Than Shwe giving more useless advice, this time to the doctors

GENERALS AS THE AXE HANDLES OF

THE NEO-COLONALISTS:

Revisiting the Financing Health in Burma

Burma comes last again in a game that most in the country don’t want to play. A re-examination of the financing of healthcare shows that Burma has the lowest per capita expenditure on healthcare in ASEAN at only $US4. This means that a country with an estimated population of 55 million spends in aggregate around $US220 million each year on healthcare. This very low expenditure is coupled with a ‘government’ that only bothers to spend around nine cents a year on the health of each person in the country. This is from a ‘government’ that earns around $US100m each month in revenue from its gas sales to Thailand. Theoretically, the ‘government’ could increase the country’s aggregate expenditure on healthcare by nearly 50 percent if it allocated only month of this revenue to health. The expenditure on healthcare in Burma is primarily very low because the country is so poor due to economic mismanagement, and because the government is utterly negligent, utilizing the apparatus of the state to further private returns, rather than enhancing the public good. In spite of its xenophobic, nationalist, self-sufficiency rhetoric, its healthcare system (if that’s what it can be called) is propped-up by foreign funds. Burma’s public healthcare system is more reliant on foreign funds than any other country in ASEAN. The situation regarding the financing of health in Burma is not only appalling in absolute terms, but on all reasonable measures is behind all the other ASEAN countries.

Lowest Per Capita Expenditure on Health

The people of Burma have by far the lowest per capita expenditure on health of the ASEAN grouping, at a very low $US4 according to WHO’s national health accounts.¹ The WHO in its 2006 World Health Report seemingly provides quite a different picture of per capita expenditure, reported as being between $US134 and $US394 between 1999 and 2003. This is because the regime’s kyat figures were converted into $US at the official exchange of K6/$US, rather than the market exchange rate. When these figures are adjusted at the market exchange rate, per capita expenditure is around $US1-2.30, somewhat similar to figures reported elsewhere.²

The very low per capita expenditure in Burma compares with Laos, whose per capita expenditure is the second lowest of the ASEAN countries, at around $US22 per capita. Burma’s per capita expenditure compares even more poorly with Cambodia, Indonesia and the Philippines, whose per capita expenditure on healthcare are around $US30, $US34 and $US45, respectively.

TOTAL EXPENDITURE ON HEALTH 2006
	Per Capita Expenditure $US	Expenditure % GDP
Burma	$US4	2.3%
Cambodia	$US30	6.0%
Indonesia	$US34	2.2%
Laos	$US22	3.6%
Malaysia	$US255	4.3%
Philippines	$US45	3.3%
Singapore	$US1035	3.4%
Thailand	$US113	3.5%
Vietnam	$US46	6.6%

Source: www.who.int/nha/en/

Burma’s low per capita expenditure is reflected in a related figure – the percentage of GDP expended on health. Burma allocates around 2.3 percent of its GDP to healthcare. This is similar to the percentage of GDP allocated in Indonesia, except in Indonesia per capita expenditure is $US34, compared with Burma’s $US4. This illustrates the relationship between economic performance and health expenditure. It is Burma’s very poor economic record that is mostly to blame for the countries appalling low per capita healthcare expenditure.

PRIVATE EXPENDITURE ON HEALTH 2006 (%)
	Private Exp/Total Health Expenditure	NGO Exp/Private Health Expenditure	Local Private Exp/Total Health Expenditure
Burma	83.2	0.20	83.198
Cambodia	73.9	15.61	73.78
Indonesia	49.6	2.30	48.454
Laos	79.2	5.95	74.486
Malaysia	54.8	0.067 (0.52)3	54.797
Philippines	60.4	1.94	60.388
Singapore	66.4	0.00	66.4
Thailand	35.6	0.88 (1.22)	35.596
Vietnam	67.6	0.27	67.597

Source: www.who.int/nha/en/

The Philippines is the runner-up with 3.3 percent of GDP allocated to healthcare, though per capita expenditure on health is much larger at $US45, again due to better economic performance. And the Philippines is hardly an economic success story. Laos, Thailand, Malaysia, and Singapore allocate between 3 and 4 percent of GDP to healthcare, though the per capita expenditure varies greatly between $US22 and $US994. Both Cambodia and Vietnam allocate a greater proportion of their GDP to health, at around 6 percent each.

