Nilar Khaing explores some problems facing women’s access to healthcare and reproductive services in rural Tanintharyi.
After the Myanmar elections in 2015, the civilian government has been trying to build a democratic system and has attempted to reform all sectors and to develop policies in an effort to achieve peace and a federal union. In order to achieve these objectives, basic healthcare services and education are fundamental things to provide for the population’s social wellbeing and healthy life.
In every democratic country, health and education should be prioritized, and are basic rights everyone should have access to. No one should be excluded. Yet, the reproductive health situation I observed during my research trip to Tanintharyi region in June 2019 shows that these basic rights are still out of reach for some. The research aims to assess the situation relating to sexual and reproductive health awareness and practices, and participants’ access to healthcare services among rural women and girls in the three townships of Dawei, Myeik and Thatyet Chaung. 12 focus group discussions, involving about 150 participants, were conducted with married and single woman above 18, and separately with girls under 18. Additionally, 15 individual interviews with key informants, including public health doctors from the health department, village health staff, volunteers and village leaders were held in May and June 2019. I conducted this research while being deployed for another research project, Communication for the Future: Building Confidence and Trust, that deals with the peace process in Myanmar.
The Myanmar National Health Plan (2017-2021) aims to “strengthen the country’s health system and pave the way towards the Universal Health Coverage (UHC)”. The UHC is defined “as all people having access to needed health services of quality without experiencing financial hardship.” Its main goal is “to extend access of the Basic Essential Package of Health Services (EPHS) to the entire population by 2020 while increasing financial protection”. According to the NHP, the goals are to promote a more effective health information system through collaboration with development partners, active engagement with the Ethnic Health Organization (EHO), non-governmental organizations (NGOs) and private-for-profit providers among the program. Yet, these objectives are far from being achieved.
In the Tanintharyi region, situated near the eastern border of Thailand, access to basic healthcare services and information is a critical concern in remote places and in villages where internally displaced persons (IDPs) stay – particularly for poor families. This area has many different religious and ethnic groups – such as the Dawei, Karen, and Mon – all of whom speak different languages (Dawei, Karen, Mon and Burmese). Myeik and Tanintharyi townships have witnessed long periods of fighting between the military and the ethnic armed groups in the years before the Nationwide Ceasefire Agreement (NCA). Many villagers have been forced to move from their original villages, and thus have been living for years as IDPs in remote areas with their community. Although some of them have been able to return to their original villages, they find that their lands are now occupied by companies’ businesses and government’s projects. These allegations have been covered in local media, NGOs and some civil society organizations working for human rights awareness and environmental concerns in Dawei and Myeik. These groups have looked at the oil-palm plantations and production industries, logging and mining industries in Dawei and Myeik. While some of these are illegal businesses beyond the government’s purview, others are government projects (Special Economic Zones) that have come into conflict with land issues in local community. That is why the IDPs who have returned are now caught in conflicts over land, livelihoods and public services, including infrastructure of roads, electricity and health facilities.
Women suffer the most from the effects of violence and war from these conflicts in Myeik and Tanintharyi. They have been living in poverty, oppression, and without protection for many years. Even though people across the country are talking about peace and the peace process, women are still not considered as stakeholders in either these conflicts or the peace progress negotiations. In Myanmar’s male-centered society, women and girls’ health issues are never prioritized. In 1948, Myanmar signed the Constitution of the World Health Organization (WHO). According to this Constitution, health is defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity so that reproductive health has to bring about inclusive physical, mental and social well-being.
Women and girls, living in remote places and IDP villages, are even more vulnerable when it comes to their reproductive health and family planning. In conflict areas, instability caused by natural and manmade disasters (floods, global warming, water pollution, scarcity of drinking water, climate change), legal and illegal mining, logging and charcoal businesses, and poor road conditions in remote places have made resources for healthcare services and skilled health workers scarce. Health accessibility is not considered an essential part of women and girls’ development and social well-being by both the government’s policy makers, implementers, and ethnic armed groups. IDPs and underprivileged women, in particular, face many hardships and struggle to find employment and stability due to the prolonged civil war and its related effects. These women survive on meagre incomes to support their daily lives and their families. Their health is often neglected, and are often without the space to voice their concerns in discussions about development and social wellbeing. They have no choice, no voice, no right and no support.
