In Myanmar, the primary healthcare (PHC) system transitioned from a period of historical neglect under military rule to a focused reform phase (2016–2020), which was subsequently disrupted by the 2021 military coup. Before the coup, the democratically elected government implemented the National Health Plan (NHP) 2017–2021, which established PHC as the central pillar for achieving Universal Health Coverage (UHC). This system relied on a network of public facilities, including Rural Health Centers (RHCs) and sub-RHCs, alongside private general practitioners and Ethnic Health Organizations (EHOs) in peripheral areas. However, the system faced chronic challenges such as high out-of-pocket (OOP) expenditures—accounting for approximately 75–85% of health spending—and a critical shortage of human resources, with only 1.33 health workers per 1,000 people, well below the WHO threshold of 2.3.

The 2021 military coup serves as a case study of a largely unsuccessful intervention from a state perspective, as it led to the near-total collapse of the formal public health system. In response, healthcare workers initiated the Civil Disobedience Movement (CDM), refusing to work under the military regime, which resulted in the closure of most public hospitals. This collapse severely disrupted essential services, including immunization programs and maternal care, leading to an increase in preventable morbidities. Conversely, a successful adaptation has emerged through the National Unity Government (NUG) and EHOs, who have established an alternative PHC network. This interim health strategy leverages telemedicine and mobile clinics to provide frontline care, particularly in liberated areas where health services have improved in some cases due to the influx of fleeing specialized health professionals.

Contributing factors to the failure of the state system include the targeted harassment of medical staff, the occupation of hospitals by military forces, and the disruption of medical supply chains. Success in alternative interventions is driven by strong community trust in CDM workers, increased collaboration between the NUG and EHOs, and the resilience of healthcare providers who continue to operate at great personal risk. Despite these efforts, the lack of reliable data, limited funding, and the ongoing threat of airstrikes remain significant barriers to a fully effective nationwide PHC system.

References

1)D’Apice, C. (2023). Providing primary health care in conflict-affected settings: The Myanmar case (Doctoral dissertation, University of Parma).
2)Ministry of Health and Sports (MoHS). (2016). Myanmar National Health Plan 2017-2021.
3)Nikoloski, Z., McGuire, A., & Mossialos, E. (2021). Evaluation of progress toward universal health coverage in Myanmar: A national and subnational analysis. PLOS Medicine, 18(10), e1003811.
4) The Lancet. (2021). The crisis of health care in Myanmar. The Lancet, 397

Primary health care (PHC) in Myanmar has expanded over the past decade, particularly in response to the growing burden of non-communicable diseases (NCDs). Here, I would like to present a case study that examined the readiness, availability, and utilization of PHC services for NCDs in Shan State, Myanmar, from January 2020 to January 2021. The study was conducted across 242 primary health care facilities in urban (Taunggyi), semi-urban (Loilem), and rural (Linkhae) districts. It assessed the readiness, availability, and utilization of PHC facilities for NCD services and compared the results among the three districts.

The findings showed that PHC services for NCDs in rural Shan State (Linkhae) face significant challenges that limit their effectiveness compared to urban areas such as Taunggyi and Loilem. Although many facilities met basic readiness standards, the rural district of Linkhae had the lowest screening rates and the highest new patient rates, suggesting difficulties in effectively managing the NCD burden.

