined as body weight lower than the value of minus two standard deviation (-2SD) of the reference body weight value for the specific age in NCHS. (National centre for Health Statistics, USA) reference data ' recommended by the FAO/WHO expert committee.
In I 991, the National nutrition survey was conducted using the Probability Proportional to population size sampling technique. According to the I 991 survey on under-three children, malnutrition was prevalent among 36.7010 of population. Gender-wise, malnutrition was seen more in boys than in girls. (39.40/0 vs 33.90/0). When analysed by age group, malnutrition was found to be minimal in 0-5 month group, representing just 3.2010 of the population and highest in I 2-23 month group, accounting for 44.80/0 of the population (45010 of the boys and 44. I %(, of the girls).
Regarding the severity of the malnutrition, I I .2% suffured from severe malnutrition (weight for age value below - 3 SD of NCHS reference) with a gender portion higher in boys (1 2.7%) than in girls (9.7%).
Another type of malnutrition is wasting or acute malnutrition denned as body weight value for the particular height less than -2 SD of NCI-IS. I I .2% ol' tl]c children suffered from wasting with a higher portion in boys than in girls. (12% vs I 0.3%). Wasting was minimal in 0-5 month group, accounting for 5% of the population only and assumed the highest in 12-23 month group, represcnting 58.6% of the children where boys and girls constituted 56.2% and 61 .4% respectedly.
As far as severe wasting (weight for height less than -3 SD NCHS) is concerned, severely wasted children constituted just a negligibie fraction of people ( I .6%) with the boys out-numbering the girls.
Another type of malnutrition is stunting defined as height for the particular age less than the value of -2 SD of NCHS. Stunt~d children constituted 40% of the children with a higher proportion in boys (41.8%) than in girls(38.3%). Study of stunting by the age group reveals the least in 0-5 month group, accounting for 6.9% of the total and the highest in 12-23 month group, with 42.5.010 of total (43. I % of the boys and 41 .9% of the girls.)
As for severely stunted children under -3SD of NCI-IS, they made up a total of l 7% of the children with a higher portion in boys than in girls. (1 9.3% vs 14.8%).
All the above findings indicate that malnutrition was prevalent among the younger children despite the nation-wide sufficiency of food production and that nutrition deficiency of various types was felt more among the boys than among the girls.
Vitamin A deficiency
The problem of Vitamin A deficiency was recognised as a public health problem from I 982 onwards. The prevalence of Bitot's spot (X1B) among 6 months to 6 years was 0.5% to 3.3%.
Anaemia
In the study reported by Myo Khin et al (1990), anaemia was found to be more prevalent in the age roup of 6-16 years than in 6 months to 6 years age group. (33.6% vs I 5.45%) among Myanmar rural children. It was also reported that iron deficiency was associated in 3-27% of anaemic children.
Iodine deficiency disorders
According to the survey in 1990, about 18% of the country's population suffered from Goitre, 36% of the population were also at risk to iodine deficiency disorders O 8% were cretins and about one million were suffuring from other manifestation of iodine deficiency. Eight (4 States & 4 Divisions) out of the 14 States & Divisions exhibited regional Goitre prevalence rate of 10% and above.
Dengue Haemorrhagic Fever
A prospective epidemiological study on DHF in Yangon community between 1984 and 1988. (Soe Thein et al) revealed that whereas only 49% of dengue fever cases were associated with secondary dengue infcction, 98% of dengue shock syndrome were associated with secondary dengue infection. It was .also observed that only 49% of dengue fever cases were associated with dengue virus type 2, but 89% of 49% of dengue fever cases were associated with dengue virus type 2.
According to NHP reports (1994), morbidity rate of DHF per I O0,000 children under 5 years is 82.2 and CFR is 3.58 for 1993.
Total number of DHF cases admitted to Yangon Children's 1-10spital were as below and incidence was very high in 1994.
