The activities of Medical Action Myanmar can be divided in clinic-based medical care performed in 10 clinics and basic health care performed by a network of 1700 Community Health Workers (CHW) in the east and far north of the country. Altogether MAM staff performed just over 1,100,000 patient consultations in 2019.
Medical care in clinics
MAM supports ten clinics in poor urban areas of Yangon, in the far north of the country and in the east of the country. The clinics are located in areas where a large proportion of people cannot afford to pay for their basic health needs. The clinics provide a mix of activities including mother and child care, treatment of malnourished children, reproductive health, family planning, treatment of sexually transmitted infections, counselling, and treatment and care for people with HIV/AIDS and tuberculosis. The consultations vary from simple out-patient visits to intensive treatment of severe diseases. The average cost of 1 consultation in the clinic including all expenses (staff, lab, medicines) is 7$.
Medical care through Community Health Workers in remote villages
MAM supports a network of 1700 Community Health Workers (CHW) to provide basic health care in the most remote villages in North and East Myanmar (Kachin, Karen, Kayah, Mon states and Thanintharyi division). Due to the remoteness of the villages and the small size of the villages, this project is very labour intensive. We make a lot of effort to reach relatively small groups of people as these villagers are often most in need of medical help. As they don’t receive any form of health care services, a visit from a MAM medical team is often the very first time that they have a trained health care worker with reliable tests and treatment in their villages.
The main goal of the project is to decrease malaria, through the provision of a simple rapid diagnostic test and good quality medicines, but the health care package has gradually expanded to other common diseases (like diarrhoea, respiratory tract infections including pneumonia) malnutrition and family planning. Since 2014 we added active-case-finding for tuberculosis to the package. These projects are very successful. Malaria is decreasing rapidly in villages where CHWs are providing malaria services.
All CHW are monitored monthly by MAM teams, led by a medical doctor and 2 – 3 local support staffs who speak the local language. Patients are visited at home to verify the quality of services provided.
Malaria is a very common problem in Myanmar. The contaminated mosquitoes trouble especially the remote areas. The treatment of uncomplicated malaria costs only 2 USD for an adult and 1 USD for a child, it is unacceptable that many people die of the infection. If uncomplicated malaria is not treated well, complicated malaria, which is much harder to cure, can follow. MAM supports a number of governmental clinics, private clinics and village health workers in remote areas by distributing laboratory tests and anti-malaria medicines. Besides curing the disease, treatment is also very effective for the prevention of the further spread of malaria. In 2019 CHWs tested 270,420 people for malaria with a simple rapid test – 11,424 were positive and treated. In addition to treatment, MAM also provides specific areas with impregnated bed nets for the prevention of mosquito bites.
These activities are aiming to contain artemisinin-resistant malaria, which was identified in 2008 in Western Cambodia. Exposure to incomplete treatment for many years has probably been the driving force in the selection of resistant parasites. Subsequent monitoring in the Greater Mekong region discovered that artemisinin resistance is also present on the Chinese-Myanmar (Kachin) border and on the Southern Myanmar-Thai border (Mon state and Tanintharyi division).
The spread of artemisinin resistance is a very serious threat to malaria all over the world and measures for containment are needed urgently to limit the spread of these parasites and to prevent a major disaster. There are currently no drugs that can replace artemisinins and the costs of wide-spread artemisinin resistance in terms of lives lost and resources used, in Asia and above all in Africa, would be immense. Only in Africa the increase in malaria deaths could be 200,000 per year if artemisinin resistance spreads.
Basic Health Care
As a result of the successful implementation of intense malaria control activities malaria prevalence of malaria has been decreasing. Therefore most patients now test negative for malaria. If only malaria treatment were to be provided, most patients would not get treated for their complaints and this would undermine the popularity and uptake of the malaria services. A basic health care (BHC) package (including referral for severely ill patients) combined with the malaria services increases the popularity and uptake of the Community Health Worker services in general and specifically increases the coverage of testing for malaria even when malaria positivity rates are decreasing. This is the first time that people in these remote village have regular access to a health care package, opposed to health care that is only accessible after several hours travel on the back of a motorbike (which is very expensive and not affordable for most!).
MAM currently has trained around 1700 CHW to perform BHC activities next to malaria activities. The CHW performed 1,100,000 basic health care consultations in 2019. The most common diseases were respiratory tract infections (32%) and gastrointestinal infections (26%). For patients who need to be seen by the medical doctor, the CHW arranges that the patient is seen by the MAM medical doctor during their next monitoring visit. If the complication is acute and needs urgent treatment, the patient will be referred to a hospital.
Tuberculosis and HIV/AIDS
In May 2014 MAM started to integrate Tuberculosis Active Case Finding (TB-ACF) into the current malaria activities. 142 CHWs have been trained on signs and symptoms of suspected TB and referral procedure. MAM provides transportation, accommodation, investigation costs and accompany some patients to the hospital for initial visit and monthly follow up.
