Chapter 4: Health

Foundation of Fear: 25 years of villagers’ voices from southeast Myanmar

Written and published by Karen Human Rights Group KHRG #2017-01, October 2017

“We dare not go to the government hospital if we have no money. If we don’t take money they don’t give us medicine [If it is serious] we have to try hard to find the money to cure the disease. Mostly we treat  things using traditional medicines. My children have never had an injection or vaccination.They called us to go and get vaccinations for our children but we were afraid because people said their children got feversafter the injection.”

Naw Ek---(female, 30), quoted in a report written by a KHRG researcher, El--- village, Mone Township, Nyaunglebin District/eastern Bago Region (published in May 1999)[1]

“They [the Burma/ Myanmar government] just declared the building of the clinics under their name [so they can claim they have worked for the development of the villages]. We know this as they have not yet [provided] enough medics, nurses and medicines. If you question the villagers [living] there, [near] the clinics that they had built, they only say that those [buildings] are not clinics [since they are never open for patients].”

Situation Update written by a KHRG researcher, Thaton Township, Thaton District/northern Mon State (received in January 2016)[2]

Key Findings

1. Access to healthcare has been a significant concern throughout 25 years of KHRG reporting. Access to healthcare for villagers has been deliberately denied through Tatmadaw’s imposed restrictions on freedom of movement and the trading of medical supplies in the 1990s and 2000s. Since the 2012 ceasefire, barriers in accessing healthcare have changed from conflict-related to infrastructure-dependent, including the lack of adequate roads to rural areas, and the lack of functioning healthcare facilities in rural areas.
2. Displaced villagers suffer disproportionately from a lack of access to healthcare and medical supplies when in hiding. Due to severe restrictions on villagers’ movement, sickness, malnutrition and disease are estimated to have killed more people throughout the conflict than the direct violent abuses of Tatmadaw and EAGs.
3. When healthcare facilities are available and accessible, patients report that they are frequently understaffed, lack essential medical supplies, and operate unreliable opening hours. Additionally, villagers have raised complaints about the acceptability of healthcare standards, particularly those made recently available since the 2012 preliminary ceasefire. They have experienced disrespectful and discriminatory Myanmar government healthcare staff, lack of information on the side effects of medicine prescribed, and arbitrary denial of treatment.
4. The standard of healthcare services, when made available, has been consistently low throughout 25 years of KHRG reports, particularly in rural areas of southeast Myanmar. Villagers have relied on traditional medics and traditional medicines, most especially during conflict and when in hiding, but this dependence continues in areas which are not served by permanent healthcare staff and in areas where medical supplies are not available.
5. Significant financial barriers persist with regard to free and equal access to healthcare. The financial consequences of Tatmadaw, BGF and EAG abuses, including financial extortion and a lack of time for villagers to work for their own livelihoods, left many villagers financially insecure and unable to pay for basic medicines. Whilst these abuses have reduced, villagers report that they continue to find healthcare inaccessible due to financial barriers including the cost of travel to hospitals, the cost of medicine, and the unwillingness of some healthcare staff to treat poorer patients.

Introduction

Based on villagers’ testimony, this healthcare chapter provides an analysis of how villagers’ experiences and perspectives in regards to their health needs have evolved over the past 25 years. Over a quarter of a century, villagers in southeast Myanmar have consistently identified access to and the acceptability of essential healthcare services as one of the biggest challenges they face, despite the changing context. Decades of conflict have severely impacted civilian health in more ways that direct abuse and torture, by prompting displacement and impeding investments and improvements in essential health infrastructure, particularly in rural areas. Since the 2012 preliminary ceasefire, the situation of human rights violations which impact the condition of villagers’ health in KHRG operation areas have improved to a notable extent. However, significant shortfalls in healthcare provision remain and whilst abuses have decreased, the additional health consequences of conflict on livelihood and financial insecurity, vulnerability to disease, lack of basic health awareness, lack of access to a range of medicines and treatments, a shortfall in skilled and qualified healthcare workers, and inadequate medical and transport infrastructure have not decreased. The result is that despite an easing of direct abuses against villagers by Tatmadaw and some EAGs, serious health concerns persist for villagers in southeast Myanmar.

This chapter is structured to review villagers’ concerns and experiences over 25 years with regard to: access to healthcare; the acceptability of healthcare services related to supplies and services; the acceptability of healthcare services related to staff and skills; and the impact of livelihood and financial insecurity on access to healthcare.

Myanmar’s legal and political commitments

The right to health is recognised as a basic human right in the UDHR,[3]  the ICESCR,[4] and a political commitment under Myanmar’s 2008 Constitution, Article 367:

“Every citizen shall, in accord with the health policy laid down by the Union, have the right to health care.”[5]

Additionally relevant, protection of the health of civilians in conflict, including the treatment of wounded[6]  and the protection of medical facilities and staff,[7]  is recognised in both customary international humanitarian law and the First and Fourth Geneva Conventions of 1949.