1986-1005
1987-3054
1988-576
1989-678
1990-3144
1991-2000
1992-586
1993-1510
1994-4376
1995-1318
Malaria
Malaria which is prioritised as the No.1 health problem of Myanmar. In the morbidity, malaria takes the lead for both gender.
According to 1993 figure, 447,OOO patients took treatment at outpatient Departments and 92,887 were admitted. Case fatality rate varics from 0.2-0.60/0. Plasmodium falciparum constitutes 85-90% of cases,while the remaining were due to Plasmodium vivax.
AIDS
Myaumar is now experiencing epidemic of HIV infection and AIDS. The first HIV positive person was detected in 1988. Up to 1993, 7152 persons were tested positive and 189 ofAIDS cases were diagnosed, while Yangon contributed 122 AIDS cases. Highest HIV positive rate was found in intravenous narcotic drug users.
There were I 6 HIV positive cases detecetcd in YCH, out of which 4 were AIDS cases who were vertically transmitted. Other 12 HIV positive cases were transfusion induced Haematological cases (Haemophilia, Thalassaemia, Hypoplastic anaemia,etc), who had been got HIV infection before HIV tests were done for donor's blood. (ie. before 1989. ). Out of 12 HIV positive patients, three were died due to disease proper not due to AIDS.
EPI Target Diseases
Extended Programme of Immunization (EPI) was launched in Myanmar in April 1978, \vith the commencement of first cycle of People's Health Plan (PIIP). A total of 176 townships were covered during PHP I and PHP II. In May 1986, six townships under EPI exerted efforts to meet the goals of UCI 1990. In November 1986, another 34 townships had carried out the UCI objectives. In 1995-96, 306 townships out of 320 townships in the Union were implementing UCI programme with success.
In UCI programme, children under one year of age are protected against Diptheria, Pertussis, Poliomyelitis, Measles, Tetanus and Tuberculosis by using potent vaccines kept bctwccn OC and 8C. In order to prevent neonatal tetanus, pregnant women were given two doses of tetanus toxoid.
Since UCI was given a strong political comitment, Myanmar UCI Programme had achieved a high percentage of coverage for all endorsed immunization. To commemorate the achievement, a ceremony was hold in Yangon, in November,1991 under the sponsorship of UNDP/WHO/UNICEF.
In 1995-96, immunization coverage for tuberculosis was 90.5%, for DPT was 87.6%, for poliomyelitis was 86.8%, & for measles was 84.3%.
Neonatal Morbidity and Mortality
Common causes of neonatal morbidity and mortality in Myanmar are :
1 . Low Birth Weight
2. Birth Trauma
3. Infection (including neonatal tetanus)
4. Diarrhoea
5. Congenital Abnormalities
6. Neonatal Jaundice
Percentage of low birth weight babies (Birth weight < 2500 grams) in the year l991 survey was 23.46% in Union. (21 .47% in urban and 24.35% in rural).
Birth spacing services which have been begining 1992 as important services which have been available in 33 townships. (1995-96). Tl]e main aim of the birth spacing services is to promote the health of mothers and children.
Health care services for pregnant women and children have been given priority and efforts are being made not only to increase the antenatal care coverage but also improve the quality of services, to ensure save delivery and that reducing the incidence of birth trauma.
Pcrinal MortaIity
Perinatal mortality rate was 25.35 per thousand live birth (1993). The cause of perinatal death is a sample of 270 deaths studied in 1977-78 are as fbllow:
l . Prematurity/Low birth weight
2. 1-1ypoxia/ Asphyxia .
3. Infections
4. Congenital Abnormalities
5. Birth Injuries
6. Cerebral Haemorrhage.
Infant Morbidity and Mortality
Common causes in Myanmar are:
l . Low Birth Weight
2. Diarrhoea
3. Chest Infections
4. Malnutrition(Marasmus)
5. Beri Beri.
Infant Feeding Practices
Exclusive breast feeding - 94. 10%
Supplementary feeding before 6 months of age - 7 1 .60%
Breast fecding continue to 1 year old - 95.00%
Breast feeding continue till 2-3 years old - 30.00%
Baby friendly hospital initiative (BFHI) is the latest strategy in the promotion of breast feeding. In Myanmar, BFHI have been successfully initiated in 7 hospitals (1993) and now practicing widely in whole country.