To prevent and treat AIDS, MAM aims to have a one-stop service where all services including testing, counselling, treatment and support for food and transport fees are provided the same day to improve compliance and make it possible for the patient to live a normal life and return to their job. In 2019 we tested 20,544 people of whom 1,017 (4.9%) were HIV (+). At the end of 2019 we are supporting 4,247 HIV+ patients. Over 85% of patients are surviving beyond 8 years. These treatment results compare very well to other projects in 3rd world countries. We believe that the low number of deaths and treatment failures is a reflection of the quality care package we give. Next to good clinical management we provide adherence counselling, travel expenses and food for six months when patients cannot yet return to work. Patients who are very sick or who live far away can temporarily stay in the MAM guesthouse, which we built nearby the clinic.
These financial and social issues can have a detrimental effect on treatment compliance (like patients selling their medicines to solve urgent financial problems). MAM also has a special treatment for HIV+ pregnant women. These treatments saves their lives, which makes them able to take care of their children, but it also prevents the spread of HIV to their unborn babies. After their baby is born, they are in the program for up to 1.5 year to make sure their medical, emotional and nutritional status stays in balance.
People with severe HIV infection have a high risk of developing blindness due to an infection of the retina by cytomegalovirus. If CMV is diagnosed early, the process – to develop blindness – can be stopped by injecting a medicine (ganciclovir) inside the eyeball. Dr Ni Ni Tun is specialized in this procedure.
Some people are at a high risk of becoming infected with reproductive tract infections (RTIs) including STDs and HIV. RTIs facilitate the transmission of HIV and it is therefore even more essential to prevent them through the use of condoms. As many women and to a lesser extent men with STI have no symptoms, and persons without symptoms do not seek treatment, clinic-based STI management should be combined with active regular screening and treatment of high-risk people. MAM clinics will provide STI screening and treatment.
In order to reach the large group of a-symptomatic STI carriers, people at high risk (female sex workers and homosexuals) will be invited to come for monthly clinic visits for STI screening. To convince people who are at high risk, but who have no complaints, to come to the clinic, a good relationship between the health provider and high-risk persons, including brothel owners, is essential. MAM tries to set up such relationships to ensure regular infection screening.
Counselling is done to support compliance with long- term treatments for diseases like HIV and TB. In 2019, 68,965 sessions were conducted and 12,189 home visits were carried out for socially weak patients. Poor compliance leads to resistance, which is a threat for all. All our clinics have Counsellors, even in Kachin where not only the geography is challenging but numerous local languages are spoken, between them our Kachin Counsellors cover the 4 main languages. One of our Counsellors also supports and oversees the work with young vulnerable children.
Children with acute severe malnutrition are extremely vulnerable for infections and death (50% mortality rate) and need treatment as soon as possible, in 2019 we conducted 41,328 consultations on children. Treatment of acute malnutrition gets special attention. Tuberculosis is one of the main reasons of child malnutrition. With the help of therapeutic feeding and tuberculosis treatment, we are able to increase their life expectancy to 90%. Luckily, most of the time a child progresses well after one treatment and does not need to come back for repetition of the treatment. Children under 5 years old are also most vulnerable to infections as dengue, cholera, measles and pneumonia. In rural slums, where infectious diseases are rampant, high mortality rates are a fact. All children that come to the clinic with severe malnutrition and/or infectious diseases receive therapeutic feeding and medical treatment. Some children, who are moderately malnourished, receive a supplementary feeding package to prevent severe malnutrition.
Referral of severe and complicated Cases
Realising that the capacity of CHW is limited, MAM set up a referral system for all severely ill and complicated patients. In those cases patients are sent to DoH hospitals to receive life-saving treatment. MAM pays for the transport and the treatment in the hospital. The aim is to avoid that a CHW will treat beyond his/her capacity and to save lives.
In October 2017 a 7-year old girl,the daughter of one of the MAM supported CHWs, was having fits several times a day and could not walk or speak. She got epilepsy 2 years previously after a head injury. She had received treatment at Myitkyina hospital for two years, but the family could not afford the regular journey to the hospital and stopped visiting the hospital. She was now in a critical condition and MAM referred her to the neuro-surgical unit in Mandalay where she was operated on. The operation was successful and her condition improved significantly. She returned home and is now able to speak a bit and walk with support. She will be receiving follow up care and treatment with support from MAM.
Many women have more children than they can care for. In poor areas this frequently leads to poverty of the family (more children to take care for and mother less likely to have an income). It can cause poor health of both mothers and children and –if women are desperate – they seek illegal non-sterile abortions, which can result in infection and death of the mother. Family planning can give a family the choice when to take children (when they are ready to take care of the –next- child).