NGO Perspective on Assistance in Burma/Burma/Myanmar

Guy Stallworthy, Population Services International

EC "Burma Day 2005" Conference, April 5th 2005, Brussels

Introduction

I am grateful to the organisers for the opportunity to speak at this meeting. I will comment on INGO activity in Burma/Myanmar, especially in health. I will argue that INGOs operate effectively and independently; that we deliver significant benefits to the people of Burma/Myanmar; and that we have also contributed to positive policy change by engaging over the long term with health professionals in the public sector. I will stress the importance of engaging the small-scale, independent private sector for socio-economic development in Burma/Myanmar. I will also comment on the discussion paper's recommendations with respect to assistance.

I do not claim to represent the INGOs in Burma/Myanmar. I have consulted with a number of my colleagues, but these are my own personal views. Most of the examples I give are from my own organisation and the areas in which we work.

INGOs in Burma/Myanmar

My comments refer to the experience of international NGOs in Burma/Myanmar. There are some independent NGOs that are not affiliated with international organisations, but they are few. Depending on definitions, there are many community-based organisations, but they are generally small and weak.

There are currently 41 INGOs employing about 3,500 people in Burma/Myanmar. Most are small, but 7 have staff over 200. A few have been operating since the early 1990s. Some have a religious orientation, most do not, but all would subscribe to the principles of humanitarian assistance mentioned by Charles Petrie.

Most work in health, but some are active in community development, water & sanitation, agriculture and other areas.

The operating conditions for INGOs in Burma/Myanmar have evolved considerably since the mid-1990s. The authorities have become much more used to us and to the way we work. Whereas our staff attracted attention to themselves by working for foreign organisations in the early- and mid-90s, this is no longer the case, and contact with foreigners is no longer so controversial.

We all operate under Memoranda of Understanding with the government, as in most countries. These agreements specify the kinds of work we will do and the areas where we will operate. They also specify that we are exempt from taxes and duties. Up to now, PSI has been able to import health commodities duty free.

In practice, we all usually avoid channelling resources to or through the government, although we coordinate with government officials at the technical level of the civil service.

While conditions have improved significantly, some operational problems remain: we are not allowed to import vehicles duty-free; we still have to seek authorisation for expatriate travel outside Yangon; some INGOs have difficulty securing permission to expand to new areas.

Scale of INGO activity in context

The 41 INGOs in Burma/Myanmar have a total budget of around $30 million. By comparison, Nepal, with half the population, has about 275 INGO with a budget of $175m. Cambodia, with a population of just 15 million, has about 115 INGOs with a budget of $110 million.

These are countries with similar levels of per capita income and socio-economic indicators. Yet on a per capita basis their level of INGO activity is 8 -10 times greater than that of Burma/Myanmar

The private sector

While the local NGO and CBO sector is weak, this is not the case for the small-scale, independent private sector. People often overlook the fact that some 80% of health-seeking behaviour in Burma/Myanmar is in the private sector. Some believe that the private sector is only for the wealthy and delivers poor quality care. We have conclusive evidence that the poor use private doctors just as much as the non-poor and that most of the clients of the private sector are poor. We have also shown conclusively that private doctors can be helped to deliver high quality care to international guidelines.

There may be as many as 8,000 private GPs in Burma/Myanmar. The Burma/Myanmar Medical Association makes genuine efforts to provide continuing medical education to its members; local chapters in some areas are active and inclusive.

There may be hundreds of thousands of small retailers of various kinds, including 3,300 registered Medical Drug Retailers. I repeat, the private sector is where most people get most of their health care.

PSI/Burma/Myanmar

I will say a few words about PSI/Burma/Myanmar to illustrate how INGOs can work.

PSI is an international, non-profit organisation with operations in 65 countries. We are also non-political and non-religious. We have been operating in Burma/Myanmar since 1995. We now have 330 staff, of whom 4 are expatriate, based in 8 offices around the country.

Our mission is to empower low income people of Burma/Myanmar to lead healthier lives. We do this through social marketing: engaging the resources, techniques and energies of the private sector to achieve pubic health objectives. Each year our staff operates in about 290 of the 324 Townships, and we believe our products get everywhere.

We sell subsidised health products to about 10,000 retailers and wholesalers around the country. Products channelled in this way include a range of condoms, an insecticide-treatment kit for mosquito nets, and a home water treatment solution.

We have developed a franchise network of private General Practitioners, known as the Sun Quality Health network. These are independent, private GPs, operating small clinics in low-income neighbourhoods. There are now 500 such doctors in the network. We work with them on reproductive health, malaria, STIs and TB.

Our communications staff includes graphic designers, a video production team, 6 mobile video units and 60 outreach workers. We produce soap operas, feature films and short spots for television. We promote healthy behaviours through advertisements in popular weekly journals and on billboards. And we conduct thousands of small-group education and training sessions per year.

Selected Results

I will highlight a few examples of what INGOs and the small-scale, independent private sector, working together, can achieve.

The condom market has grown from less than 3 million in 1996 to about 33 million in 2004. This represents a massive change in behaviour and in socio-cultural conditions. The "aphaw" social-marketed brand represents at least 75% of the total and has driven this growth.

Through the SQH network, we are providing about half a million quality reproductive health consultations per year.