Several factors contribute to this situation in rural Shan State (Linkhae):
1. Significant Gaps in Financing and Governance
• Financing: The mean score for financial readiness was only 38.20%, far below the 70% adequacy threshold. This was largely due to the absence of community health fund policies, which are important for reducing out-of-pocket expenses and improving access to care.
• Governance: Rural facilities experienced low levels of community participation and engagement, limited cooperation with community organizations, and insufficient local resource mobilization for essential services such as ambulance transport. Preventive services, including screening for hypertension and diabetes, were also underutilized.
2. Disparities in Human Resources and Training
• In the urban district of Taunggyi, 89.6% of health workforce positions were filled, whereas only 64.4% were filled in the rural district of Linkhae.
• Historically, PHC in Myanmar focused more on communicable diseases, meaning many Basic Health Staff (BHS) lacked specific training in NCD prevention and control. Although training has improved, the lower number of appointed staff in rural areas continues to hinder service delivery.
3. Limited Availability of Specific NCD Services
• Mean scores for assessment and referral of suspected cancer cases and management of respiratory diseases were considerably lower across all districts, including rural Linkhae.
4. Higher Prevalence of Risk Factors in Rural Areas
The limited success of PHC services is also linked to higher risk factor prevalence in rural populations. Rural communities often have higher levels of behavioral risk factors, such as alcohol consumption and low fruit and vegetable intake. This contributes to the high new patient rate in Linkhae, placing additional pressure on a PHC system that already has lower readiness and availability compared to urban districts.
5. Infrastructure and Supply Chain Challenges
Utilization of NCD services is constrained by infrastructure limitations and inconsistent medicine supplies. Even when essential medicines were officially available, frequent stockouts made it difficult for rural patients to rely on PHC facilities for continuous chronic disease management.

Reference:
https://pmc.ncbi.nlm.nih.gov/articles/PMC9659547/

Case Study: Myanmar’s PHC Response to COVID-19 (2020)
Myanmar faced first COVID-19 case on 23 March 2020, which is followed by a larger second wave in August 2020, resulting in over 125,000 cases and 2,697 deaths by December. Before the first case, the government began active surveillance and stocked essential medical supplies, while issuing guidance to health workers based on WHO recommendations.
To coordinate the pandemic response, an Intersectoral Central Committee and a Containment and Emergency Response Committee were established to lead multisectoral strategies, guide case management and public health measures.

Service Adaptation and Innovation
• Testing Expansion: Daily tests increased from 400 to 12,000 by September with RDTs.
• Frontline Support: BHS shortages were filled by mobilizing Red Cross volunteers, medical/nursing students, and retired professionals for fever clinics and quarantine centers.
• Digital Communication: Tablets were distributed to midwives in 2019, rapid training and public health messaging via apps, Viber, and Facebook (1.6 million subscribers).
Although these measures are implemented, routine immunizations stopped temporarily in April–May, showing the system’s human resource limits, and required months of midwife-led outreach to recover.

Key Success Factors
• High-Level Political Commitment: Centralized committees made sure rapid decision-making.
• Digital Leapfrogging: Early tablet distribution helped maintain communication and training.
• Social cohesion: Village-level COVID-19 Protection Committees and volunteer initiatives, like providing meals for quarantine patients, extended the reach of PHC services into areas with weak formal infrastructure.

Challenges and Limitations
• Human Resource Fragility: Over-reliance on a limited number BHS caused service gaps.
• Weak Formal Community Channels: Informal solidarity helped, but sustainable engagement structures were lacking.
• Infrastructure and Coordination Gaps: Limited labs and challenges in conflict-affected areas slowed response.

Lessons and Future Outlook
The 2020 experience highlighted that community-led resilience can compensate for some system weaknesses but cannot replace a robust PHC infrastructure. Moving forward, Myanmar needs to invest in health workforce expansion, formalize community engagement, strengthen labs, and integrate digital tools to prepare for future public health emergencies.

Reference
https://iris.who.int/server/api/core/bitstreams/f9c25f6f-06e0-4351-9dcd-0374440f5b29/content (Myanmar: a primary health care case study in the context of the COVID-19 pandemic)

I would like to share this case study, titled “Three Decades of Devolution in the Philippines: How This Has Shaped Health Financing and Public Financial Management Reforms”. This study was published in 2022 and developed with the support from ThinkWell and World Health Organization. It is part of a series produced to explore the implications of devolution for health financing and public financial management in several countries, including the Philippines.

