Topic Discussion 1: Improving health system

[Wirichada Pan-ngum]

Please providing an example of health system improvement in any health setting and discuss the possible barriers that could occur in that system improvement process. (10 Marks)

[Wah Wah Lwin]

In Myanmar, one of the major public health challenges is tuberculosis (TB), especially in urban slums, migrant communities, and conflict-affected areas. An example of health system improvement is scaling up of community-based TB screening and proper treatment support through national TB program, township health hospitals and basic health staff. Mobile teams and community volunteers can actively screen high-risk groups such as household contacts, factory workers, migrants, and internally displaced persons (IDP) using symptom checklists and rapid diagnostic tests such as chest X-ray, sputum AFB. This improves access and coverage by delivering TB services to people who may not visit health facilities because of cost, distance, or stigma. It also improves quality and safety by enabling early diagnosis, proper infection control, and standardized treatment using the national TB guidelines, reducing transmission and minimizing risks of drug resistance TB. In terms of efficiency, it increases technical efficiency by detecting and treating more TB cases with the same workforce through outreach and rapid diagnostic testing; improves productive efficiency by combining the efforts of health staff and trained community volunteers to lower the cost per case detected and treated; and enhances allocative efficiency by prioritizing resources for high-burden areas such as Yangon’s peri-urban townships such as Hlaing Thar Yar and border regions rather than spreading funds across low-risk populations. This also promotes equity. Horizontal equity ensures that people with similar TB symptoms receive the same diagnostic and treatment services regardless of geography, while vertical equity provides additional support, such as nutrition, transportation, and treatment supervision, to groups with greater needs, including the poor, migrants, and people living with HIV.
Despite these benefits, barriers remain, including stigma that discourages testing, long treatment duration leading to poor adherence, limited laboratory capacity, workforce shortages, funding constraints, and access issues in conflict-affected regions. Addressing these challenges through community engagement, patient support, and system strengthening is essential to improve TB control in Myanmar.

[Than Htike Aung]

In many public health HIV programs, one of the persistent challenges has been the long turnaround time for viral load (VL) test results. Although VL testing is routinely performed, delays often occur because samples collected at peripheral health facilities must be transported to centralized laboratories, results are processed manually, and paper-based reports are physically returned to clinics. These delays limit clinicians’ ability to identify treatment failure early and take timely action, ultimately affecting patient outcomes and program performance.
To address this challenge, an electronic viral load recording system was introduced as a health system improvement intervention. The system was designed to manage the entire VL testing process, including sample registration at the health facility, tracking of sample transport to the laboratory, and delivery of test results back to the facility by email. At the point of sample collection, each VL sample is electronically recorded and assigned a unique identifier. This allows both the sending facility and the receiving laboratory to monitor the status of the sample throughout the transport and testing process. Moreover, the testing facility can also prepare each batch of VL sample in advance for efficient machine usage. Once testing is completed, results are entered into the system and automatically sent to designated facility email addresses, eliminating the need for physical result delivery.
The introduction of this electronic VL recording system significantly reduced turnaround time for VL results. What previously took several weeks due to transport delays, misplaced samples, and slow paper-based reporting was shortened to less than two weeks in many facilities. The system also improved efficiency by reducing sample loss, minimizing transcription errors, and strengthening accountability between health facilities, transport services, and laboratories. Healthcare workers were able to receive results more quickly, review them in a timely manner, and make prompt clinical decisions, such as enhanced adherence counseling or switching patients to second-line antiretroviral therapy when necessary.
Beyond improvements in turnaround time, the system contributed to better overall program management. Program managers could monitor sample volumes, identify bottlenecks in transport or testing, and take corrective action based on real-time data. The availability of electronic records also supported data quality improvements and facilitated reporting to national HIV programs and partners.
However, the implementation process was not without challenges. Some health facilities faced limited internet connectivity, which affected timely data entry and email result delivery. Healthcare workers required training to adapt to the new system, and initial resistance to changing established workflows was observed. Sustainability also depended on continued investment in system maintenance, technical support, and integration with existing health information systems. Despite these barriers, the electronic VL recording system demonstrated that targeted digital health interventions can substantially strengthen service delivery, reduce turnaround time, and improve efficiency within resource-constrained health settings.