Basic health information and access to healthcare services for women and girls is a form of empowerment as it can lead to better reproductive health care during adolescent years in areas of personal hygiene, safer sex practice, contraception and healthier lives, especially in rural and remote areas. Access to public health care services and sources of information thus need to be made affordable: To improve women and girls’ health and wellbeing in social life, to empower their economic situation and to involve them into the political environment – this can lead to equality and equal rights for women. But who cares for them?
Provision of Public Health Services: Some Challenges
Although there have been improvements in health facilities and services since the transition to a civilian government, there remains a wide gap between the two entities: the regional government, and local ethnic armed groups’ administration in Tanintharyi region. Ethnic armed groups, such as the Karen National Union (KNU) and the New Mon State Party (NMSP) are controlling parts of some townships under their own administration and management. Often, they do not allow outsiders such as government civil servants and other visitors from local or international organizations to enter. These ethnic armed groups are also unwilling to support the implementation of regional government projects’ in road construction and rural development activities in the villages around their territory. As my recent research conducted in Tanintharyi region demonstrates, landmines remain a threat to local community. According to the ongoing NCA discussions, EAOs are implementing their own administration of areas in which they are based. As a result, there is a difference in how the regional government and EAOs’ administrations approach business and political conflicts in remote and IDP villages. In this situation, community needs and rights are always compromised and neglected.
Women are also burdened with the lack of access to formal healthcare services and information. Remoteness remains a key challenge to the provision of proper health services. Public healthcare centers are far away from the villages, and the poor condition of roads, coupled with the infrequency of affordable transportation makes travel particularly risky during the rainy season. Moreover, related difficulties in communicating with health workers and midwives due to language differences only add to the anxieties of women from rural areas. Women are left without resources for ways to improve their healthcare practices and knowledge, while disparities between the rich and the poor, different ethnic groups, different languages and different religions persist.
Many people from remote areas and of lower socioeconomic class neglect minor health problems because they cannot afford the health expenses necessary for consultations and hospitalization. In many cases, these minor issues can develop into serious health concerns when left untreated due to a lack of knowledge in preventable and curable diseases. For those afflicted with serious health concerns, they cannot afford higher quality medical treatment because of limited access to hospitals or medical facilities in rural areas.
Additionally, it is difficult to find quality midwives when facing minor health issues or during delivery. Midwives do not want to take risks, and prefer to send a woman to the hospital. As midwives are themselves busy with other matters, they are not available to help these women at all times. Midwives are also unable to reach every village because there are a maximum of ten rural health centers per township. There are approximately two to three midwives, and one Health Supervisor. There is only one Health Supervisor available at each center which is known to the Regional Public Health Department. There are insufficient human resources to cope with the necessary provision of health services, while half of the population in Mergui and Tanantharyi region lives in remote areas with poor road infrastructure.
As there is no public transportation connecting remote villages, people have to use their own private motorbikes or highway buses to get to the hospitals and the rural health centers. In some villages in Myeik Township, it takes about an hour by car or motorbike to get to the nearest one. This is even more difficult during the rainy season due to the poor condition of the roads. Basic healthcare services for women during their pregnancy (such as regular check-ups with health workers or midwives) are not possible due to the lack and cost of convenient transportation for poor families.
Education on Sexual, Reproductive Health and Family Planning
Findings from my study show that knowledge about sexual and reproductive health, maternal and child health care, family planning and resources about sexually-transmitted diseases among these populations are scarce. Most married women above 18 have little education about the importance of regular health checkups during pregnancy due to the infrequent access to midwives and health workers. Women believe that until the day of delivery, regular check-ups are not necessary. Most of them cannot afford the expenses for regular visits. Few are educated about sexually-transmitted diseases (STDs), even HIV/AIDS. Older women above 40 have less practice in contraception. Most of them already have 5 to 9 children. Middle-aged women under 40 use contraceptive injections and oral contraceptives such as the pill – even if they do not like the side effects it causes. Married women often have unwanted pregnancies.
During my interviews and in discussions with married and single women, we discussed family planning, preferred contraceptive methods, their access to contraceptives, as well as women’s economic status. Most married women use contraceptive injections that last for three months, or daily oral contraceptives which they can access in public rural health care centers. These are free of charge and provided by the government, but are available only during the rural health care center’s opening hours. Contraceptive services in public health care facilities are supposedly free, but donations of 500-1000 MMK are expected as a sign of politeness. Outside of the rural health care center opening hours, patients have to pay about 2500 MMK for contraceptive injections and 500 MMK for daily oral contraceptive pills. Many low-income and poor women cannot afford this cost – the equivalent amount of which adds up to transportation costs and the eventual loss of their daily income as day laborers. Private and INGO’s health clinic services are not accessible near or in the villages, but only in the downtown area. Women do not receive adequate information about the side effects of the contraceptives, such as potential weight gain, dizziness, and other unpleasant feelings. They are also unaware of alternative contraceptives that may be appropriate for their health needs. They are not aware of the pros and cons of birth contraceptives as there are no consultations provided, and little prioritization of women’s knowledge about reproductive health.