Devolution is a reform that typically involves the transfer of different government functions related to sectors, such as health, from the national government to sub-national units. I think this case study paints a clear picture of the primary care system in the Philippines and how devolution has affected it. Some of the topics presented in the study are:
– Key policies that shaped the health system of Philippines, such as RA No. 7160 or the Local Government Code of 1991 (mandated responsibility and autonomy to manage local health facilities and services to different levels of local government units) and the RA No. 11223: Universal Health Care Act.
– Organizational structure of the public health system, showing relationships among government levels and health offices devolved to the local government units
– Devolved health functions by level of government, from the smallest local government unit (barangays) to provinces
– Health system fund flow
– Total health expenditure from 2014 to 2019
– Health expenditure by health care financing scheme from 2014 to 2019
– Revenue raising to fund health care provision and health promotion activities
– Pooling of funds for health among various actors of the health system
– Purchasing (how pooled funds are allocated to providers and used to pay for services)
– Reporting, oversight, and accountability of local government units

The following are the findings of the study:
1. Resources generated at the national level continue to be the most important source of revenue for health for local governments. According to the Department of Finance, 61% of local financing in 2019 came from external government sources.
2. Independent management and administration over local services is guaranteed as part of the decentralization arrangements of the Local Government Code, thus the management and financing of health services is dependent on the political discretion of elected Local Chief Executives.
3. Even with this continued dependence on intergovernmental fiscal transfers for health services, the ability of national bodies to influence local government decision-making for health budget and financing continue to be insignificant.
4. Overall, the structural changes brought about by devolution have failed to ensure equity in distribution and efficiency in utilization of resources across sub-national entities, particularly for health.
5. Devolution has also resulted in a lack of coherence and clarity in purchasing roles, which has hindered efforts to strengthen the strategic purchasing function of PhilHealth.
6. The current policies and purchasing mechanisms contribute to the weakened ability of national and subnational government to provide financial risk protection.
7. Since devolution was enacted 30 years ago, policies that affect health financing and PFM for health continue to be pushed forward.

The authors recommend the following solutions to address the challenges in the primary care system with regards to devolution:
1. The DOH needs to focus more on its role in sector-wide stewardship and oversight and provide authoritative guidance to LGUs through supportive implementation and monitoring mechanisms.
2. PhilHealth, in its role as a strategic purchaser, can support the DOH by activating prospective payment schemes that provide more financial resources for LGUs and local providers, balanced with the right incentives for performance.
3. Tools such as the Local Investment Plan for Health (LIPH), Local Government Unit Health Score Card, and PhilHealth contracting should be seamlessly re-designed to become binding Service Level Agreements (SLAs) between the national and sub-national entities to guide the expenditure of the local government units for health.
4. The implementation of the Special Health Fund at the provincial- and city-wide level can work to ensure standardized monitoring of expenditures for health at the local level and guarantee the reintegration of local government units that will lead to more efficient and equitable health financing.
5. Local governments and other key stakeholders need to be empowered to properly and efficiently execute allocated funds and ensure that financing reforms are maximized once implemented.

Reference:
Nuevo, Christian Edward, Jemar Anne Sigua, Mary Camille Samson, Pura Angela Co, and Maria Eufemia Yap. 2022. Three Decades of Devolution in the Philippines: How This Has Shaped Health Financing and Public Financial Management Reforms. Case Study Series on Devolution, Health Financing, and Public Financial Management. Manila: ThinkWell.

https://thinkwell.global/wp-content/uploads/2022/04/Philippines-Case-Study-April-2022.pdf

In Myanmar, the primary care system is the foundation of the country’s health services. Primary care is delivered mainly through public health facilities such as rural health centers (RHCs), sub-rural health centers (sub-centers) and township health departments. These facilities provide basic services including maternal and child health, immunization, infectious disease control and treatment of common illnesses. Primary care also depends heavily on community-based health workers such as Auxiliary Midwives (AMWs), community health volunteers and malaria volunteers, who bring services closer to people in rural and under-served areas. These community workers were introduced decades ago to improve access to care in villages and remain vital in areas where formal health infrastructure is limited. Myanmar’s primary care system has strengths like wide community reach and local health workforce involvement, but it faces major challenges, including insufficient financial investment, shortages of trained staff, and weak infrastructure and management capacity in many townships.