[Kevin Zam]

One example of health system improvement in Myanmar is strengthening Primary Health Care (PHC) in rural areas by improving the capacity of Basic Health Staff (BHS) such as health assistants and midwives. This includes training BHS to provide integrated services (maternal and child health, nutrition, immunization, TB and malaria), improving referral systems, ensuring essential medicines, and involving communities in health activities. This helps increase access to basic health services and improves early detection and treatment at community level.
Possible barriers
– Shortage and high workload of health workers in rural and conflict areas
– Limited and unstable funding for primary health care
– Shortages of medicines, equipment, and poor transportation
– Weak health information and reporting systems
– Poor coordination among government, NGOs, and ethnic health organizations
– Low health awareness and socio-cultural barriers in communities
– Security and access problems due to conflict
While PHC strengthening is effective in improving health system of Myanmar, many system-level challenges can affect implementation.

[Soe Wai Yan]

In Myanmar, the malaria remains a significant public health concern, particularly among rural, remote and conflict-affected populations. Over the past decade, Myanmar has implemented major health system improvements through the National Malaria Control Program (NMCP) with the goal of malaria elimination. One notable example of health system improvement is the strengthening of community-based malaria services, especially through the deployment of Integrated Community Malaria Volunteers (ICMVs).
A key improvement in Myanmar’s malaria program is the expansion of community-based malaria diagnosis and treatment. Under this approach, trained community volunteers provide early malaria diagnosis using rapid diagnostic tests (RDTs), provide antimalarial treatment and refer severe cases to health facilities. This strategy improves access to essential malaria services in hard-to-reach areas where formal health facilities are limited.
Additionally, the program has strengthened surveillance and reporting systems by integrating malaria data into the national health information system. Real-time case reporting has improved early outbreak detection and targeted interventions. The distribution of long-lasting insecticide-treated nets (LLINs) and targeted indoor residual spraying (IRS) has also contributed to reducing malaria transmission. These interventions led a system-level improvement by enhancing service delivery, workforce capacity and health information systems.
As a result of these efforts, Myanmar has seen a substantial decline in malaria morbidity and mortality, demonstrating the effectiveness of health system strengthening in disease control.
Despite these improvements, several barriers may hinder the successful implementation and sustainability of the malaria program.
First, geographical and logistical challenges are major barriers. Many malaria-endemic areas in Myanmar are remote, forested, or affected by poor transportation infrastructure. These conditions make it difficult to deliver supplies such as RDTs, medicines, and bed nets, and to supervise community health workers regularly.
Second, human resource constraints can limit program effectiveness. Community malaria volunteers often work with limited incentives, leading to high turnover and reduced motivation. Inadequate training refreshers and supervision can affect service quality, including correct diagnosis and treatment adherence.
Third, political instability and conflict pose serious challenges. In conflict-affected regions, access to communities may be restricted, disrupting service delivery and surveillance activities. Population displacement can also increase malaria risk while making follow-up and reporting more difficult.
Fourth, financial sustainability is a critical barrier. Myanmar’s malaria program relies heavily on external donor funding. Any reduction or delay in funding can disrupt program activities, including procurement of medicines, training, and monitoring. Limited domestic health financing may threaten long-term malaria elimination goals.
Finally, community awareness and behavioral factors may affect program success. Misconceptions about malaria, inconsistent use of bed nets, and delayed care-seeking behavior can reduce the impact of interventions, even when services are available.
In conclusion, the community-based malaria control program in Myanmar represents a significant health system improvement by increasing access to diagnosis, treatment and prevention services in underserved areas. However, barriers such as geographical challenges, human resource limitations, political instability and community-related factors may hinder effective implementation.

[Yin Moe Khaing]