Some women do not like to take contraceptives because they cannot stand the side effects or cannot keep up with regular access to basic medication. Other alternatives such as the Intrauterine Contraceptive Device (IUD) is costly for poor women who have to commuteto the downtown area for this service. Most are not willing to do it because of the lack of information about what an IUD is and how it will affect them. Alternative methods such as condoms or sterilization are not preferred or well understood.
Most girls I interviewed who were aged 18 and under were shy to speak out on matters of sexual and reproductive health: this includes knowledge and practices about personal hygiene, safer sex practices, STDs, and contraception. They also do not know what sexual and reproductive health generally means. They have little knowledge about sexual and reproductive health. Only a few girls in our focus groups could answer questions about HIV and AIDS disease, and its transmission via sexual intercourse. This was information they received from social media and some NGOs’ websites. Otherwise, many of the young girls I interviewed work in Thailand, and in remote companies’ project sites near the mining and logging zones along the Thai-Myanmar border area as migrant laborers to support their families. They do not have a safe working environment, and the risks of STDs and unplanned pregnancies are increased when they are not educated about reproductive health and methods to prevent STDs. Some of the girls I interviewed have already experienced unwanted pregnancy and early marriage. Other women and young girls also shared stories about rape, and gender-based violence. According to them, these abuses often happen in their place of work. These are some of the barriers to empowering women in their daily routine and social life.
Other Resources/Alternatives to Health and Sexual Education
All the women and girls I interviewed were motivated to get health education and awareness about sexual and reproductive health. Health education and awareness was not previously available in their villages, and the older generation of women had few means to access online sources about reproductive health. In the villages, there are many potential sources for volunteering in health education for adult young girls. Some of these girls stopped schooling before finishing their higher education in order to help with their parents’ business, or to work as casual laborers. Other women related that they did not want to go and work away from their families. Women who were motivated to volunteer in teaching about health education were also more influential than village leaders in the community’s work.
Education on health, access to healthcare services, and resources for such knowledge are related priorities. Providing all three, in turn, can support and empower women’s lives to achieve better health practice for themselves and their families. These behavioral changes will affect how women manage family planning, as well as care for their reproductive health in order to prepare themselves for a better, healthier life. Healthy women and girls who have knowledge of how to care for their own health, and prevent related diseases will be more confident in their ability to make decisions for themselves, and control their fertility.
Based on my study’s findings, I would like to issue the following recommendations:
- The public health system should collaborate with local and international organizations to provide health education, possibly in the form of health information centers run by village health volunteers.
- More village health volunteers needed to link health care centers with remote villages. Trained health volunteers can complement the work of mobile clinics.
- Development of additional health education centers at the village level to provide spaces for women and girls to access health education and consultation services.
- Use of social media to disseminate health information and health-related interviews with professionals and practitioners’ on a regular basis at both the local and national level.
- Most importantly, the national healthcare system must be equipped with quality health workers, facilities and infrastructure – increasing the number of the rural sub- health care centers and rural health care centers, establishing the community health information and education centers, and accessibility of road, electricity, and water and sanitation supplies at health centers, housing for health staffs.
(Image courtesy of Nilar Khaing)
 Ministry of Health and Sports, T. R. (2016). Myanmar National Health Plan (2017-2021), p. VIII.
 Constitution of the World Health Organization. (2006). Basic Documents, Forty-fifth edition, Supplement, October, p. 1.
Nilar Khaing has been working as Freelance Consultant in Research and Training for four years. She has over ten years’ experience in Humanitarian and Development working on issues related to health, water and sanitation, emergency response in disasters, gender mainstreaming, protection and peace building with International and Local NGOs and UN organization. She studied Politics and Public Policy at the Myanmar Institute of Politics and Public Policy. This post is part of a series of articles produced in the context of a fellowship program developed by the Norwegian Institute of International Affairs (NUPI) in partnership with Urbanize: Policy Institute for Urban and Regional Planning. The author wishes to thank Camille Dancoisne for her help in developing this paper.