Based on salient findings, we structured the results in two large themes - the impacts of COVID-19 on the provision of care and the impacts of COVID-19 on accessing and using care. The sub-themes under the impacts of COVID-19 on the provision of care were: availability of services at the health facilities, availability of service providers at the health facilities and availability of medicines, equipment and other commodities. The sub-themes under the impacts of COVID-19 on accessing and using care were: seeking care, reaching care and receiving quality care (according to three-delay framework). Lastly, we also explored how people cope with the crisis, including how they received information to cope with the crisis and sought available alternative health care services.
1. The impacts of COVID-19 on the provision of care
Although Myanmar responded early to the COVID-19 breakout, it faced three major waves1 of the pandemic, starting from March 2020. The findings here will be described wave by wave.
1.1 Availability of services at the health facilities
It was found that the health facilities which had been open and easily accessible were not available anymore during the COVID-19 period. During the first and second waves of COVID19, almost all the health facilities and health staff shifted their efforts to COVID-19 prevention and care activities rather than routine health care services. According to the participants, this shift caused interruption to the routine health services such as antenatal care, immunization, NCD management and basic emergency care in most of the public health facilities. This limited availability reached its peak in the third wave. During the third wave of COVID-19, the overburdened Myanmar health system had to face the additional crisis of serious human resource shortages and challenges of personal safety from the unexpected political situation, which has made it a lot more difficult for the service users to access routine essential health care services.
“Yes … this pregnancy is … much more difficult for me. In previous pregnancies, I could easily access to the hospitals. And I did not have to worry about receiving AN care at the UHC (urban health centre), receiving the blood testing and urine testing services.” (IDI 8)
Pregnant women faced difficulties in seeking routine obstetric care services because many primary care facilities within their reach that had previously provided these services, shut down. To receive those services, some had to travel for a very long distance and had to spend much more time to get to the services.
“Since the health centres near me are all closed, they told me to go to the Gymkhana (the largest tertiary hospital for Women’s Health in Myanmar, also known as Central Women Hospital) which was very far from South Dagon (about an hour from my home with a taxi) I had to go there four times to get one antenatal service … and it costed a lot each time … I left …. in the morning …. around five am in the morning and arrived at the hospital around seven am.” (IDI 8)
Some people with chronic diseases needed to change their service usage from public hospital to private hospital as public hospitals were not able to provide the usual services during the COVID-19 period.
“We could not go to North Okkala General Hospital since February. All the public hospitals were not able to give regular services including blood transfusion since February. So, we had to change to private hospitals to get blood transfusion, which was very costly” (IDI 3)
Moreover, COVID-19 positive patients were not able to receive services in government public hospitals as there was a severe imbalance between the patient load and health staff. As many of the COVID-19 positive cases were not treated in time, community spread worsened and demand for health services was intense, especially during 3rd wave, and home-based care for COVID-19 was the only option, involving a terrible chase for oxygen supply by the community.
“It was … my next-door neighbour. ….. He died. He went to Yangon General Hospital and no space available there, so he went to North Okkala General Hospital because his oxygen level kept dropping. He couldn’t get a chance to be admitted at the hospital and came back home. He died immediately after coming back home. That’s what happened near my home. This is the reality.” (IDI 11)
Additionally, the services at the general practitioner clinics in the community reduced compared to the first and second waves. Many of the clinics shut down due to the high intensity of community spread of COVID-19 infection in the third wave.
“It was … umm. sometimes, during this period, umm .. naturally, .. the doctors were afraid of … they sprayed with sanitizers when patients left their clinics and closed the clinic .. many difficulties… So, we had to inquire which clinic opened because many clinics closed at that time and doctors are also afraid of accepting the COVID-19 patients.” (IDI 11)
1.2 Availability of service providers at the health care facilities
The primary, secondary and tertiary care facilities faced serious shortages of skilled health staff not only because of COVID-19 infections hitting health staff but also because many health staff were in the Civil Disobedience Movement during the third wave.
“The problem was doctors and nurses’ shortage. I felt so sorry for the doctors and nurses at the hospital. There were many patients and only a very few doctors, they had huge workload, they must be very tired. As a result, they became less efficient. I was punctured 3 or 4 times for one blood test.” (IDI 3)
Patients outnumbered the capacity of the health staff in the health facilities, especially at the tertiary health care facilities.
“So, with lesser number of skillful professionals, it is harder for the patients. And there were situations like patients outnumbered the health staff. It was such a hectic situation.” (IDI 3)
In the community, the people could still rely on the services provided by the community providers and health volunteers like auxiliary midwives and community health workers for minor illnesses.