Not all private health expenditure comes from local sources, as some proportion is provided by NGOs that obtain their funds outside the country. Most of this expenditure is foreign aid is channeled through NGOs, typically to bypass the local government. Cambodia with NGOs providing 16 percent of private expenditure on healthcare is the only country where NGOs contribute a significant percentage to a healthcare system in ASEAN. In Laos, NGOs provide nearly 6 percent of private health expenditure. NGOs provide even a smaller proportion of private healthcare expenditure in the Philippines and Indonesia at around 2 percent. Surprisingly given the rhetoric of those supporting aid to Burma, most (recorded) aid funds are not channeled via NGOs, recorded as only 0.2 percent of private healthcare expenditure, a similar proportion as that provided in Thailand and Vietnam. In fact, as discussed below most aid funds are channeled via the regime.

Importance of Private Expenditure on Healthcare

The very poor economic policies of the regime are prime reason for the low per capita expenditure on healthcare in Burma. Healthcare for most people in most countries is substantially funded by private expenditure, whether through private health insurance or by simply purchasing healthcare when the need arises. This means that the GDP/capita is an important determinant of the amount that individuals and families can spend on their own health. Since, the economy in Burma is so moribund people on average can only afford to spend around $US3.32 each on healthcare. The ineptitude of the regime in terms of economic management is responsible for such a dismal figure.

Not only is the amount spent on healthcare very small in Burma, but people in Burma have to provide the highest percentage of their healthcare from their own pockets, with personal private expenditure in 2006 accounting for nearly 83.4 percent of total health expenditure. This compares with Laos and Cambodia, where personal private expenditure accounted for around 74% of total health expenditure. Third place went to Vietnam with individuals and families providing around 67 percent of the country’s expenditure of healthcare. Whereas, people in Indonesia only provide around 48 percent of healthcare expenditure; whilst in Thailand only 35 percent of expenditure came directly from personal expenditure.⁴ Note that Cambodians, Laotians, Indonesians, Thais and Vietnamese not only provide a smaller proportion of the funds for their healthcare, but are also able to spend significantly more than their Burmese counterparts.

As the institutional framework in Burma is so poor, private health insurance does not exist. Cambodia is the only other ASEAN country sharing the stage with Burma in this regard. Private health insurance, though typically only available to the wealthy and middle class in poor countries is nevertheless an important component of private health expenditure, as it provides a safety net, especially when the state is remiss. Of those countries with private health insurance Vietnam and Indonesia have the lowest proportion of private health expenditure covered by private insurance at 3 and 5 percent, respectively. Private health insurance in the Philippines and Laos accounts for 10 percent of private expenditure on health. Malaysia and Thailand with better institutional structures have created a system where private health insurance accounts for 14 percent of private expenditure on health. Hence, even the middle class (as small as it is) in Burma have to fund all their expenditure on healthcare out of their pocket, when any emergency arises.

SPDC Spends Nothing on Healthcare

Burma’s state managed healthcare system contributes around 17 percent of the country’s total health expenditure, which is a smaller percentage than any of the other countries in ASEAN. Even the Laos and Cambodian state managed healthcare systems contribute more, providing around 21 and 26 percent of the country’s healthcare expenditure, respectively. This spending is even much less than the other poor countries in ASEAN with the governments of Vietnam, Philippines and Indonesia contributing 32, 40 and 50 percent, respectively.

However, these figures do not reflect the state’s contribution to their own healthcare system, as they include aid funds (or loans) channeled via the state. In the case of Burma, aid provides 82 percent of the regime’s expenditure on healthcare, which mean that the ‘government’ provides only 3.0 percent of the country’s healthcare expenditure. The proportion of funds provided by foreign donors to the state’s health system is considerably higher than that provided to any other of the governments in ASEAN. Foreign donors only provide the state managed healthcare system in Cambodian and Laos with 40 percent of their expenditure, whilst the Philippines and the Vietnamese public healthcare systems receive only 5 percent of their funds from foreign donors.

