Discussions of DEA results, strengths and weakness
The findings of this analysis demonstrated that eleven (39.3%) out of twenty-eight countries were technically efficient and the remaining seventeen inefficient countries could improve 1.28% (compared to efficient countries in this study) without using more resources. Being the least efficient country, Pakistan had the lowest HALE and the highest IMR. Countries with the highest HALE, Maldives, and lowest IMR, Lebanon and Malaysia, were among the efficient countries and as expected, majority of efficient countries had higher than average HALE and ISR. Although Bangladesh and Cambodia had slightly lower than average HALE and ISR, they were on efficiency frontier because of their very low inputs. This suggests that these countries made good use of their scarce resources to produce good health outcomes.
The findings from a previous study that includes all low-, middle- and high-income Asian countries showed that Bangladesh was the only efficient country belonged to lower middle-income countries and majority of efficient countries; Singapore, Japan and Cyprus, belonged to the high-income countries (15). In our study Bangladesh was also one of the efficient countries, but results were not completely comparable because of the differences in number of countries, inputs and outputs involved.
The DEA’s identification of peers provides an important and useful policy information for inefficient countries to reform their health systems. The selected sample in this paper included Asian countries only. Geographic proximity makes it easier for country to relate within their region. An inefficient country could focus more on peer countries with higher reference weights as they are likely to be better role models to emulate their health care policies and practices.
Although DEA is very useful, it has its own limitations. The method cannot measure true efficiency and results can change depending on the number and nature of DMUs selected in the sample. The inefficiency results tend to be underestimated as it is calculated in relation to the efficiency frontier of the sample. For instance, Myanmar’s efficiency score 0.9794 does not mean that it could improve only by 2.06%. It means that Myanmar could improve 2.06% compared to the most efficient country in the sample selected.
In this analysis, only CHE per capita, doctor density and nursing and midwifery personnel density were used as inputs. Although other factors outside of health system like education, social class, lifestyle, environmental factors and country policy etc. play an important role in health outcomes, these factors were not taken into account in this study.
Comparative analysis of health systems of Myanmar, Bangladesh and Sri Lanka
Myanmar should learn successful strategies of health systems from its benchmark countries, Bangladesh and Sri Lanka, to improve efficiency. “A system framework for analysing the efficiency of health care resource use” indicates that health system efficiency can be influenced by a set of policy instruments: financing, provider payment methods, organization and regulation (10). The policy makers should target these instruments to reform their health system to be more efficient. In the following sections, the health systems of three countries are compared and analysed in terms of policy instruments. However, provider payment methods are not used owing to a lack of comparable data.
Table 3 describes health financing of Myanmar, Bangladesh and Sri Lanka. Myanmar’s current health expenditure is around 5% of GDP. The majority of CHE comes from OOPs (77%) and domestic general government health expenditure is only 14% (18). Health insurance scheme called ‘Social Security Scheme (SSS)” for employees is regulated through the Ministry of Labour, Employment and Social Security, but its contribution is negligible (31).
In Bangladesh, current health expenditure is only 2% of GDP. CHE is mainly made up of OOPs (73%) and only 16% are contributed by domestic general government health expenditure (18). In recent years, some non-governmental organizations (NGOs) have piloted health insurance schemes, however, there is no successful health insurance in Bangladesh yet (32).
The CHE of Sri Lanka is around 4% of GDP. Government health expenditure is the highest (43% of CHE) and OOPs is the lowest (50% of CHE) among three countries (18). Even though national health insurance scheme has not yet developed, there are a contributory health insurance scheme that covers some public-sector employees, a growing private health insurance industry that covers mostly private sector employees and publicly-financed school health insurance scheme that covers all students, with caps on claims (33). Sri Lanka has introduced tax on sugar sweetened beverages to tackle risk factors for non-communicable diseases (NCD) (34).
Myanmar’s health care system has evolved with changing political situation and growing demand from people. Although both public and private sectors are involved in health care financing and provision, the Ministry of Health (MOH) remains the major provider of comprehensive health care services providing all aspects of health care. The MOH supervises both administrative and technical functions of state/region health departments, district health departments and township health departments (35). The private, for profit, sector has expanded rapidly especially in major cities and it is estimated to provide 75%-80% of ambulatory care (31).