Case Study: Malaria Volunteer Intervention (Successful Example)
A case study of a primary health intervention in Myanmar is the use of community malaria volunteers (later integrated community malaria volunteer – ICMV) to improve malaria control in rural communities. Since the early 2000s, village health volunteers trained to diagnose and treat malaria using rapid diagnostic tests (RDTs) and provide appropriate treatment have been deployed in remote areas. Research has shown that in areas where these volunteers were present, community knowledge about malaria increased and more people sought early diagnosis and treatment, compared with areas without volunteers. The longer the program operated in a community, the higher the level of malaria understanding among residents. This intervention helped improve access to malaria care in rural regions where formal health services were weak, helping to reduce malaria burden and improve community health.

Factors Contributing to Success
Several factors contributed to the success of this malaria intervention at the primary care level:
_Community trust and participation: Volunteers were members of the local community, which made people more willing to seek help early.
_Training and tools: Volunteers were trained in malaria diagnosis and treatment and given RDTs and medication.
_Focus on rural areas: The program specifically targeted remote villages with limited access to formal health centers.
These features helped make the intervention effective in providing basic care at the community level.

Conclusion
Overall, primary care in Myanmar is a mix of public health facilities and community-based services. While the involvement of community health workers has led to successful interventions like improved malaria care at the village level, the system still needs greater investment, better workforce support, and stronger infrastructure to ensure consistent and high-quality primary care for all.

Reference
https://link.springer.com/article/10.1186/1475-2875-13-5
https://pmc.ncbi.nlm.nih.gov/articles/PMC10227472/
https://chwcentral.org/myanmars-community-based-health-workers/

Thank you for sharing your case study and discussing how the primary care intervention was implemented.

Primary Healthcare System in Myanmar

In Myanmar, the Ministry of Health is further divided into six departments, which provide healthcare services to the entire population. The Department of Public Health provides basic and primary healthcare services. Primary health services are provided to the population of Myanmar through a mixed system of public, private for-profit, private not-for-profit, ethnic health organizations (EHOs) and international development assistance. In the public sector, preventive and curative health services are delivered through four main channels: 1) township and station hospitals; 2) rural health centres (RHCs); 3) sub-RHCs in rural areas; and 4) urban health centers. Based on MoHS data obtained in 2021, PHC services are provided through 319 township hospitals, 771 station hospitals, 98 urban health centers, 1849 RHCs, 8700 sub-RHCs in public sectors, and 3911 private general clinics. This data is not included in the EHOs’ health facilities. But, the primary healthcare system in Myanmar has encountered severe disruptions due to the COVID-19 pandemic and the political instability since 2021.

Key disruptions

The following are key points of the primary healthcare system disruption.
• Large numbers of public-sector health workers joined the Civil Disobedience Movement (CDM)
• Closure or militarization of township hospitals and rural health centers
• As of August 2023, 385 attacks on health care have been documented since February 2021 via the WHO Surveillance System for Attacks on Health Care (SSA), leading to 58 deaths and 188 injuries (WHO, 2023).
• Breakdown of financing, supervision, supply chains, and routine services

Case Study

According to a public health situation analysis published by the WHO in August 2023, the Myanmar vaccination programme became largely weakened at the primary care level after the 2021 coup in Myanmar. Immunization services in Myanmar are mainly dependent on township health teams, midwives and village outreach, which were disrupted by widespread health-worker shortages, security issues, and closure of public health facilities. Vaccine supply chains and cold-chain systems also broke down due to transport restrictions, electricity interruptions, and reduced supervision, making regular outreach sessions difficult or impossible. Although NGOs and ethnic health organizations managed to deliver vaccines in some locations through mobile clinics or cross-border programs, these efforts were fragmented and could not compensate for nationwide coverage gaps. This case shows that even well-designed and cost-effective primary care interventions fail when governance collapses, frontline workers are not protected, and supply systems are disrupted.