GOVERNMENT EXPENDITURE ON HEALTH 2006
	Total Govt. Health Exp/Total Health Expend (%)	% Govt. Health Exp Financed by Aid	Govt. Exp Minus Aid/ Total Health Exp (%)
Burma	16.77	82.03	3.0
Cambodia	26.1	41.30	15.3
Indonesia	50.4	2.24	49.29
Laos	20.8	41.3	21.04
Malaysia	45.2	0.0	45.2
Philippines	39.6	5.46	37.44
Singapore	45.2	0.0	45.2
Thailand	64.4	0.0	64.4
Vietnam	32.4	6.33	30.32

Source: www.who.int/nha

The lack of healthcare expenditure by the state again differentiates Burma from the other ASEAN countries, as all the other governments contribute some funds to providing healthcare for their citizens. The winning place is accorded to a ‘government’, (not an appropriate term for SPDC) that has the money to spend on healthcare and other services, accumulating around $US100m each month from the sales of the country’s gas reserves.

GOVERNMENT EXPENDITURE ON HEALTH 2006
	% Govt. Health Exp to Social Security	Govt. Exp Minus Aid & Social Security/ Total Health Exp (%)	Per Capita Govt Exp. Minus Aid & Social Security Exp $US
Burma	8.88	2.2	$US 0.09
Cambodia	0.00	15.3	$US 4.59
Indonesia	21.57	36.87	$US 12.54
Laos	23.65	0.087	$US 1.91
Malaysia	0.84	44.84	$US 114.33
Philippines	28.72	26.69	$US 12.01
Singapore	17.11	27.9	$US 288.72
Thailand	12.44	56.38	$US 63.71
Vietnam	63.47	17.75	$US 8.17

Source: www.who.int/nha

Some of the governments in ASEAN allocate a sizeable proportion of their healthcare expenditure to social security, typically to public servants and war veterans.⁵ As this expenditure is typically centred on a small proportion of the population these funds are also deducted from each government’s expenditure on healthcare in order to provide a better understanding of the size of the expenditure on the majority of the population.⁶ In this regard, Burma’s regime allocates less than 10 percent of government health expenditure to social security, a smaller proportion than other governments in ASEAN. The highest proportion of government health expenditure allocated to social security, at nearly 65 percent is in Vietnam, most of which is allocated to veterans of the North Vietnamese army. Other governments in ASEAN, including Laos, Indonesia and the Philippines allocate 20 or more percent of their healthcare budgets to the privileged in the public service.⁷

Once aid funds and government expenditure on social security have been removed from each government’s healthcare budget, the actual amounts provided by the governments in ASEAN for health care can be calculated. This again illustrates the paucity of funds allocated by the regime to healthcare, with the state only providing around 9 cents each year for each person in the country. Even the Laos government with its considerably higher proportion of expenditure allocated to social security managed to spend another $US1.90 on each of the country’s citizens in 2006. Cambodia, which does not have to support the healthcare of its public servants managed to spend double that of the Laos government at around $US4.50 and conversely, Vietnam that does spend a sizeable proportion of its healthcare budget on war veterans still to managed to spend an additional $US8 on each member of its population. All the other governments in ASEAN managed to spend considerably more on each of their citizens.

There is yet another factor to be considered with regard to these figures, as they include expenditure not only by the Ministry of Health, but also other ministries including expenditure on health provided for the armed forces, prisons, schools and universities (WHO 2006:160). Some of the countries in ASEAN, notably Thailand, Laos, Vietnam, the Philippines, Cambodia and Indonesia spend a considerable proportion of their health budget outside of the Ministry of Health, but unfortunately WHO’s national health accounts do not specify the ministries, which control this expenditure. The allocation of this expenditure is worthy of further analysis, but outside the parameters here. WHO’s national health accounts indicate that most of Burma’s government’s healthcare expenditure is located in the Ministry of Health, but as with the other countries in ASEAN the proportion spent on the military is unknown.

Begging for Healthcare

The health expenditure of all the countries in ASEAN except for Thailand, Malaysia and Singapore are partially funded by foreign aid and loans. The largest proportion of health expenditure funded by aid is in Cambodia, Laos and Burma. In 2006, aid funding contributed 22 percent of total expenditure within the Cambodian health care system; whilst in Laos aid funding was 14 percent. Burma not quite the winner here as in 2006, aid provided around 14 percent of total health expenditure. This does however mean that foreign donors are contributing substantially more to the healthcare of Burma’s population than its own government. This is the government that prides itself on self-reliance and fosters xenophobia, but refuses to allocate resources to the health of its own people. Instead the regime relies on funds from the despised foreigner, so it can spend on its ludicrous fascist style new capital and other absurdities including a nuclear reactor. Showing they share the same refined aesthetic sense as another of the world’s tumors, the government of North Korea. If the regime believed its own nationalist rhetoric, why does it allow foreigners to prop-up healthcare expenditure, even though it has the resources to support its own system.