In addition to international law, villagers explicitly recognise health as an essential right, and necessary for their access to other basic rights, including education and livelihood security:

“Every rightis important but you have to be healthy if you want to gain education.Therefore, the right to education can [only] come after the right to health care.Things are like that. You must be healthy ifyou want to study. Ifyouare healthy, youcan work toearna living. To be able to earn a living, you need to [also] have freedom of movement and the right to work. Thus, [if you have these] there is no barrier to block your rights. As a human, we have to use our rights in an appropriate way. Nobody should disturb [take away] our rights. We have to take our rights fully [not one right without another] and we have to do our best. If we can work, we can get [enough] food. If we get food, we are healthy. As long as we are healthy, we can study. If we can study, we will be educated. If we are educated, we can improve our community.

Naw Ew--- (female, 24), Ex---- village, Khel Ken Koh village tract, Kyaukkyi Township, Nyaunglebin District/eastern Bago Region (interview received in December 2016)[8]

Access to healthcare: attacks and restrictions

Decades of prolonged conflict in southeast Myanmar have intertwined with the systematic abuses of armed actors against civilians and caused, amongst other concerns, deliberate and debilitating attacks on villagers’ access to healthcare. Particularly in the late 1990s and early 2000s, medical facilities which were often established and run by the local community with KNU or CBO support, were targeted or destroyed by the Tatmadaw[9] as part of their aggressive ‘Four Cuts’ policy.[10] For example, one photo caption written by a KHRG community member from Hpapun District in 2002 shows:

“[This photo shows] There mains of a clinic built by the KNU at Oo Da Hta near the Salween River in Hpapun District. The clinic was built to provide medicine and some measure of healthcare to villagers in the area. The clinic was only temporary because of the possibility of SPDC [Tatmadaw] troops moving into the area. The SPDC came and burned it in early May 2002 at the same time that they burned Kho Kay village.”

Photo Note written by a KHRG researcher, Hpapun District/ northeastern Kayin State (published in December 2002)[11]

Attacks on healthcare facilities continued as Tatmadaw sought to drive villagers out of certain areas, directly blocking their access to healthcare. These were not isolated attacks but part of Tatmadaw strategy to crush any forms of community reliance, evident through almost 20 years of KHRG reports, prior to 2012. Where emergency healthcare facilities were provided, such as by Back Pack Health Worker Team (BPHWT) and Free Burma Rangers (FBR), they were also at risk of being attacked, as was the case when Tatmadaw shelled one IDP site in Ma No Roh village tract, Tanintharyi Township, Mergui-Tavoy District in January 2011 whilst BPHWT were providing emergency medical care to the displaced villagers, evidenced in the testimony of a BPHWT medic:

“It happened when I was staying at P--- village [IDP hiding site] and looking after patients. The SPDC Army [Tatmadaw] Soldiers came and fired mortars at the place we stayed. At that time, during the mortar attack, we all ran up to the mountain, including the children.”

Saw Ep--- (BPHWT) (male, 30), P--- village, Tanintharyi Township, Mergui-Tavoy District/Tanintharyi Region (published in September 2011)[12]

Deliberate attacks on villagers and their basic health infrastructure have receded since the signing of the 2012 preliminary ceasefire. A further change in villagers’ access to health is their perception of their safety and security to travel. Many villagers since the 2012 ceasefire report that feel safer to travel and face fewer restrictions on their freedom of movement, which has resulted in greater physical access to healthcare services.[13] Prior to this, life-threatening restrictions were imposed on villagers by Tatmadaw. Movement restrictions obstructed villagers living in supposed “rebel” or “black”[14] areas from travelling to reach hospitals or clinics, and from traveling outside of their home communities to buy medical supplies.[15] Villagers who did so risked being arbitrarily arrested, abused or shot on sight by Tatmadaw. Tatmadaw actively prohibited any medicine reaching these areas as part of their program to make sure no supplies could reach opposition forces, enforcing these restrictions at frequent checkpoints or arbitrarily searching villagers on roads and village paths to check they were carrying no medicine. These prohibitions were ultimately more deadly than Tatmadaw’s direct attacks:

“The villagers in hiding have also lost many people to disease. In every group of families there are people suffering from malaria and other fevers, diarrhoea, dysentery, oedema, respiratory and stomach ailments. Many more have died this way, particularly children and the elderly, than have been shot by the troops. None of the villagers have any medicines, they only have whatever herbal remedies they can find in the forest. Before this operation began they could walk to towns to buy medicine or medicine sellers would occasionally come through their areas, but no longer. Even in parts of eastern Shwegyin Township which should be an easy walk to Shwegyin Town, SLORC/SPDC[Tatmadaw] forces have blocked off all the paths since late 1997 in order to prevent these villagers from having any access to outside food or medicines.”