I would like to consider that an example of a health system improvement could be the integration of rehabilitation services into the primary health care (PHC) system at township and community levels.
Rather than delivering rehabilitation only through NGO or hospital clinics, rehabilitation—including physiotherapy, basic functional assessments, early intervention, caregiver education, and provision of simple assistive devices—would be embedded into routine primary health care services. This means training primary health care workers and community volunteers to deliver basic rehabilitation support, detect developmental delays early, and refer children with complex needs to higher levels of care. Integrating rehabilitation into PHC brings services closer to families, reduces travel cost and delays, and improves equitable access for children in rural or underserved areas. This approach reflects WHO’s guidance that rehabilitation should be part of universal health coverage and included at primary care level to reduce cost and improve timeliness and equity of service delivery.
However, there could be possible barriers in this process. First, there may be insufficient training programs or ongoing supervision for primary healthcare staffs. Without a strong, well-trained workforce, integration can be ineffective or inconsistent. Second, integrating rehabilitation requires funds for training, basic equipment, supervision, and assistive devices. In resource-limited settings like many parts of Myanmar, health budgets may prioritize acute care and infectious diseases, leaving rehabilitation underfunded. Third, leadership and governance, clear policies and leadership at national and local levels are needed to support integration. Moreover, health information and monitoring systems are also needed. Routine health information systems often do not capture rehabilitation data, making it difficult to monitor coverage, quality, or outcomes. Without clear indicators, planning and advocacy are weakened. Last but not least, stigma and lack of awareness about disability can limit caregiver engagement with rehabilitation services.
Reference: https://www.who.int/activities/integrating-rehabilitation-into-health-systems
https://www.who.int/publications/i/item/9789241515986

[Nang Phyoe Thiri]

An EHO operates in hard-to-reach, conflict-affected area providing primary health care services and public health awareness sessions. Until last year, data from service delivery were collected using paper-based systems. Key challenges are seen in data quality, report timeliness, data usage, data fragmentation to gather meaningful insights from data and many more.
The EHO launched a digital transformation initiative in HIS system to promote HIS improvements.

Key activities include:
HIS system assessment – Using various tools to gather information about strengths and areas of improvement in current HIS.
Stakeholder advocacy – Advocacy sessions are conducted to get stakeholder buy-in.
Standardization of forms/formats – Paper forms/formats which were previously diverse depending on various donor and project requirements are standardized. This helped the organization readiness for smoother digital transformation.
The variables included in the forms are chosen by cross-checking minimum donor requirements, selected health system indicators and by reflecting current implementation activities.
Development of Data Management and data flow SOP – to streamline the data flow and data management procedures from data sources, data collection, data collation, data analysis, reporting and data usage.
The SOP includes data flow maps, selected health system indicators, roles and responsibilities, standardized forms/formats, detailed process throughout the data lifecycle including data storage, data privacy and data security.
Capacity building to staff – HIS focal points and related staff are trained on digital skills and HIS software.
Pilot testing – The digitalized HIS was tested for three months followed by review meetings and modifications of the process according to the users’ feedback.
We finally aim to integrate HIS with LMIS & HRIS to foster data usage and data-informed decision-making. Regular reviews and modifications will be needed to enhance the adoption and success of the transformative change.

Key barriers are:
Limited digital literacy – field staff have limited digital capacity and high staff turnover rate leads to loss of trained staff. We introduced training in basic digital skills first, to enhance staff readiness.
Resistance to change – some senior staff are accustomed to legacy paper-based system, and we need to conduct sessions of advocacy to get buy-in.
Digital infrastructure and internet connectivity – basic digital infrastructure and internet connectivity is an important issue in remote and conflict-affected areas.
Sustainable financing for system transformation and system maintenance – long-term financing and technical support remains a challenge.
Data security and privacy issues – for legal, ethical and reputational risks.

Improving HIS and driving digital transformation in an EHO setting can significantly strengthen service delivery, outbreak detection, accountability, and strategic planning. However, success depends not only on technology but also on people, processes, financing, leadership, and governance. Anticipating barriers—such as limited digital skills, infrastructure gaps, sustainability risks, and weak data culture—and addressing them through phased implementation, strong capacity building, and institutional ownership is critical for long-term impact.

[Wirichada Pan-ngum]

Good discussions of Myanmar health system for many diseases. There seemed to be common issues of capacities, access to internet and technology, political stability etc.

[Tee Tar]

Strengthening the health system in Myanmar is extremely challenging, mainly because of long-standing political crisis, fragmented authority, and low levels of trust. For more than seventy years, military rule and protracted conflict, particularly in ethnic areas, have severely weakened public health and education systems and led to the systematic neglect of ethnic communities.
As a result, health services in ethnic areas rely heavily on community-led and ethnic health organizations, which operate with limited resources, weak recognition, and constant security risks. These political realities strongly shape what is possible in health system improvement.

