"A military coup in Myanmar in February 2021 has led to widespread conflict and has had a severe impact on its health care system. Many health care workers have been involved in civil disobedience and protests against the coup, including boycotts. Organisations such as the WHO and Insecurity Insight have also reported on attacks on health care in the country. Since February 2021, the UK government has provided over £120mn in humanitarian and development assistance in Myanmar. On 29 of February 2024, Lord Crisp (Crossbench) is scheduled to ask the following question for short debate: Lord Crisp to ask His Majesty’s Government what assessment they have made of the role that the United Kingdom could play in supporting health workers in Myanmar, and contributing to the reconstruction of the country’s health system. 1. The 2021 military coup Headed by Aung San Suu Kyi, Myanmar’s National League for Democracy (NLD) took power following elections in 2015 after decades of military rule.[1] Elections in 2020 led to further NLD gains and the military made an accusation of electoral fraud. In February 2021, Myanmar’s military commander in chief Min Aung Hlaing launched a military coup that overthrew the elected government. A civil disobedience movement (CDM) developed following the coup. The UN Special Rapporteur on the situation of human rights in Myanmar, Thomas H Andrews, stated that this led to the development of a national unity government: Following the formation of CDM, members of parliament who had been elected in the November national elections but prevented from taking their oath of office by the junta established the Committee Representing Pyidaungsu Hluttaw. From the Committee emerged the broader and more inclusive National Unity Government in April, to provide leadership, build international support and serve as the legitimate representatives of the people of Myanmar.[2] Militias formed in opposition to the coup, including as part of the ‘People’s Defence Force’ (PDF) under the National Unity Government.[3] The UK government has said that a wide range of people were involved in the protests: In response to military rule, people from a range of backgrounds and professions took part in large scale protests across Myanmar throughout 2021. Sources differ on the scale of the protests from daily figures of 10s to 100s of thousands depending on the location and timing. However, the UN summarised that by March 2021 millions of people had protested across 100s of towns. ACLED [The Armed Conflict Location and Event Data Project] recorded over 6,000 anti-coup demonstration events throughout 2021. In 2022, direct action continued but evolved to include civil disobedience, flash mobs, silent strikes and smaller anti-junta protests across the country.[4] The response of the military has included violence and arrests: Military response to opposition includes violent oppression of peaceful protests, arbitrary arrests of protestors and family members, property raids and seizures (particularly of NLD members), and to a lesser extent enforced disappearances and extrajudicial killings. Threats, harassment, violence, and direct attacks occur against those associated with or perceived to support pro-democratic or anti-junta groups, and on civilians in areas where there is conflict between the military and armed groups.[5] In a written statement in February 2023 marking two years since the coup, minister of state at the Foreign, Commonwealth and Development Office, Anne-Marie Trevelyan, said the coup had led to millions needing humanitarian assistance: The consequences for domestic and regional stability are clear; over 17 million people are now in need of humanitarian assistance—a staggering increase of 16 million in just two years; over 1.5 million people are displaced within Myanmar, with a million more in neighbouring Bangladesh, Thailand and India; illicit economies are thriving; and democratic gains have been reversed. Recent figures indicated Myanmar suffered some of the most intense violence in the world in 2022, with conflict-related deaths second only to Ukraine. There is a clear trajectory of increasing violence, human rights violations and abuses, to which the UK has responded with a range of tools.[6] Ms Trevelyan said the UK condemned the “brutal actions” of the military regime and supported “all those working peacefully to restore democracy in Myanmar”. She said that the military must engage with the National Unity Government and respect the “democratic aspirations of the people of Myanmar”: We support all those working peacefully to restore democracy in Myanmar. The military must engage in inclusive and meaningful dialogue with the full range of opposition voices, including the National Unity Government (NUG), and respect the democratic aspirations of the people of Myanmar. In 2022, UK ministers spoke regularly with counterparts in the NUG. We call on the military to immediately end its campaign of violence and release the thousands of people it has detained arbitrarily, including Aung San Suu Kyi. The military must engage in inclusive and meaningful dialogue with the full range of opposition voices in order to respect the federal, democratic aspirations of the people of Myanmar.