Bill & Melinda Gates Foundation

Managing Primary Health Care at Scale: Myanmar’s Sun Quality Network

April 08, 2014

Since the early sixties the people of Myanmar lived under various forms of military rule. Health indicators stagnated at low levels, and progress towards development was slow[1]. There was little investment by the government in health services, so people bore 80% of the costs of their health services and turned to a range of private sector providers for the majority of services.[2]  The quality of these services was often low and of limited range, with significant gaps in provision of preventive care, reproductive health and communicable diseases.

We visited Dr. Aye Aye Mu, who provides care to patients in Yangon. She joined the Sun Network in 2002.

In 2008 the foundation decided to invest in Myanmar’s primary health care. The foundation made a grant to Population Services International (PSI) to expand their primary care services nationwide, helping to ensure the people of Myanmar had access to high-quality, low-cost basic health care. This included screening and treatment for HIV, malaria and TB as well as diarrhea, pneumonia, and reproductive health services.

Fast-forward to 2014. We arrive in Myanmar with Lani Marsden and Carmine Bozzi to complete an end-of-project assessment. PSI has achieved its goals: scale, cost-effectiveness and integration in primary health care. PSI’s Sun Network engages primary care doctors through a social franchise model. This model allows the doctor to benefit from PSI’s marketing and branding, access a dependable and quality supply chain of subsidized essential medicines, and receive on-going training and mentorship. In return, the doctors agree to provide high-quality, low-cost care to their communities. The Sun Network also engages community health workers who extend the doctors’ reach by providing malaria prevention and treatment, reproductive health services, pneumonia diagnosis and referrals, diarrhea prevention and treatment and referrals for TB. To date 4,702 providers have been trained (around 1,800 doctors and 2,800 rural health providers). They are operating in 226 townships, covering nearly 70% of the country’s townships.

The combined efforts of the doctors and rural health workers allow PSI to provide around 2.5 million out-patient visits a year.[3] To distribute PHC commodities through the network, it costs PSI around $3 per patient visit. Of course, what the patient pays for these services is a fraction of this cost – less than 50 cents per visit.[4] PSI maintains its cost-effectiveness through a well-oiled management system that collects data, analyses and course-corrects continuously. Some highlights: over the life of the project, the Sun Network has distributed more than 140 million condoms, over 3 million treatments for diarrhea (oral rehydration salts with zinc), provided nearly 8 million reproductive health consultations, and preformed 1.3 million rapid diagnostic tests for malaria linking nearly 377,000 people to appropriate treatment.

Though we don’t have any official data (there hasn’t been a census in Myanmar since the early eighties, nor has there been a Demographic and Health Survey – both forthcoming), impressions suggest Sun Network had a major impact on the health of the country during a very difficult time.

Over the past few years the government has been taking steps towards a more liberal democratic structure. Following on these changes, the country is in the midst of rapid economic growth and development. The government has drastically increased its health budget and set ambitious goals, including provision of universal health coverage by 2030. The World Bank Group and development partners are eagerly supporting President U Thein Sen and Minister of Health Pe Thet Khin’s inspiring vision. As the government outlines its health sector strategy they are not starting from scratch; they can benefit from and build onto the Sun Network’s cost-effective, high-quality system for out-patient care.  We know from governments’ experiences in Cambodia, Bangladesh, India, Bolivia, Guatemala, Pakistan, Haiti, Madagascar and Senegal that contracted private providers can deliver care at scale, in a cost-effective manner which results in increases in health coverage, even in poor areas.[5] Achieving universal health coverage in Myanmar will require a creative, inclusive approach to scaling service delivery. We look forward to learning from Myanmar’s quest to ensure all of its people can live a healthy and productive life.

[1] Even today, the United Nations Development Programme ranks Myanmar 149th (of 186) on its Human Development Index.

[3] The Sun Network, Myanmar: An evaluation of performance. Roger England. Unpublished. 2013.

[4] What gets subsidized in a social franchise? Tracking the flow of funds in the Sun Quality and Sun Primary Health Network in Myanmar. David Bishai et al. Unpublished. 2012. Note that this is based on an analysis of 2009 data. Roger England estimates that this analysis takes into account around 60% of the full costs of operating the network and estimates that the network’s full cost per DALY averted is around $40-50.

[5] Loevinsohn, B. and A. Harding (2005). "Buying results? Contracting for health service delivery in developing countries." The Lancet 366(9486): 676-681.

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