Report written by a KHRG researcher, Hpapun and Nyaunglebin Districts/ Kayin State (published in February 1998)[16]

Villagers caught with medical supplies had these items confiscated as part of the ‘Four Cuts’ policy and faced the risk of excessive abuse under the accusation that they were using medical supplies to support Karen ethnic armed groups (EAGs)[17] or trade with villagers in hiding, a common strategy used by villagers to support each other throughout oppression.[18] Villagers who were forcibly relocated faced further abuse as they were relocated to areas under strict Tatmadaw surveillance, without access to services including healthcare or medical supplies, forced to buy basic medicine at inflated prices from Tatmadaw medics, and were restricted from traveling outside of these relocation zones without paying extortive fees for permission letters in order to access hospitals or clinics when sick.[19]

Access to healthcare: consequences of human rights abuse

Villagers also report that they have faced life-threatening and debilitating health consequences as a direct consequence of abuse which has been worsened by the situation of healthcare service and standard. Villagers, most notably prior to the 2012 ceasefire, have been repeatedly subjected to violence, torture, killing, forced labour, and made to work as porters,[20] with severe and often long-term negative impacts on their health. Forced to work as porters, villagers have been tortured, made to carry heavy loads for long distances with enforced restrictions on food, water and medicine during their labour, resulting in severe weakness and, for some, death.[21] An escapee porter conscripted by Tatmadaw, Daw Ea--- from Thaton District, testified about the insufferable health consequences of portering:

“I had to carry bombs for 21 days through the forest and over mountains, into the areas where they’re fighting the Karen soldiers. It was almost impossible to keep up because the load was so heavy and we got   almost no food. If we were lucky, [22] oncea day we got a little rice, but nothing to eat with it... We were all very weak, and many men and women were ill with chills and fever, but the hurt and sick were still forced to carry their loads and keep up, even if they had to bd dragged.”

Daw Ea--- (female, 32), quoted in a report written by a KHRG researcher, Kyaikto Township, Thaton District/northern Mon State (published in January 1992)[23]

Due to the inhumane conditions villagers have endured during portering and forced labour, villagers have suffered from various diseases and health ailments. Without adequate access to healthcare facilities and services, countless villagers have died of treatable diseases during decades of Tatmadaw’s oppressive control, often malaria or diarrhoea.[24] The abuses by Tatmadaw and at times EAGs therefore have had prolonged health impacts for villagers, including weakness, disease and death, that extend beyond the direct remit of violent abuse for which they can be directly held accountable for. The lack of acceptable and accessible healthcare services in southeast Myanmar therefore carries with it memories of negligence and abuse by Tatmadaw of villagers’ health under conflict.

As a result of human rights abuses perpetrated by Tatmadaw and EAGs, many villagers chose to strategically displace themselves. This further limited their access to healthcare, and IDPs or villagers temporarily in hiding have faced some of the most severe health impacts of the conflict, dying from preventable diseases. Saw Eo--- describes the conditions of people hiding from Tatmadaw in Nyaunglebin District in 1999:

“The most common illnesses they suffer fromare fever and malaria. People with fevers or malaria who wouldn’t normally die are dying because there is no medicine. Most of the people who have died are children, ages 1 to  years old. I saw children with fevers, and because they had no medicine the fever never went down. Even though they put sesame oil on t he body of the child, they still die. There is no gauze, no cotton and no medicine for when someone is injured. All they have are their traditional healing practices, but those are not perfect without some medicine as well.”

Saw Eo--- (male), quoted in Report written by a KHRG researcher, Nyaunglebin District/eastern Bago Region (published in May 1999)[25]

Access to healthcare: lack of investment in rural areas

Basic physical access to healthcare facilities therefore can be life-saving, including freedom of movement for villagers to travel to access clinics and medical supplies as well as the commitment to making more services at a higher standard available in rural areas. The lifting of restrictions and the reduction of the abuses of forced labour, torture and extrajudicial killings has evidently increased the potential for villagers to access healthcare, and the pressure has now turned to improving infrastructure and healthcare standards to support this. Whilst in some areas the situation of access to acceptable healthcare has improved, rural villagers continue to report significant barriers and remain at higher risk of sickness, disease and death than their urban neighbours. Much of the investment in improving healthcare access in recent years has largely focused on larger villages,[26] towns, and cities. Therefore, most villagers in rural areas continue to report that the distance they must travel to access the nearest hospital or clinic is too far, particularly in emergency cases.[27] Additionally, this distance burdens them financially due to travel costs, and is especially difficult for vulnerable populations such as pregnant women and elderly villagers.[28] Saw Es---- in Htee Th’Blu Hta village tract, Hpapun District, 2016, describes the as yet un-met need for improved infrastructure and healthcare services in rural areas:

“When I was sick, my neighbours had to carry me to the hospital on a bad [unpaved] road. Therefore, if people [authorities] construct a better road for us then it will be a good thing for us. If we have a good road then we can go to hospital by car, then we will arrive to hospital quickly. There is no hospital in the eastern area [where the rural villages are located] so we have to go to the western area [where the town is located].”

