FEBRUARY 2019 Delivering Healthcare amid Crisis: The Humanitarian Response in Myanmar ALICE DEBARRE Cover Photo: A doctor from Médecins ABOUT THE AUTHOR Sans Frontières does a medical checkup on a patient with tuberculosis ALICE DEBARRE is a Senior Policy Analyst at the and HIV confection, Shan state, International Peace Institute. Myanmar, July 5, 2013. Eddy McCall/MSF. Email: [email protected] Disclaimer: The views expressed in this paper represent those of the author ACKNOWLEDGEMENTS and not necessarily those of the International Peace Institute. IPI IPI owes a debt of gratitude to its many donors for their welcomes consideration of a wide generous support. IPI is particularly grateful to the Bill and range of perspectives in the pursuit of Melinda Gates Foundation for making this publication a well-informed debate on critical possible. The author would also like to thank stakeholders policies and issues in international in Myanmar who generously gave their time to contribute affairs. to this research, as well as Elliot Brennan, Non-resident Research Fellow at the Institute for Security and IPI Publications Development Policy, and Derran Moss-Dalmau from the Adam Lupel, Vice President Office for the Coordination of Humanitarian Affairs for their Albert Trithart, Editor insights. Gretchen Baldwin, Assistant Editor Suggested Citation: Alice Debarre, “Delivering Healthcare amid Crisis: The Humanitarian Response in Myanmar,” International Peace Institute, February 2019. © by International Peace Institute, 2019 All Rights Reserved www.ipinst.org CONTENTS Abbreviations . iii Executive Summary . 1 Introduction . 2 Myanmar: A Complex Web of Crises . 4 VIOLENCE, SEGREGATION, AND UNDERDEVELOPMENT IN RAKHINE ETHNIC ARMED ORGANIZATIONS AND DISPLACEMENT IN KACHIN AND NORTHERN SHAN The Provision of Healthcare in Myanmar . 10 A POOR PUBLIC HEALTH SYSTEM ACCESS TO HEALTHCARE IN RAKHINE ACCESS TO HEALTHCARE IN KACHIN AND NORTHERN SHAN Trends and Challenges in the Humanitarian Health Response . 18 THE SCOPE OF THE HUMANITARIAN HEALTH RESPONSE LIMITED HUMANITARIAN ACCESS WORKING WITH LOCAL ACTORS AND COMMUNITIES PROVIDING HUMANITARIAN AID AMID DEVELOPMENT AND HUMAN RIGHTS CRISES Conclusions . 26 ADJUSTING THE SCOPE OF THE HUMANITARIAN RESPONSE ADVOCATING FOR BETTER HUMANITARIAN ACCESS STRENGTHENING LOCAL CAPACITIES ADDRESSING THE DILEMMAS INHERENT IN PROVIDING AID AMID A DEVELOPMENT AND HUMAN RIGHTS CRISIS iii Abbreviations ARSA Arakan Rohingya Salvation Army IDP Internally displaced person KIA Kachin Independence Army KIO Kachin Independence Organization NLD National League for Democracy OCHA UN Office for the Coordination of Humanitarian Affairs OHCHR Office of the UN High Commissioner for Human Rights UNDP UN Development Programme UNFPA UN Population Fund UNHCR UN Refugee Agency WHO World Health Organization WFP World Food Programme 1 Executive Summary Lack of access to people in need is one of the main challenges to the international humanitarian Myanmar simultaneously faces multiple armed response in all three states. All humanitarian conflicts and crises, each with its own challenges. In actors, including those providing health services, Rakhine state, the government’s persecution of the have to apply for travel authorizations from the Rohingya people has led to massive displacement, government. Most international organizations, and as have decades of armed conflict in Kachin and all international staff, have been refused access to northern Shan. Combined with chronic underde - non-government-controlled areas in Kachin and velopment, these humanitarian crises have left northern Shan since 2016. As a result, many people without access to adequate healthcare, international organizations work through local leading international humanitarian actors to step NGOs, which comes with its own challenges. in. This paper looks at the state of healthcare in Efforts to ensure meaningful participation of these three states, the role of humanitarian actors in affected populations in the development and the provision of health services, and the trends and implementation of programs also remain challenges affecting the humanitarian health inadequate, partly due to access constraints. response. Finally, the relation between humanitarian and The public health system in Myanmar is development efforts, as well as peace and human generally poor, and government funding for health rights efforts, has been a key question in Myanmar. services is among the lowest in the world. There are As the crises become protracted, there is a push for wide discrepancies in health services between rural more development work, not least from the and urban populations and between central and government. Some fear this comes at the expense of peripheral states such