[7] In a January 2024 answer to a written question asking when the UK government had last raised the treatment of pro-democracy advocates in Myanmar at the UN, the government said it had co-sponsored a resolution at the UN general assembly and supported the International Criminal Courts investigation of acts committed against the Rohingya: On 15 November 2023 the UK co-sponsored a UN General Assembly resolution calling on the Myanmar military to release all those who have been arbitrarily detained on political grounds. We will continue to seek opportunities to raise our concerns at the UN and other multilateral fora. We support the International Criminal Court Prosecutor’s initiative to investigate acts committed against the Rohingya. In November, we jointly filed a declaration of intervention at the International Court of Justice in The Gambia’s case alleging Myanmar has perpetrated genocide against the Rohingya, in order to set out our interpretation of the relevant provisions of the Genocide Convention before the Court.[8] 2. Impact of the coup on Myanmar’s health system The World Health Organization (WHO) has said “the crisis has spread in such a way” that the entire population of Myanmar, 56 million people, are now facing some level of need.[9] The UN Office for the Coordination of Humanitarian Affairs (OCHA) has stated that a third of the population, 18.6 million people, are now estimated to be in humanitarian need.[10] The OCHA’s ‘Humanitarian needs and response plan’ (December 2023) for Myanmar estimates that 12 million people will need humanitarian health assistance in 2024. The OCHA has stated that whilst the provision of public essential health services has “partly resumed” in large urban areas, overall access to health care, essential medicines and medical supplies continues to be “fragile, fragmented, and uneven”.[11] The OCHA says that this is exacerbated by long-term inequalities and that the health system is deeply politicised, which is affecting the return of health workers. This in turn hinders access to health care particularly for girls, women, people with disabilities and other vulnerable groups. The WHO has also reported that whilst the situation has improved in some large cities, overall health service access is still severely constrained: The health services remain significantly impacted by the increasing conflicts and security and economic stress. While a reversal in the trend in the provision of services is observed in some large cities, such as Nay Pyi Taw and Yangon, since the pandemic and the events of February 2021, the overall access to health services remains severely constrained and fragmented, with a heavy reliance on local partners supporting their own communities.[12] The WHO has said that prior to the current situation Myanmar had made progress in reducing the prevalence of communicable diseases, including malaria and tuberculosis.[13] The WHO said Myanmar had also shown “remarkable progress with regard to key sustainable development goals (SDG) targets of maternal mortality, newborn mortality and child mortality”.[14] However, it has stated that the established monitoring systems, such as District Health Information System 2, that allowed for an evidence-based determination of the functionality of Myanmar’s current health system “are non-functional”. The WHO’s country office therefore developed “alternative, ad hoc monitoring systems” to allow it to monitor access to health services: The data had been collected by observation from 360 townships by WHO field-based staff and Myanmar Country Office staff since April 2021. WHO, in collaboration with the World Bank, has conducted a phone survey across Myanmar to analyse the current situation regarding access to health care and medicines, and private sector providers’ response. Increased challenges to availability and affordability of essential medicines were observed while difficulties in transporting supplies to conflict-affected areas were also noticed.[15] The WHO reported that the Covid-19 pandemic had impacted medical training resulting in the “closure of all training institutions throughout the year 2020 with no graduation of the health workforce cadres, adding to the constraints”.[16] The WHO has characterised health care in Myanmar as facing the following challenges: In Myanmar, people are facing heavily restricted access to formal health services, including those run by public hospitals and de facto government clinics. Moreover, a large share of households continues to depend on health care services that are provided by private health care facilities while self-care remains a key approach adopted by them. Additionally, ethnic health organizations (EHOs) continue to fill significant gaps in health care provision. Lack of primary health care in villages, high cost of secondary health care at hospitals and movement restrictions in availing tertiary health care in capital cities continue to hinder access to health services. These restrictions are causing life-threatening suffering, notably mental and psychosocial burden, and death from medical emergencies. Minorities and other ethnically vulnerable populations continue to face severe constraints and a fragmented health care system in the wake of Covid-19 and the political changes in February 2021. Although Myanmar was hit by the deadliest wave of Covid-19 during June–September 2021, severely disrupting health sector functioning, the third and fourth waves in 2022 continued to put the health system under strain. The health system was crippled by a limited bed capacity, challenges to making oxygen and essential medicines available, and an inadequate health workforce, leading to excess death and disability. However, since then, the testing capacity and the vaccination rate have increased, which in turn have improved the level and development of seroprevalence.