International aid agencies used to have difficulty in engaging Myanmar Government under the isolated military regime, but this is changing under the quasi-civilian government (36). At present, community-based organizations, local and international non-governmental organizations are increasingly involved to deliver health care services across the country. However, one review article about ‘Healthcare in Myanmar’ suggests donors to discuss the health care systems more openly to reduce overlapping functions and to avoid duplicated donations (31).
The Bangladesh health system is made up of five-layers. The lowest level is village health facility with community clinics, the second layer is Union health and Family Welfare Centre, the next level is the Upazila Health Complex and the fourth level is the district hospital with theatre facilities. Medical colleges and post-graduate institutes offering a wide range of health services are at the top of the health system (37).
The government of Bangladesh accommodates many stakeholders and explicitly works together with the private sectors, local and international non-governmental organizations (NGOs) and informal providers. Extensive community programs are very successful in reaching all households in community and implementing health programs such as maternal and child health and family planning programs etc. Pro-women development programs in economy, education as well as health sectors shown to improve health of the population (38).
Sri Lanka’s mixed health care system consists of a tax-funded public sector and a fee-for-service private sector. The public sector provides 95% of inpatient care and approximately 50% of outpatient care. The central Ministry is responsible for providing technical guidance and policy making, medical education, research and development, management of national facilities and purchasing and distribution of drugs and medical supply. The nine Provincial Directors of Health are responsible for the management and implementation of health services in the provinces (33,39).
Systematic investment and a firm foundation of primary health care have resulted in the country’s many health achievements like reaching most of the targets of Millennium Development Goals (MDGs), reducing maternal and neonatal mortality and eradicating communicable diseases such as malaria, tetanus and filariasis etc. Therefore, country’s primary health care system has been recognized internationally as a low-cost high-impact system (34,40). Sri Lanka’s MOH cooperate with other government agencies, development partners, academia and non-governmental organizations in implementing its activities, so that a multitude of partners are active in the health sector in Sri Lanka (34).
In terms of regulations and policy, Myanmar has regulations for licensing medical professionals, the national essential medicine policy, the food and drug administration regulations and national health plan every five years but there are few resources and limited capacity to implement them (41).
The government of Bangladesh has established professional regulatory and statutory bodies such as the Bangladesh Medical and Dental Council and Pharmacy council, etc. The National Drug Policy was updated in 2016 to ensure the access to the essential medicines. The Health Care Financing Strategy 2012-2032 was developed aiming to increase funding to reduce personal expenditure on healthcare services and to protect financial risk (37).
Sri Lanka has regulations for essential drugs and drug development, medical doctors and nurses to benefit people. Health master plan 2007-2016 was set out to rationalize primary health-care delivery structure. The national policy and strategic framework for prevention and control of non-communicable diseases was finalized in 2010 to highlight the strategy on health delivery organization change. National health policy 2016-2025 was guided by principles of people-centered care, equity, quality of services and financial protection (33,40).
What Myanmar can learn from Bangladesh and Sri Lanka
Bangladesh has been recognized as an example of “good health at low cost” and praised for exceptional health achievements (42).
First thing that Myanmar should learn from Bangladesh is its extensive community-based health service delivery system. It reached almost all the households in rural areas and achieved high coverage. For decades, both government and NGOs use large-scale community-based health workers to address the shortage of human resources in health sectors. One successful tuberculosis (TB) community program (more than 90% cure rate) was already adopted by South Africa for treatment of TB and Human Immunodeficiency Virus (HIV) (43).
Another thing to learn is Bangladesh government’s willingness to create an environment for pluralistic health system. Government of Bangladesh has partnered with NGOs, private sectors, informal providers and international donors etc., to address limitation of health care resources in government in order to improve health outcomes of population (43).
Last but not the least, Myanmar should look at how women empowerment in education, economic as well as in health sectors make impressive achievement in Bangladesh’s health system. Bangladesh’s education policy that favours girls reduced gender inequality and helped achieve almost universal primary education for aged 6-10 years. Grameen’s microcredit for poor rural population, especially for women, was well known innovation in economy and was awarded Nobel Peace Prize in 2006 (38). This microcredit program, together with improvement in education, helped increase women empowerment. This, in turn, has positive effect on women decision making power within and beyond their own family including decision making for health of their family members. In health sector itself, women are employed as frontline workers for most community-based programs, and have exceptional achievements (44).