as Rakhine, Kachin, and the humanitarian response. Furthermore, the Shan. In Rakhine, there are only nine public health political and human rights situation has led workers per 10,000 people, and access to secondary humanitarian organizations to question the nature and tertiary healthcare is limited. The Rohingya— of their engagement with the state, in particular in many confined to camps for internally displaced IDP camps. persons (IDPs)—are particularly affected by This paper makes several recommendations for barriers to accessing healthcare. In Kachin and improving the humanitarian health response in northern Shan, access to healthcare is similarly Myanmar. These include: inadequate, with insufficient trained personnel and • Adjusting the scope of the humanitarian specialized services. Community-based or ethnic response: Humanitarian actors and donors health organizations provide primary healthcare in should not lose sight of the humanitarian needs many areas without government facilities. in Kachin and northern Shan. They should also However, these organizations often have limited improve outreach, communication, and trust capacity and are not equipped to deal with serious building to correct the perception of bias toward health issues. Rohingya communities in Rakhine. There should In these crisis-affected areas, UN agencies and be more programming on mental health and international and local NGOs play an important clinical responses to sexual and gender-based part in providing healthcare services. However, violence. much of the international focus has been on • Advocating for better humanitarian access: Rakhine state, with less funding for programs in Humanitarian actors should constantly advocate Kachin and northern Shan. Within Rakhine, for better access. UN member states and donor international organizations face accusations of bias agencies should also put its weight behind the toward the Rohingya community, despite efforts to humanitarian response in Myanmar. develop programming for all communities in Rakhine. Moreover, health actors have focused on • Strengthening local capacities: Donors should the response to malaria, HIV/AIDS, and tubercu - ensure they have the flexibility to fund local losis, leaving a critical gap in mental health services organizations that do not fit within their and clinical health responses to sexual and gender- traditional requirements. International organiza - based violence. tions should also continue to fund and train 2 Alice Debarre ethnic and community-based health organiza - 135 ethnic groups officially recognized by the tions in Kachin and Shan, as well as community government. The country is majority Bamar, and health workers and volunteers. Efforts to give a minority ethnic groups reside primarily in voice to affected populations should be strength - Myanmar’s peripheral states. Historically, there is a ened. chasm between the Bamar central regions and • Addressing the dilemmas inherent in providing peripheral states, which have long been marginal - aid amid a development and human rights ized and disenfranchised. Ethnic minority parties crisis: In Rakhine in particular, finding a suffered a devastating defeat in the 2015 election common position on engagement is vital to and are therefore under-represented in parlia - 3 ensuring the humanitarian response does not ment. During the elections, some ethnic parties felt perpetuate the unsustainable status quo. The UN undermined by the NLD, which campaigned hard country team and other humanitarian and against them, and some members of ethnic minori - development actors in Myanmar need to better ties chose to support the NLD over their own align their humanitarian, development, and parties, revealing fractures within these groups. human rights efforts. UN member states also The most marginalized group is the Rohingya— need to take a strong stance to push for change in most of whom reside in Rakhine state—which the both the humanitarian and human rights government of Myanmar does not recognize as an situation in the country. official ethnic group. The government and its policies have effectively rendered the Rohingya Introduction people stateless, which has made them the world’s largest stateless population and led to severe Over the past decade, Myanmar has undergone a violations of their human rights. Myanmar is also series of transitions. Since independence from British religiously diverse, with a Buddhist majority and colonial rule in 1948, Myanmar’s military, known as minority Christian, Hindu, and Muslim popula - the “Tatmadaw,” 1 has heavily dominated the tions. country’s political space. The transition from military Myanmar has been plagued by internal armed rule to an (at least nominally) civilian parliamentary