“If I encounter health problems, … I will ask help from Sayarma (an auxiliary midwife). I have only her near me to rely on. She said not to worry about the delivery. She said she would be there for me. So, I rely on her.” (IDI 9)
1.3 Availability of medicines, equipment and other commodities
With increasing prices during the COVID-19 period, people faced serious shortages of drugs, especially in the third wave. This impact was significantly seen on the COVID-19 positive patients, and on the people with chronic illnesses, especially during the peak of the outbreak.
“Because at that time, we could not buy the usual brand and only the similar ones were available. The last time, it was … the stocks were very limited, even paracetamol was not available. I always bought paracetamol India brand with 200 Kyats for one strip, but it became 1,500 for one strip. The pain killers were all stocked out. The demand was so high. Thus, the price became very much higher.” (IDI 6)
Compared to first and second waves of COVID-19, the tertiary health facilities have been facing shortages of essential drugs and other medical supplies most seriously during the third wave. The most important and significant shortage was the unavailability of oxygen supplies for COVID-19 patients, which took many lives.
“He died (the neighbour) due to not getting oxygen in time. Although he went to two big hospitals. Oxygen was so scarce, and the only hope was at the hospitals and so sad even though he reached there… he did not receive it. (IDI 11)
2. The impacts of COVID-19 on accessing and using care
We structured our findings on utilization of care according to the three-delay model.
2.1 Seeking care
Regarding care seeking practices, almost all pregnant women who participated in the study had knowledge and previous experiences of when to seek health care relating to pregnancy and delivery. However, it differed in the chronic care group. These people often lacked knowledge of regular and emergency care, depending upon the duration of diagnosis. For those with longer illnesses, they often thought that it could be treated by themselves using simple remedies. This perception may put them into danger because of delays in seeking care.
Seeking care also depends on financial flexibility. Those of medium socio-economic status were abler to overcome the obstacles in seeking health care and to plan for emergency situations than those of low socioeconomic status.
For the people with a low socio-economic status, during the COVID-19 third wave where the twin crises happened, financial difficulty became the major challenge in seeking necessary skilled obstetric and other medical care. Due to their inability to access skilled care in this phase, people with low socio-economic status reported feelings of hopelessness, which could cause negative pregnancy and disease outcomes.
“Right now, my husband’s work is not very good because there was long period of closing down, his job was suspended for two months. I have no job now. Previously, me and my mother opened a small shop of “Mont-hin-khar (Myanmar traditional rice noodle)”, but now, we have to close the shop as people were afraid to buy and eat from outside vendors and it is very difficult for us. I haven’t prepared anything for the delivery yet.” (IDI 12)
“This time I got pregnant, I felt really depressed and even thought about …. nonsense … like
… umm … due to these COVID-19 and coup crises … I even thought about having an abortion. But I controlled my mind and took care of this pregnancy since it is reaching to its fourth or fifth month. I have been depressing a lot. (IDI 8)
There was reticence in some cases of low socio-economic status individuals seeking care due to COVID-19 due to concerns about the burden it may impose on the family.
“I told my family that … I will try to take care of myself as much as possible. But if something happens, and I need to be hospitalized, I would rather die. I don’t want to give troubles to anyone, no one is financially ok. It would be like giving my burden to the others.” (IDI 10)
Regarding knowledge of the disease process, people with medium socio-economic status (and often education levels) seemed to better understand their disease and care process and to have more knowledge on when to seek care.
“Although, my doctors asked me to check-up with them every two to three months, I regularly did my lab tests once a month just to monitor myself.” (IDI 1)
2.2 Reaching care
During the COVID-19 period, it was very hard for the community to reach care. Transportation difficulties were one of the major problems described by the participants in reaching the health care facilities, especially for the pregnant women of lower socio-economic status. Many of the participants needed to spend larger amounts of money per month, e.g. approximately one-third of the monthly earning for some people, on the transportation cost per visit as the only available health facility was so far from their residence. For emergency conditions and at night, many philanthropic organizations helped the community by providing ambulance services, yet this was of limited help for those who seek regular care.
“For one visit, transportation alone costed me 15,000 MMK. I had to leave home very early in the morning around 5 am to reach there in time at 7 am.” (IDI 8)
Transportation cost was not a serious problem for the pregnant women of medium socioeconomic status. But these participants also needed to worry and plan for emergency conditions, since night-time curfews had been announced in almost all townships of Yangon (this was stricter during the third wave of COVID-19).