One important example of health system improvement in this context is strengthening disease surveillance at the community and primary health care level, particularly in conflict-affected and resource-limited ethnic areas. Disease surveillance is essential for early detection of outbreaks, timely response, and practical planning where communities are vulnerable and health resources are scarce.

In many ethnic health service areas, disease surveillance remains weak due to fragmented reporting systems, reliance on paper records, delayed data sharing, and limited feedback to frontline health workers. Strengthening this system may involve using simple standardized tools, basic mobile or digital reporting, regular data review, and clearer feedback links between community health workers, ethnic health organizations (EHOs), clinics, and coordination bodies. When done well, improved surveillance helps detect outbreaks earlier, supports better use of limited resources, and allows decisions to be based on real information from communities.

In practice, stronger surveillance improves coordination across the system. Community health workers can report priority diseases more quickly, clinics can respond sooner, and ethnic health authorities can plan activities based on up-to-date data. It also helps health workers see reporting as useful for improving services, rather than just paperwork.

However, in my personal point of view, several barriers have affected this health system improvement process:

1. Political and governance barriers:
Long-term military control, lack of rule of law, and ongoing conflict have weakened public institutions and accountability. Limited coordination between actors, parallel systems, and unclear leadership make it difficult to build and sustain a unified surveillance system.

2. Human resource and capacity barriers:
Many health workers in ethnic areas have limited training in data collection, analysis, and digital tools. Heavy workloads, insecurity, displacement, and high staff turnover reduce data quality and consistency.

3. Infrastructure and resource barriers:
Remote areas often lack reliable electricity, internet access, and reporting devices. Many ethnic health services depend on short-term humanitarian funding, which threatens sustainability when funding decreases.

4. Trust and data protection barriers:
Health workers and communities may fear misuse of data or political consequences, especially in conflict settings. Limited trust among different health actors and varying levels of digital and political understanding also reduce information sharing.

In conclusion, strengthening disease surveillance in Myanmar’s ethnic and conflict-affected areas is an important way to improve the health system and make better use of limited resources. However, success depends on addressing political, governance, capacity, infrastructure, and trust-related barriers. Technical improvements alone are not enough without long-term investment, inclusive governance, and sustained support for ethnic health systems.

[Hteik Htar Tin]

In recent years, the Sexual and Reproductive Health (SRH) service provision improvement in Myanmar is one of the improvement of health system targeting in reduction social barriers about SRH and make behavioral changes among the communities. As Myanmar is one of the developing countries, only governmental system is not enough to provide health services for all communities. Non-governmental organizations (NGOs) and local organizations (Community based organizations (CBO), ethnic health organization (EHO)) are largely participating to get universal health coverage (UHC) perceptively. About 10 years ago, both medical and non-medical communities were reluctant to talk about SRH in public health education and accepted as this was inappropriate according to culture and norms. So, many violations of SRH to girls, women and LGBTQ+ were happened and sexually transmitted diseases were spreading among working aged group and it caused huge impact on health status of country.
Due to these results, both Ministry of Health (MOH) and NGOs were collaborating to change the behavior of Myanmar communities relating the risky behaviors of sexual and reproductive health, to get equitable reproductive health services (fully consent contraception, respectful treatment for sexually transmitted infection, private consultations, safe abortion care, ante-natal care, emergency obstetric care). This brings many changes for health system: trained many basic health staff and community volunteers about SRH, seen the changing behavior about SRH among the community (overcome social norms and beliefs), known their rights and can advocate to get by youths and adolescents. Decentralization of governance in health system is ongoing and it makes evidence-based decision in implanting health projects. These are the current health system improvements.
To sustain this improvement, all dispersed activities and data should be combined and shared among stakeholders. Current challenge is weakness in timeliness of reporting, not widely accessible to standardized data reporting and sensitivity issue of data sharing in some areas. The health information sharing is important in health governance and one of the system barriers. The second barrier is financial support and the current health system required risk pooling or risk sharing practice as health financing sector. The service costs at private health systems are very much higher and the public health system cannot cover all basic health services, the services of NGO cannot reach for all levels, the communities have to pay out-of-pocket expenditures to get health services.