HEALTH SERVICES IN MYANMAR
Since the launching of the people's health plan in 1978, efforts have been made to close the gap in health care delivery services and fulfil the needs of the rural community and under served areas. With the completion of the 3 cycles of people's health plan extending from 1 978-1990, public access to basic health service has improved dramatically from 27.3% of total population in 1960 to 64.63% in 1993.
Activities to promote the health standard of the people in Myanmar are being carried out by National Health Committee formed in 1991/92 by the State Law and Order Restoration Council(SLORC). National Health Plan (1993-96) has been formulated under the committee in accordance with its National Health Policy. A number of stratagies and activities are directed specifically to vulnerable groups such as children and expectant mothers, the under served such as the population in hilly regions and borders areas. The plan is composed of 6 broad programmes as mentioned below:
l . Community Health Care Programme
2. Disease Control Programme
3. Hospital Care Programme
4. Environmental Health Programme
5. Health System Developmcnt Programme
6 Organization and Management Programme
Under the guidence of National Health Comnity measures taken for the development of Health Services are as follows:
¥ Expending Hospltals, dispensaries and health centres
¥ Appointing more health personnel and sending them to local as well as over seas training and refresher courses
¥Expending disease prevention and controlling works
¥ Encouraging more participation of co-operatives, joint ventures, private and NGOs in health care services
¥ Carrying out birth spacing and child immunization works extensively .
¥ Implementing cost sharing system in providing health services
¥ Carrying out medical research works extensively
¥ Expending sports and physical education activities
According.to the 1995/96 provisional data 737 hospitals, 332 dispensaries, 1427 rural health centres, 358 maternal & child health centres, 88 primary health care centres, 85 school health teams were opened, showing increases of 45 hospitals, 30 dispensaries, 52 rural health centres, I O maternal & child health centres, 5 primary health care centres and 5 school health teams during the Four-Year Short-Term Plan.
According to 1995/96 provisional data, 12950 doctors, 860 dental surgeons, 9851 nurses, 1 328 health assistants, 1683 lady health visitors, and 8143 midwives are giving health care services showing increases of 884 doctors, 124 dental surgeons, 233 1 nurses, 52 health assistants, 67 lady health visitors, and 734 midwives duting the plan period.
Controlling & prevention of Acquired Immune Deficiency Syndrome (AIDS) has been started since 1992, and continue surveilIance on controlling AIDS have been carried out for 0.24 million people at 100 townships in States & Divisions. Serological tests & dissemination of health education on AIDS havc been also been made. .
With a view to promoting health services, Iaws relating to health are enacted and notification issued: such as National Drug Law, Prevention and control of communicable Disease Law etc. Moreover, notification on tax exemption on 36 essential drugs imported from abroad was issudd and private entrepreneurs were allowed to sell drugs in accordance with prescribed rules and regulations.
In order to improve the health status of mothcrs and children, medicines for birth spacing were distributed~m 33 townships and 70 percent of married women from. those townships were given health education on birth spacing.
Innoculation for prevention against six cantagious and fatal diseases of children under one year has been carried in 306 townships by 1995/96. Utilization of safe water and latrines programmes were also expanded.
Community cost sharing programme was initiated in I 993 and upto I 995/96, private wards:, 73 laboratories and 23 X-ray departments have been opened at 90 hospitals.
Health care services were carried out not only by the Ministry of Health but also by the organization & under the other ministries and the private sector.
The State has been increasing the expenditure on health services yearly. During.the plan period expenditure insurred by the State for health services encountered to k 8902 million. inclusive of k 2235 million by the Ministry of Health and k 501 million by other ministries totalling k 2736 million in 1995/96.