References

https://www.who.int/teams/primary-health-care/evidence-and-innovation/primary-health-care-case-study-compendium/detail/myanmar–a-primary-health-care-case-study-in-the-context-of-the-covid-19-pandemic

https://cdn.who.int/media/docs/default-source/searo/myanmar/documents/public-health-situation-analysis-phsa_myanmar_august-2023.pdf

Since Thai PCUs are being shared in the study material, I’d share another perspective of how PCUs can contribute to chronic disease management.

Case Study: The CKDNET – Chronic Kidney Disease Prevention in the Northeast Thailand

The CKDNET project was designed to address the high prevalence of chronic kidney disease in rural areas by moving care from specialized hospitals directly into the PCUs. You can see its detail and workflow in the reference. It focuses on screening high-risk groups and managing patients in CKD stages 1-4 to prevent them from reaching end-stage renal failure.

How it works at the primary care level:

– PCUs are supported by a specialized team including nurses, pharmacists, dietitians, and physical therapists. They work together to manage medication, diet, and lifestyle changes right at the local clinic.
– Village health volunteers are trained to identify at-risk neighbors and encourage them to attend screenings. They also play a role in home visits, checking on patient compliance with their diet and medications.
– The program standardizes care protocols so that PCUs can provide a level of specialized management that was previously only available at a provincial hospital.

What contributes to the success:

– Community engagement: Since PCU staff and health volunteers are local, patients trust the advice they receive. This leads to much higher retention in the follow-up compared to a big hospital, which also includes travelling and waiting many hours for a follow-up visit.
– Effective teamwork: For example, pharmacists and dietitians take the lead on counseling, reducing the burden on doctors and nurses. Therefore, the patients get more detailed advice on how to manage their condition.
– Early Intervention: The system can detect CKD in the early stages, slowing down the decline of kidney function and effectively decreasing the burden of end-stage requiring dialysis.

And not only does this project manage CKD effectively at the community level, but it also contributes to a CKD registry, providing the essential data needed for long-term disease monitoring and health management.

Reference: https://pmc.ncbi.nlm.nih.gov/articles/PMC7450931/
(CKDNET, a quality improvement project for prevention and reduction of chronic kidney disease in the Northeast Thailand)

The primary care system in Myanmar has undergone significant changes, especially following the political events of February 2021.
1. The Traditional Structure (Pre-2021)
Historically, Myanmar’s primary care was anchored by the Township Health System (THS). This system was designed to cascade from the township level down to the grassroots:
Township Hospitals & Station Hospitals: Served as the primary referral centers.
Rural Health Centers (RHCs) & Sub-Rural Health Centers (SRHCs): The core facilities for rural populations.
Frontline Workers: The system heavily relied on Midwives (MWs), Public Health Supervisors, Auxiliary Midwives (AMWs), and Community Health Workers (CHWs). Midwives, in particular, were the backbone of rural primary care, handling maternal and child health, immunizations, and basic disease control.

2. The Current Reality (Post-2021):
Today, the formal public health system is highly fragmented. Due to the Civil Disobedience Movement (CDM), conflict, and resource shortages, many government facilities are understaffed or non-functional. As a result, primary care is now largely sustained by a patchwork of:
Ethnic Health Organizations (EHOs): Running parallel health systems in border and conflict-affected areas.
Non-Governmental Organizations (NGOs) & Community-Based Organizations (CBOs): Providing mobile clinics and supporting local volunteers.
Village Health Volunteers: Local community members trained to handle specific health issues like malaria, tuberculosis, and basic maternal care.

