The research revealed a lack of trust in the Government administration among ethnic people, between: ethnic communities and Government officials; EHO/CBHO health workers and the MoHS; as well as between some district administrators and military brigades of the KNU and the Government. This represents a significant challenge to collaboration between ethnic health workers and the Government health system.
Between Ethnic Communities and the Government
The civil war and human rights violations against the non-Bamar ethnicities has created a lack of trust in the Government among the ethnic communities that EHO/CBHOs serve. One participant details their experience in the field:
‘As soon as they hear a Burmese name, or that the Burmese are coming, they will just think of the old times when the military comes and destroys the village. There are still many cases when (EHO/CBHO staff) told the patients to go to the (MoHS) hospital [but] the patient still ignores going to the hospital, because they do not trust the Government yet.’ (IDI9, Field Health Worker)
There has been a prolonged historical separation between ethnic and Government governing structures. Ethnic community trust in the Government, and therefore the MoHS, is essential in order for MoHS staff to work alongside EHO/CBHOs in ethnic communities. Without peace and reconciliation, ethnic communities remain apprehensive about any form of Government administration, including those of the health sector.
Between Conservative District Administrators and Military Brigades of the KNU and the Government
KNU has a decentralised administration structure, therefore different areas are governed by different KNU district administrators and military brigades who have decision making power over their controlled areas. Some conservative KNU district administrators and military brigades deny access to any Governmental bodies who wish to enter their territories. The increased presence of the MoHS was perceived to be a form of Government administration expansion. Regions under complete KNU control rely on EHO/CBHOs to meet the ethnic people’s health needs. One respondent working as a health worker in a conservative region states they have not worked with the MoHS staff due to KNU policies:
‘Currently they do not have any staff coming from the Ministry of Health and Sports... The reason KNU have that policy is because they are concerned about the expansion of Government administration to their controlled areas.’ (IDI2, Field Health Worker)
In territories of mixed EAO and Government control, some KDHW branches have a different stance and work more closely with the MoHS on some programs:
‘Mixed area means you have the Government administration, you have the KNU administration. So, there’s no way to stay away from each other… in mixed areas we have more collaboration between MoHS and the KDHW health workers.’ (IDI11, Leadership)
Despite this pragmatic approach to collaboration with the Government, there continues to be breaches in trust. This is due to the violations of the ceasefire such as the building of MoHS ‘Rural Health Centres’ (RHCs) in ethnic areas, one respondent elaborates:
‘Government do not respect the ethnic territories. They come and build the Rural Health Centre, or the Sub Health Centre in the ethnic areas, they do not respect, do not inform, do not consult with us… we feel like they do not respect our administration.’ (IDI11, Leadership)
In the current climate of Covid-19, the Tatmadaw have stated KNU’s screening posts breach the NCA (24), whilst the KNU have stated the Tatmadaw have violated the NCA by forcing ethnic health workers to leave checkpoints, and burning down some screening posts (25). Action by the Tatmadaw and the Government that violates the NCA will continue to engender a lack of trust among some brigades of the KNU and the Government.
Between EHO/CBHO Health Workers and the MoHS
Some EHO/CBHO health workers also felt apprehensive about the MoHS and their intentions, especially with the building of RHCs. One field health worker explains that the centres are not always well resourced:
‘The Government staff they’re trying their best, but… in some areas they have very good infrastructure… But inside the building there’s no medical supplies or medical staff.’ (IDI2, Field Health Worker)
Two respondents share their confusion and concern over the Government`s intentions:
‘There are 9 health facilities that they built. Just close to the existing [ethnic] health organisation’s health facilities. So, does that mean they built it for their own people, or do they come to take the area?’ (IDI4, Leadership)
‘Government come and build an RHC, but they did not assign any people, no medicine, no staff. We are also wondering whether we should take this facility back.’ (IDI11, Leadership)
Some ethnic health workers have said that MoHS staff visit the RHCs periodically to provide outreach services, as this health worker explains:
‘They come to the [Rural] Health Centre only once a month. And once a month they will stay in the centre for 2 or 3 days. And when they come, they just take the data from them. How many ANC (antenatal care patients) ...Then the next month they will come and give the ANC (antenatal care) care to that patient.’ (IDI9, Field Health Worker)
This would be aligned with the MoHS strategy, as the NHP states that services can be provided on a scheduled basis through outreach services until a more permanent solution is found (11). Depending on the region, some ethnic health workers have good relationships with MoHS staff who work at these RHCs, as this respondent describes:
‘In some areas they have good relationships [with RHC staff] and sometimes they even work together. For example, giving health education in the school.’ (IDI9, Field Health Worker)
Ethnic health workers and MoHS staff do not have a good relationship in other areas, given the expansive nature of the MoHS in taking over ethnic health facilities, as explained by the respondent:
‘In some cases, before the ceasefire, Back-Pack team was already in the village and they worked together with the village community, and then they set up a clinic… But after the ceasefire, Government administration came in and take over the building, and then they named it RHC (Rural Health Centre) … After that, they stopped working together.’ (IDI9, Field Health Worker)
RHCs are one example of how a lack of trust between ethnic health workers and MoHS health workers can be propagated if strong relationships aren’t built. The MoHS’ actions can sometimes be perceived as expansive and controlling. One participant notes the negative ‘competing spirit’ between the MoHS and EHO/CBHOs during a humanitarian response to flooding in Kayin state.
‘At that time Back-Pack tried to support [with items] like rice, basket, some donations... As soon as Back-Pack arrived… the Burmese Government also came and gave donations, but with very little support like three packs of [instant noodles] …the competing spirit is still going on.’ (IDI8, Central Office Coordinator)
Many participants agreed that trust building between health workers in the EHO/CBHOs and the MoHS is crucial. This will take time as the political and health systems have been apart for many years as these two respondents explain:
‘I think it will take time to know each other, [there's] a need to build trust….being apart for years… So, it's not easy to trust each other.’ (IDI4, Leadership)
‘It’s been many years that we are under different systems… So, trust building is the main obstacle for collaboration.’ (IDI6, Central Office Coordinator)
Building trust and communication between health workers is key to bringing people together after working in different systems for years. If Myanmar reaches a sustainable peace agreement, peace and reconciliation can begin.