“At that time, there was a curfew … and I was thinking of how I would get to the hospital if there was an emergency .. how to do if I needed an ambulance … who would come with us…. and so on. We live in Sanchanung, so I gathered all the information of the social support organizations in Sanchaung and noted down and contacted them in advance. That was quite an amount of work.” (IDI 2)
For people with chronic illnesses, reaching a health facility even in normal times was a different experience for people of different socioeconomic status. According to the study participants in the medium socio-economic group, more options such as private clinics and specialist care were available as alternatives to health care services at the public health facilities. For those in the lower socio-economic group, fewer options were available and accessible.
“I could not afford to consult with a specialist doctor since I have been struggling to earn money for daily foods. Providing food for the family daily was a bigger struggle for me. I asked the doctor … if I could not come anymore, would it be possible for me to continue the prescribed drugs on my own. He said to continue taking the prescribed drugs if I could not come for regular follow-up. If I have severe shortness of breath and chest pain, I go to the general practitioner near here and took some injections.” (IDI 10)
No matter what their socio-economic status is, it was evident that people needed to spend more time and money than usual in reaching care, especially during the third wave. Thus, when they did not have sufficient family support, people could not reach health care in time. It was found that most of the people from lower socio-economic groups did not intend to ask their family members for help and support since they did not want to put more burden on the family members who had been struggling for daily needs and food. Thus, some of them said they would rather die than go to the health care service, the cost of which they would not be able to afford during this difficult time. Additionally, the limited availability of physical cash in-hand was one of the major reasons in stopping people accessing to health care.
“For us, we had just enough money to stay alive. It was so much worse than before. If there would be an emergency now, … I mean an emergency health issue which would cost us 5 or 10 million, we would rather die.” (IDI 11)
“Another issue is the cash. We dare not spend the cash we have in hand. As you know, physical cash is very scarce now, and cash cannot be taken out easily from any bank since the coup. We need to save it. Example – if you feel ill .. at some hospital, you know .. when we go to Grand Hanthar (private tertiary hospital), they accept to be paid with the card or mobile banking, but that is not available after every 20th of the month. Shwe Lamin (private hospital) doesn’t accept mobile banking at all. We need to pay for everything in cash. That is why I made it clear at home, if one of you wants to go and get the services at the private hospitals, go before the 20th. (laughing)” (IDI 1)
All participants, rich or poor and with or without family support, mentioned that they did not really have solid plans for an emergency. Even the people from medium socio-economic status were unsure what to do, who to turn to and to which health facility they would go because there were very limited health resources around the city during the twin crisis.
“Ummm … I … right now … really … think … I think that I am helpless. I don’t know where to go if something happens, you know. The emergency unit at Yangon General Hospital is …. umm …. How can I say? … I am not sure if it is still operating now due to CDM and Non-CDM issues. Another news I heard was … umm …. If COVID-19 positive patients come in, I heard that they refused to admit, they refused to accept these patients.” (IDI 1)
2.3 Receiving quality care
Regarding receiving quality care, some people needed to move from the public government hospital to the private hospitals to continue regular treatment for their illness, which cost much more than in the government hospital, which became a burden for the patients.
“We could not go to public hospitals since February, so we went to private hospitals for blood transfusion. Example - if I can go to the North Okkala government hospital for blood transfusion, it would cost much lesser. And because of COVID-19 risk, the expenses become much higher at the private hospital.” (IDI 3)
Receiving quality care at the public or private hospitals became very challenging for all people, no matter what their socio-economic status is, especially after the military coup in February.
“So, comparing these 2 periods, in the first period, people only suffered from the COVID-19 impact because the government was good; but in second period, people have additional burdens besides COVID-19 because the government was bad. As you know, many people have faced the life-threatening situations more than before. The worst thing they did was limiting the medical equipment and drugs, and finally arresting the doctors and nurses, restricting the activities of philanthropic organizations.” (IDI 3)
While people could not reach care in time during this period, many physicians and consultants provided teleconsultation services, yet the increased consultation fees were considered to be one of the challenges in receiving quality care, because during the COVID-19 period people had fewer job opportunities, resulting in lower earnings than before.