This year PSI alone will reach 500,000 people through small-group training sessions, and a further 450,000 people with mobile video shows.

PSI treated about 15,000 cases of falciparum malaria last year. I don't have figures for all INGOs, but MSF/Holland alone treated 134,000 cases of malaria last year.

Various INGOs have shown how to engage vulnerable populations in a respectful, participatory way. These populations include IDUs, MSM, FSW, street children).

Policy changes

In addition to directly delivering a range of services to scale, INGOs have contributed (along with UN specialised agencies) to a number of significant changes in the health policy environment. I'll mention just a few:

* The policy on harm reduction amongst injecting drug users is one of the most progressive in the region; INGOs are allowed to do needle exchange and drug substitution activities in specified townships.

* In recent years there have been significant changes to national treatment protocols and guidelines for malaria, STI and AIDS

* As of this month, INGOs are allowed to do HIV testing within VCT programmes

* Preparation of recent Global Fund proposals has been inclusive, with full participation of NGOs

* I mentioned condom sales. The policy environment for condom promotion has evolved considerably since 2001, when we began mobile video shows in rural areas and scaled up our small-group training sessions. In 2003 we began to take out full page advertisements in journals, using the chameleon ("bothinyo") as a "spokesperson" with associations rooted in Burma/Myanmar culture. In 2004 we placed billboards around the country for the first time, though not in Yangon. This week we have had a major breakthrough: "bothinyo" and "aphaw" are sponsoring a new weekly football show on national television. The EC has funded this work for the last 3 years. Unfortunately, we may have to scale back these activities next year because EC support is coming to an end.

* TB is a very interesting case. Around the world, government attempts to control TB have traditionally failed to engage other sectors. WHO recognises that it is important to promote public-private mix for DOTS, the TB treatment protocol, but progress has been slow. Burma/Myanmar not only has a national TB programme that is considered by WHO to be one of the best amongst the high-burden developing countries, but they have also embraced PPM with enthusiasm. Our programme to franchise DOTS in the private sector is unique. In just the first year of operations, we have begun treatment for 3,000 TB cases, adding about 20% to case detection in the areas where we work. In more than 20 years in this business, I have never seen more open, constructive and productive approach to partnership by any government department anywhere.

So productive engagement on sectoral policy is possible.

Other INGO contributions

Other INGO representatives would have been able to speak authoritatively about work in education, agriculture, water & sanitation or community development. I will note just one general way in which INGOs are contributing to socio-economic progress in Burma/Myanmar, and that is human resources development. Most INGOs have demonstrated modern management styles and techniques in a country where people have had little exposure to outside companies and organisations. This is real capacity building: the experience of participating in a social organisation that is entrepreneurial and results-oriented, in which performance and talents determine promotion and authority, for example.

Comments on the discussion paper recommendations

I welcome the proposals for expanding the level and scope of assistance. Regardless of policy on diplomatic and political relations, it is not right to deny normal levels of assistance to 50 million people. Properly managed assistance does not hinder political progress and can facilitate it.

I believe that it would be a big mistake for the EC to neglect health, for many reasons:

* The needs are great, as others have detailed

* We cannot assume that the Global Fund will serve those needs, for many reasons; one reason is that the GF does not address serious problems such as reproductive health, water & sanitation, iron deficiency, etc.

* Addressing health has positive knock-on effects for other sectors, such as productivity and education

* There is a proven delivery capacity amongst INGOs and the private sector as well as in the pubic sector

* When addressing health, societies inevitably come to confront other issues such as gender, vulnerable groups, freedom of information, stigma, etc

Increased aid should be delivered through the INGO, private sector and local independent NGO/CBO wherever possible. In many cases, this is the most effective way to get he job done. In addition, it supports the long term objectives of nurturing civil society as a foundation for a democratic society.

Where necessary, I see no reason not to channel assistance to government departments, provided it is based on a rigorous analysis that demonstrates that the task in hand is important, that it can best be achieved by the public sector, and that the department concerned has demonstrated will and capacity to achieve the desired results. Such analysis has been rare.

Above all, it is essential that an expanded aid programme be managed to the highest standards of accountability and performance expectations. This is a platitude that can apply anywhere, but it is especially true in Burma/Myanmar because of the political context. Such standards have sometimes not been applied up to now. An expanded aid programme should be managed directly by the EC, with technical assistance from UN agencies, with a heavy role for INGOs and the private sector in implementation, and with an appropriate role for government in both policy and implementation.

Summary Conclusions

1. INGO function independently in accordance with principles of humanitarian work

2. The space for us to do so has improved significantly over the years, even if there are still problems

3. We can go to scale in delivering significant services and other benefits to the poor in most of the country

4. We can interact productively with health professionals in the civil service and facilitate significant positive change in the sectoral policy environment

5. The small-scale independent private sector is a powerful partner in going to scale

6. While significant, the scale and scope of our activities is small relative to need, especially if we compare with other countries

7. The EU should increase the amount and scope of aid to Burma/Myanmar

8. Health should continue to be an area of priority for EC assistance

9. The aid should be delivered in a way that maximises the role of civil society and the private sector, while retaining an appropriate role for government

10. The EC should directly manage the aid programme and maintain the highest standards of performance expectations and accountability