[17] The WHO has said that nearly half of Myanmar’s population (46%) is reported to be facing poverty, with “serious repercussions for the cost of health care”. It has said, that particularly in conflict areas, access to health care has been put out of the reach of common people by: significant shortages of key essential medicines continuing supply chain disruptions high inflation rates (about 20% in 2022–23) The WHO also said that a “continued depletion of tax revenue” had resulted in budgets cuts to the health sector.[18] The WHO has said the “total collapse” of the health management information system has meant that the availability of data is constrained. This has led to health programmes related to diseases such as malaria, tuberculosis and HIV/AIDs seeing a reverse in data collection and analysis used to monitor these diseases and assist with their prevention and control. The WHO has said that a new law had forced several NGOs to either shut down or reduce their operations: Declaration of a new Registration Law, mandating civil society organizations including health facilities and associations in 2022, has forced a sizeable number of NGOs to either shut down or partially close operations. The new law has crippled their functions, restricting access to financial resources from donors, in a considerable manner.[19] The UNHCR stated that the law made “registration compulsory for both national and international non-governmental organizations and associations”.[20] 2.1 Health workers in Myanmar Particular concern has been raised about the impact of the current situation on health workers in Myanmar. BBC News reported that organised resistance to the February 2021 coup “started with health care workers announcing a boycott of state-run hospitals”.[21] The WHO has also said that health workers “were among the first to express dissent with regard to the military takeover through civil disobedience; this involved 50% of the health workforce in the public sector”.[22] It said this led to a “significantly reduced health workforce in the public sector”. The WHO has said that the ‘national health workforce account’ could not be updated due to “limitation in engagement with the de facto authority since 2021”. There have also been attacks on health services following the coup. The WHO has said that there have been 385 attacks on health care reported via its surveillance system since the coup: Since February 2021, more than 385 attacks on health care have been documented via the WHO’s Surveillance System for Attacks on Health Care (SSA). These attacks have led to at least 58 deaths and 188 injuries. Each attack is deeply concerning as it affects access to and availability of essential health services–especially for women, children and other vulnerable groups.[23] The non-governmental organisation Insecurity Insight has reported that there have been 1,087 attacks on Myanmar’s health system since the 1 February 2021 coup.[24] It has said “at least 880 health workers have been arrested, 97 killed and 117 injured undermining health care providers’ ability to maintain safe staffing levels to effectively meet patient needs”. The OCHA has said that whilst the numbers of attacks reported differ between organisations they continue to be among the highest globally: Attacks on health care are monitored by a number of organizations, notably World Health Organization and the non-governmental organization (NGO) Insecurity Insight. Across all tracking efforts, reported attacks on Myanmar’s health care system continue to be among the highest globally in 2023, varying between at least 66 to 330 depending on the different definitions and levels of verification used. Even considering likely underreporting, indicative records shows that at least 14 health workers were killed and 21 wounded in 2023, with local aid workers most at risk.[25] The non-governmental organisation Physicians for Human Rights has said that attacks on health care workers “include arbitrary arrests, detentions, and violence committed against all types of health care workers, ranging from doctors and nurses to emergency medics and volunteers”.[26] In a report published in January 2022, Physicians for Human Rights reported that at first attacks were primarily targeted at health workers involved in nationwide protests: Initially, attacks primarily involved Myanmar security forces taking action against health workers participating in nationwide protests, the Civil Disobedience Movement [CDM], and the provision of medical care to injured protesters and bystanders.[27] However, the organisation has said that over time the attacks changed: Over time health care workers believed to have ties to the NUG [National Unity Government] or PDFs [People’s Defence Force] were targeted, including during raids of health facilities and charity organizations accused of aiding injured PDF members or supporters. Attacks by other armed actors on health care workers have emerged, particularly against those who have continued or returned to their civil servant roles and have reportedly pressured staff participating in CDM to return to work, or are believed to be military informants.[28] The OCHA’s humanitarian response plan has said that an estimated 372 medical teams are needed to meet humanitarian needs across Myanmar, “with a current gap of 202 teams”.[29] The OCHA has said the effective provision of health assistance is being undermined by a series of factors, including armed conflict and limited funding: Amid the continuation and escalation of armed conflict, limited funding and legal, administrative and security barriers persist in undermining the effective provision of adequate health assistance to an increasingly vulnerable population.