“At that time, my renal doctor had stopped practicing at the clinics completely because he followed the civil disobedient movement and only the teleconsultation or the messenger was available to be in touch with him.” (IDI 1)
“And the consultant fees have been starting to increase since that time. Previously, my wife went to the clinic near the post office which costed only 4,000–5,000 each time. Now, it increased to 9,000.” (IDI 6)
3. How households coped with the crisis
In our study, we found that many people coped with the twin crises of COVID-19 and the political unrest by relying on their faith and religious teachings. Family support structures also played an important role in helping families to cope. Many of our study participants mentioned that they could overcome the stresses and challenges with the support from their family members. We also found that having a good social network was very important to overcome the obstacles faced. Apart from good family support structure and good social network, study participants stated that having small children in the family was one of their stress relievers. Regardless of the socio-economic status, it was noticeable that if participant had a good and organized family support structure, they were better able to access health care more.
“My son is very supportive and is like … I don’t even need to say a word. My daughter-in-law is also very good to me, so is my son-in-law. They said, “the money didn’t matter, only mom’s health mattered.” My daughter-in-law, son and younger daughter, all of them took great care of me.” (IDI 3)
Regarding COVID-19 restriction measures, it was found in our study that people followed the rules and restrictions that were announced by the Ministry of Health very well. At first, people found it hard to follow these restrictions, but the fear of contracting the infection made them accept and follow the rules. To cope with COVID-19 situation, study participants reported that they had changed their lifestyle by wearing masks, washing hands frequently, and practicing the social distancing effectively.
“I think people follow these measures seriously. Because people get frightened since there are many deaths. No one dared to go out. The streets were cleared. Because they were afraid. Afraid to get the infection.” (IDI 6)
Our study participants tried to find alternative pathways to receive the necessary health care services, such as teleconsultations and mobile clinics. The community-based philanthropic organizations and community-based health volunteers played very important roles in households seeking care practices during this difficult time of COVID-19. They supported community members in searching for oxygen and necessary and scarce medicines for COVID-19, but faced official restrictions on their own activities.
“And to fight COVID-19, ….. with the previous government, many philanthropies … like U (name) and his foundation provided lands, buildings, and donated millions of moneys to the government to fight COVID-19. Many people were supported and that is why I think there were lesser positive cases back then. But now, the philanthropies dare not donate oxygen and other necessary things widely in public. Our current motto is “From the people to the people”. So, some active people tried to stabilize the prices of foods and other goods by selling with much lower prices. But they cannot do that very widely because the military tries to arrest them very often.” (IDI 3)
Regarding receiving information to cope with the COVID-19 situation, almost all of the participants reported receiving updated information from Facebook as a primary source. After the coup, people mainly relied on Facebook for information and updated news, rather than state-owned TV channels and newspapers, yet a few of study participants tried to receive news and information from the newspapers. Almost all participants thought that TV channels were not a reliable source of information during this twin crisis. People’s trust in the news media has changed since the February coup.
“On TV …. The news is …. Umm … The news could be biased because of the political reasons.
Umm .. so, I think it is not that reliable.” (IDI 9)
“Previously, regarding the information, we relied on the government’s broadcasting channels, example – previously with Aunty Su’s government, she personally broadcasted the information on TV to get people attention more. I think this way, the message and information that government wanted to give reached more to the people. Now, we do not watch TV news, not listen to radio news anymore, frankly speaking, it is because they announced many fake news.” (IDI 3)
During the first and second waves of COVID-19, before the coup, people relied on the Ministry of Health and Sports Facebook page very much for all the COVID-19 news, information, and preventive measures, but this changed after the coup.
“Previously, when you look at the MOHS Facebook page, you know how many new cases, increasing or decreasing, you know it exactly. Now, it is not good anymore, you cannot get this information from MOHS page plus I don’t watch TV anymore.” (IDI 1)
“Previously, we watched TV, listened to the advises from the respectable professionals, we received the information this way. But now, we have to rely on the advises posted on Facebook by the doctors, professionals, respectable volunteers and technical persons. … We mainly get the information from the trustworthy and respectable online news media.” (IDI 3)
Regarding receiving information for available alternative health care services like teleconsultation services for routine care and treatment, online COVID-19 consultation services for positive patients and information on the availability of oxygen, medicines and other necessary medical equipment, these were all updated mainly on Facebook. People needed to check the respective Facebook pages every day to receive updated information during all three waves of COVID-19.
“I feel like I have enough knowledge. Like I said .. many people shared on Facebook if there is something new. I use it most of the time, so I think am up to date. I don’t watch TV but Facebook and You tube. I tried to get the updated news as much as I can.” (IDI 2)
“I read and followed the posts on Facebook posted by the well-known physicians.” (IDI 11)
Footnote
1 1st wave – March 2020 – August 2020
2nd wave – October 2020 – February 2021
3rd wave – June 2021 – September 2021