[Salin Sirinam]

Changing of dialysis policy in Thailand

In 2022, Thailand changed its national dialysis policy from a Peritoneal Dialysis (PD) First model to Patient-Led Dialysis. This improvement aimed to allow patients to choose their preferred dialysis modality (HD or PD) based on individual clinical needs and lifestyle preferences without additional financial burdens. The goal was to move away from a “one-size-fits-all” approach and increase patient safety by reducing the morbidity and mortality risks sometimes associated with forced PD in unsuitable candidates.

However, recent reports have shown that this policy has significant barriers, leading to unintended consequences for both patients (e.g. worse clinical outcomes from poorly planned initiation) and the health system (e.g. over-dialysis and the neglect of home-based PD). The barriers include:

– Informatics Barrier: A lack of interoperability between hospitals, private HD providers, and the budget payer’s database (NHSO-National Health Security Service). This makes it difficult to monitor real-time efficiency or track patient outcomes across different stakeholders

– Workforce Constraints: The increase in demand for HD has led to a shortage of specialized healthcare professionals, which affected the quality of treatment

– Financial Sustainability: This affected the Universal Coverage Scheme budget, as HD is significantly more expensive for the health system to maintain than home-based PD

– Incentive Bias: Private clinics may prioritize HD sessions for revenue generation, which could lead to over-dialysis for unsuitable candidates

Ref: https://www.nature.com/articles/s41591-025-04084-w
https://www.hitap.net/en/document/policy-brief-191-sustainable-kidney-replacement-thailand-2022-reform/

[Wah Wah Lwin]

Thanks for sharing dialysis policy in Thai, Khun Salin. It’s sad to know that private clinics prioritize on profits rather than patients’ actual needs. Yeah, it’s also happening in my country as well, where policy is weak and ethical issues are neglected.

[Jenny Bituin]

I would like to share about PhilHealth Check Utility (PCU) Liveness Check, a health system improvement introduced last October 2025 by PhilHealth, the government corporation tasked to administer the National Health Insurance Program of the Philippines. PCU is an online tool accessible via the PhilHealth Member Portal that allows individuals to verify their PhilSys (Philippine identification system) registration and validate their PhilHealth membership status. Using personal details and facial recognition, it confirms identity, performs liveness checks, and automatically tags verified users in the PhilHealth database to support secure and streamlined access to all benefits.

Here are the barriers that we have encountered/will possibly encounter while using the PCU:
1. Accessibility
Using PCU Liveness check requires a stable internet connection and a smartphone with camera, which some patients do not have access to. Some patients were also not very computer/digitally literate, making the process of using the tool difficult for them.

2. Increased consultation and waiting time
A PCU liveness check must be done by the patient during the selection of his/her preferred primary care clinic, First Patient Encounter (FPE) assessment, and every consultation. Using the PCU tool every consultations increased consultation time because many patients need assistance using the tool, especially those who are using it for the first time and those who received errors during the liveness check.

3. Additional burden to patients and healthcare workers
As stated in the PhilHealth circular patients must use the PCU liveness check every time they avail a service with their accredited public or private healthcare providers. For example, a patient who availed medical consultation for three consecutive days must also do the PCU liveness check for those three days. Repetitive liveness check adds a burden to both the healthcare workers and the patients.

4. Data privacy concerns
The PCU tool asks for the patient’s personal details and facial recognition, and some patients may be hesitant to share their personal information in fears of their data being hacked/compromised.

[Myo Thiha]

Community-based HIV Testing and Linkage to Care in Ethnic areas of Myanmar

In ethnic areas of Myanmar, access to facility-based HIV testing services is often limited due to geographic and many other conditions. This initiative includes community-based HIV testing services and linkage to treatment by trained CBS and community-based health workers from local ethnic communities. HIV screening services are integrated into outreach activities with clear referral linkage to ART providers operated by EHOs, NGOs, and nearby public facilities.

Possible barriers under current situation

Security and Access to service constraints – the ongoing conflict and travel restrictions can disrupt outreach activities, supervision, patient referrals, and service continuity.

Stigma, Discrimination, and local governance – HIV-related stigma, combined with cultural norms in these communities, may limit the KPs from testing. Additionally, drug eradication policies in some areas create barriers to accessing PWID.

Supplies and commodities challenges – Limited access to standard test strips, self-test kits, ART, and commodities are still challenges in these areas.

HR and Capacity gaps – Community-based health workers may have limited formal training, refresher training, and minimal supervision, affecting service quality.

[Author]

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