From Sri Lanka
Among low- or middle-income countries, Sri Lanka health care system has been recognized to achieve good health outcomes, financial protection and low cost. Many countries are praised for achieving two out of three, while few can claim to have done so well as Sri Lanka on all three (45). One important thing Myanmar can learn from Sri Lanka is its firm foundation of primary health care system that accounts for the country’s achievements. The public health care system comprises two streams of primary care services: preventive and curative sectors (33,40).
Preventive health sector covers the entire country systematically and have already achieved impressive results in maternal and child health and communicable disease control activities. Preventive service delivery is decentralized to the provincial departments of health led by medical officer of health who is a general practitioner with public health training. Each medical officer of health is supported by a public health team consisting of assistant medical officer of health, public health inspectors, public health nurses and public health midwives. On the other hand, Sri Lanka’s government has now been reforming the curative health sector- which is not well organized as preventive one - focusing on the primary care level to address the increasing burden of non-communicable diseases (33,40).
Myanmar health care system is still weak in above mentioned practices. Therefore, it will be very useful for Myanmar to adopt these approaches: strengthening primary care services, training community-based health workers in rural area, cooperating with donors and restructuring health financing system, in order to reform its health system.
First of all, Myanmar’s primary health care system should be strengthened. As a lower middle-income country (LMIC) where there are limited health care resources, strengthening primary health care is the most efficient way to provide good health care at low cost. In fact, investing in primary care which provides prevention, promotion as well as treatment, will achieve good value for money. According to WHO policy note, putting primary care second place to hospital services is one of the challenges for Myanmar health system to achieve universal health coverage (46). Myanmar health system review also mentioned that allocating a majority of budget to secondary and tertiary hospital care services at the expense of primary health care could cause detrimental effect on equity (41). This is the evidence of how primary health care is important in a LMIC like Myanmar. Allocating more budget to primary care as well as increasing overall government’s financial investment in health will be necessary to strengthen and upgrade primary health care. Moreover, medical officer or general practitioner who run the primary health care should have proper training that Myanmar still lacks.
Myanmar has an inadequate number and uneven distribution of skillful health workers between urban and rural area (31,46). To address this issue, government should work together with NGOs to train and retain local people in order to have sufficient community-based health workers for underserved rural population. In particular, for maternal and child health, women health workers should be prioritized as women are more comfortable to talk about their health issues to women health workers. In addition, women employment can also increase women empowerment from their own income.
As a LMIC, Myanmar government’s health expenditure (US$ 8 per capita for 2016) is far lower than proposed target (more than 5% of GDP and more than US$86 per capita) to achieve universal health coverage (47). This means that Myanmar will need help from international aid agencies to address the shortage of health care resources in government. To use the donor’s health care resources efficiently and to reduce overlapping donations, Myanmar government should cooperate and discuss openly with international aid agencies and NGOs.
In terms of health financing, neither of these three countries has established health insurance. However, they recognize the need of financial protection and they are now piloting and trying to reorganize their financing strategy. In addition to the practices mentioned above that already proved efficient in Bangladesh and Sri Lanka, Myanmar should now consider financing reform in parallel with its efficient countries. At present, Myanmar government do not have sufficient resources, so that government cannot, realistically, provide health insurance for all citizens. A combination of different insurance models will be the only option that could provide financial protection for the whole population.
Current health insurance scheme, the social security scheme (SSS), providing health insurance for formal workers covers only 1% of the population. The health care services provided by the SSS do not satisfy the customers for poor health facilities and long reimbursement process. Firstly, that social security scheme should be scaled up and strengthened to cover all formal workers with contributions from both employees and employers. As formal sector employees and their families pay for (as contributions to SSS) the free public health services they currently consume, there will be more free public resources left to the poor.
To cover elderly, poor and vulnerable population, tax-based health insurance should be arranged through direct and indirect tax. One option to be consider for increasing government tax revenue is ‘excise tax’ - a kind of tax imposed on products that have a negative impact on health like sugar-sweetened beverages, tobacco, alcohol and fossil fuels (48). Such tax can be earmarked to finance health system only. Imposing excise tax can result in healthier population as well as can generate additional revenues.
For the population who are not eligible for SSS and tax-based insurance scheme, community-based health insurance should be set up. As weak management, technical and financial difficulties are the common problems of community-based health insurance scheme, government and NGOs should provide subsidies, technical and management advice as appropriate to successfully implement community-based insurance scheme.