[30] Number of workers in Myanmar’s health system before the coup In a section on the status of Myanmar’s health system “pre-crisis”, the WHO expressed concern that the density of health workers in the country was one of the lowest in the South-East Asia region. Prior to 2021, the WHO had observed a density of 17.8 health workers per 10,000 population in Myanmar. It has said an average of 22.8 health workers per 10,000 population is required to deliver a package of health services, compatible with the health Millennium Development Goals (MDGs).[31] The MDGs were 8 goals that UN members agreed to try to achieve by the year 2015.[32] They have been superseded by the Sustainable Development Goals (SDGs).[33] The WHO now estimates that 44.5 health workers per 10,000 population are required to “adapt services to the standards” of the SDGs. However, the WHO has described Myanmar as having one of the lowest health worker availability levels in the region, with issues including the even deployment of staff: Comparing health worker densities across countries in the South-East Asia Region and with the thresholds just described, Myanmar is one of the countries with the lowest health worker availability; it is only above Bangladesh. Beyond the overall limited availability of human resources in the system, deployment is also suboptimal since it is based on norms linked to facility nomenclature and size rather than on need or performance. The resulting allocation leads to insufficient personnel in some areas and exceeding capacity in others, along with inadequate skill mix, as proven by the limited number of complete critical care teams to run ICU beds during the COVID-19 crisis.[34] 3. UK government assistance to Myanmar In March 2023, Lord Crisp (Crossbench) asked the government in an oral question what support it was providing for health workers in Myanmar “who are caring for patients outside the areas controlled by the military government of that country”.[35] Responding for the government, then minister of state at the Foreign, Commonwealth and Development Office (FCDO), Lord Goldsmith, said that Myanmar’s health system had been in crisis since the coup and the UK was a leading donor on supporting health care needs in the country: My Lords, Myanmar’s public health care system has been in crisis since the coup. We are concerned about Myanmar’s level of basic health care services and childhood immunisation rates. The UK is a leading donor on supporting health care needs in that country. This financial year, the UK has provided £13.95mn for health care in Myanmar, which is being delivered by the UN, by civil society and by ethnic health care organisations. This support is saving the lives of vulnerable women and children.[36] Lord Goldsmith also said the UK government supported health professionals in Myanmar who were risking their lives: We applaud the Myanmar health professionals who are risking their lives to continue treating patients. We commend the NHS volunteers who are sharing their skills and knowledge with colleagues and friends in Myanmar, taking huge risks in doing so. I absolutely pay tribute to them. Since the coup, we have provided around £100mn to support those in need of humanitarian assistance, to deliver health care and education for the most vulnerable and to protect civic space. In 2021–22, we provided nearly £50mn in aid to Myanmar, including £24mn of life-saving assistance for 600,000 people. I am not in a position to comment on future expenditure, but I think it is very clear from our recent track record that this remains a priority focus for the FCDO.[37] As part of its approach to increase transparency in the government’s aid spending, the FCDO publishes the ‘UK–Myanmar Development Partnership Summary’ (17 July 2023). This provides an overview of the department’s development activity, development priorities, and financial information (including budgets and breakdowns of spend) in Myanmar. This sets out information on key programmes, including the ‘Myanmar-UK health partnership programme’: [The] Myanmar-UK Health Partnership programme (MUHP)—£6mn—aims to promote equitable access to health services for people from the most disadvantaged areas in Myanmar—especially in ethnic and conflict-affected areas—and to enhance the health partnership between the UK and Myanmar. The key intended impacts of the programme are: a reduction in maternal, newborn and child illness and deaths; and a reduction in the burden of human immunodeficiency virus (HIV), drug-resistant tuberculosis and malaria through supporting stronger local health responses including in partnership with UK institutions.[38] In December 2023, the government said it had provided over £120mn in humanitarian and development assistance in Myanmar, “focussed on life-saving assistance, emergency health care, water, hygiene and sanitation services, and education”.[39] In July 2023, the government provided the following breakdown of spending on official development assistance (ODA) by year: From 1 Feb 2021 to 31 Mar 2022: we provided £8mn In financial year 2021/22: we provided £49.5mn In financial year 2022/23: we provided £57.3mn In financial year 2023/24: our allocated budget is £30.1mn (we have spent £5.13mn so far).[40] 4. Further reading OCHA, ‘Myanmar humanitarian update No 35: 2023 year in review’, 12 January 2024 Medicins San Frontieres, ‘Health workers struggle to respond amid severe restrictions in Rakhine state’, 16 January 2024 Physicians for Human Rights, ‘“Our health workers are working in fear”: After Myanmar’s military coup, one year of targeted violence against health care’, January 2022..."