TOTAL AID/TOTAL HEALTH EXPENDITURE (%)
	2000	2001	2002	2003	2004	2005	2006
Burma	1.1	6.15	6.88	6.1	11.2	10.9	13.9
Cambodia	9.4	18.65	19.43	28.4	26.7	25.7	22.3
Indonesia	10.8	4.44	3.30	3.5	3.0	4.6	2.3
Laos	30.3	12.63	15.00	20.00	10.3	11.3	14.1
Philippines	3.5	3.7	2.8	3.8	4.0	5.1	3.3
Vietnam	2.7	2.8	3.5	2.6	1.9	2.0	2.2

Source: www.who.int/nha

Expenditure on Immunization

All the governments of ASEAN provide at least some funds for basic immunization programs, except for the ‘governments’ of Burma and Laos (WHO 2005). All the funding for the program in Burma is provided by foreign donors, notably the government of Japan and the Western democracies. The immunization program in Burma is overseen by UNICEF, but implemented by the Myanmar Maternal Child and Welfare Association (MMCWA), a fascist style mass organisation controlled by the wives of the senior generals. This is their special contribution to the country, using the resources of taxpayers from foreign countries, whilst pretending to being loyal daughters of the nation.

% EXPENDITURE PROVIDED BY GOVERNMENT IMMUNIZATION PROGRAM 2003
Burma	0
Cambodia	7
Indonesia	90
Laos	0
Malaysia	100
Philippines	3
Singapore	100
Thailand	100
Vietnam	55

Source: World Health Report (2005)

The Philippines also shows an unimpressive commitment to their country’s immunization program contributing only 3 percent of total expenditure. Even the Cambodian government has managed to provide 7 percent of the funds for its country’s basic immunization program. All these governments compare to Vietnam’s that provides 55 percent of the funds for its young population to be vaccinated. Thailand, Burma’s old enemy having implemented rational economic policies can afford and chooses to allocate enough resources, such that it does not have to depend on the largesse of foreigners to protect its young population.

We do not begrudge the people of Burma our assistance. We do however, object to a ‘government’ that steals the revenue from gas sales, which rightly should be allocated to the state’s budget where it can be used to improve the situation for ordinary Burmese. We also object, to the irrational, wooly-headed, muddled economic policy making of a regime that has stifled economic growth. The ridiculous lame-brained policy making of the regime has impoverished the country meaning that on average Burmese people can only spend around $US3.32 each on their own healthcare. We also object to the deceit of a regime that pretends that it has taken responsibility for immunizing the young of the country. Healthcare and immunization programs should not be the plaything of the over-adorned wives of the generals (via the Myanmar Maternal and Child Welfare Association), most of whom, as with their husbands have little expertise in anything, except lauding themselves over the population. All in all the regime and its hypocritical nationalist rhetoric and lame-brained economic policies are objectionable.

Ministry of Health (Burma) Health Statistics – www.moh.mm/

World Health Organisation National Health Accounts – www.who.int/nha

World Health Organisation (WHO) (2003) Guide to Producing National Health Accounts with Special Applications for Low-income and Middle-income Countries, World Health Organisation.

World Health Organisation (WHO) (2005) World Health Report 2005: Making Every Mother and Child Count, World Health Organisation, Geneva.

World Health Organisation (WHO) (2006) World Health Report 2006: Working Together for Health, World Health Organisation, Geneva.

1 www.who.int/nha/en/

2 This was done simply, by assuming that the market exchange rate in 1999 was on average K800/$US and the market exchange rate in 2003 was on average K1,000/$US. The original figure was simply multiplied by the official exchange rate (K6/$US) and adjusted for the average market exchange rate.

3 The figures in brackets for Malaysia and Thailand include local funds provided to NGOs to supplement the healthcare of others within their country.

4 The proportion of private healthcare expenditure has dropped significantly in the last 10 year particularly with the introduction of under Thaksin of the 30 baht health card scheme, which has its own financing problems.

5 Strictly these should not be included in government expenditure, but many of the ASEAN countries do so.

6 Of course the proportion covered under these schemes no doubt varies, but any analysis in this regard is outside the scope of this note.

7 It is not clear from the data whether this expenditure covers healthcare payments for those in the military.