A Successful Case Study: The Sun Primary Health (SPH) Malaria Intervention
A highly successful and well-documented primary care intervention in Myanmar is the Sun Primary Health (SPH) franchise program, launched by Population Services International (PSI) Myanmar.
The Intervention:
Malaria has historically been a massive burden in rural Myanmar. To combat this, the SPH program recruited and trained local community members (such as traditional birth attendants, farmers, or retired nurses) to become volunteer health workers in remote villages where there were no doctors or formal clinics.
These volunteers were trained to:
1. Provide accurate malaria information and counseling.
2. Use Rapid Diagnostic Tests (RDTs) to accurately diagnose malaria on the spot.
3. Administer Artemisinin-based Combination Therapy (ACT) for positive cases, ensuring early and effective treatment.
A cross-sectional study evaluating this intervention across rural townships found that communities with an SPH provider had significantly higher malaria knowledge (e.g., knowing to use insecticide-treated nets) and were much more likely to seek treatment from a trained provider rather than buying unregulated drugs from local shops. Another evaluation of the program showed that the training significantly improved the quality of pediatric malaria care provided by these rural workers, and this improvement was sustained over time.

Contribution Factors to the Success of Story
Several key factors made this primary care intervention successful:
Task-Shifting to Trusted Locals: By training ordinary community members who already lived in the villages, the program bypassed the severe shortage of doctors and nurses. Because these volunteers were locals, they already had the trust of their communities, which encouraged people to seek care from them.
Equipping with the Right Technology: Providing volunteers with RDTs was a game-changer. It allowed laypeople to accurately diagnose malaria in minutes without needing a laboratory or microscope, preventing the overuse of antimalarial drugs and ensuring patients got the right treatment immediately.
Standardized Training and Support: The volunteers were not just given supplies; they underwent standardized training based on WHO guidelines and received ongoing support and supervision.
Performance-Based Incentives: The program utilized incentive schemes based on the number of malaria cases tested or treated, which kept the volunteers motivated and engaged in their work.
Accessibility and “Dose-Response”: The intervention brought life-saving care directly to the patients’ doorsteps, eliminating the need for rural patients to travel long distances to township hospitals. The study also noted a “dose-response” effect—the longer the SPH provider was active in a community, the higher the community’s overall health literacy and positive health-seeking behaviors became.

Reference
Improving malaria knowledge and practices in rural Myanmar through a village health worker intervention: a cross-sectional study
https://pmc.ncbi.nlm.nih.gov/articles/PMC3893499/

Primary health care (PHC) in Myanmar
PHC in Myanmar is mainly delivered through township hospitals, station hospitals, rural health centers, and sub-rural health centers under the Ministry of Health. Basic Health Staff such as health assistants, lady health visitors, midwives, and public health supervisors provide preventive and basic curative services at community level. PHC focuses on maternal and child health, immunization, communicable diseases (such as HIV, TB and malaria), and increasingly non-communicable diseases (NCDs). In many ethnic and conflict-affected areas, Ethnic Health Organizations (EHOs) also provide similar primary care services.
A successful example of primary care intervention in Myanmar is the community-based malaria control program in Myanmar. In this program, community health workers were trained to use rapid diagnostic tests and provide early treatment within villages. This reduced delays in treatment and helped lower malaria transmission in remote areas.
Several factors contributed to this success. First, services were delivered by local community members, which increased trust and access. Second, there was strong collaboration between government health authorities, EHOs, and international partners. Third, there was reliable supply of medicines and diagnostic tools. Finally, the intervention focused on early detection and prevention, which are key principles of primary health care.
However, challenges remain. Political instability, workforce shortages, supply chain disruptions, and reliance on donor funding affect sustainability. This shows that while PHC interventions in Myanmar can be effective, long-term success depends on stable governance, strong financing, and continuous support to frontline health workers.

Reference
Smithuis, F., Kyaw, M. K., Phe, U. O., Aye, K. Z., Htet, L., Barends, M., & White, N. J. (2013). Effectiveness of artemisinin combination therapy in Myanmar. The Lancet Infectious Diseases, 13(3), 211–218. https://doi.org/10.1016/S1473-3099(12)70301-4