Saw Es--- (male, 45) Et--- village, Htee Th’Blu Hta village tract, Bu Tho Township, Hpapun District / northeastern Kayin State (interviewed in December 2016)[29]

The Myanmar government has taken steps to address this void in services for the rural population, attempting to train and dispatch health workers to rural areas in southeast Myanmar where they previously were not working. However, physical access such as inadequate roads and bridges reinforces the isolation of these villages, as many health workers cannot access them, or are unwilling to access them:

“Although theTownshipadministratorsendsa doctor from Thandaunggyi Township [to the villages], the doctor does not go to the villages since there is problem for the car to travel there. The road which goes to the villages that the doctor has to take for treating the [villagers’] illnesses takes three hours by motorcycle. The road is also rough since it was constructed by the villagers. The doctor said, “I cannot sacrifice myself,” and he turned back at the half way [point].”

Situation Update written by a KHRG researcher, Thandaunggyi Township, Toungoo District/northern Kayin State (received in November 2015)[30]

Myanmar government health workers being absent from their appointed villages, as evident in the above case, have serious consequences for villagers in need of healthcare, such as the death of a mother in child birth:

“On May 29th 2014, in Toungoo District,Thandaunggyi Township,a villager from A--- village delivered her baby. There were mid-wives appointed by the [Burma/Myanmar] government, but they were never in the village. She had to deliver the baby with a hired [non-formally trained] midwife. Because she delivered the baby with a hired mid-wife, it took so long that her placenta did not come out and the hired mid-wife [had to] cut her placenta out with scissors. The blood ran without stopping and she died. If there were mid-wives [from the Burma/Myanmar government] and medicine, we could have saved the pregnant woman”.

Situation Update written by a KHRG researcher, Thandaunggyi Township, Toungoo District/northern Kayin State (received in July 2014)[31]

The above case shows that even when Myanmar government health workers have been appointed in rural areas, they often do not stay in the village reliably or permanently, leaving villagers to rely on unskilled, traditional medics. In many cases where government health workers refuse to go to rural areas despite the health needs of villagers, they are also unwilling to stay in the villages because of poor living conditions, further deteriorating rural villagers’ access to healthcare.[32] As noted by a community member in Bilin Township, Thaton District in 2014:

“In Ec---village, the Myanmar government setup a clinic for the villagers but the government health worker who is going to take care of the villagers does not want to live amongst the Karen people. I heard from the villagers that she said that if she is given the responsibility of injecting vaccines [for the villagers], she will come and inject the vaccine and then she will return to her village.”

Situation Update written by a KHRG researcher, Bilin Township, Thaton District/northern Mon State (received in November 2014)[33]

The above testimony by a KHRG researcher suggests that not only physical barriers of a lack of clinics and infrastructure in rural areas impact villagers’ access to healthcare, but also ethnic divisions continue to impact the adequacy of healthcare that Karen villagers receive, as a trained, appointed Myanmar government health worker does not want to live “amongst the Karen people”.

In some areas however, villagers report that there has been a marked increase in the number of Myanmar government health services available,[34] including both the number of staff and number of newly constructed clinics. Naw Ew--- from Kyaukkyi Township, Nyaunglebin District in 2016 notes Myanmar government staff are now more present in her area and villagers feel safer to contact them:

“Regarding healthcare, in the past it was not easy to call a Myanmar government doctor if we were sick. Now there are Myanmar government doctors entering our village. Our Karen people are just health workers [without full medical training]. Therefore, if we get a serious illness, we just call the Myanmar government doctor. In the past, when we were sick, we dared not to call doctors at night. That is why some sick people suffered until they died. After the ceasefire, we dare to go to call the doctors to come and provide medical treatment whenever we want to.”

Naw Ew--- (female, 24), Ex---- village, Khel Ken Koh village tract, Kyaukkyi Township, Nyaunglebin District/eastern Bago Region (interview received in December 2016)[35]

However, villagers report that many healthcare facilities that have been established in the post- ceasefire period are poorly constructed and lack trained medical staff, equipment, and essential medicines.[36] As reported by Saw PP--- from Dooplaya District in 2016:

“Currently, there is hospital but there are no medics and medicine. And sometimes there is medicine but there are not enough different types of medicines so [villagers] have buy [medicine from outside].”

Saw PP--- (male, 37), Win Yay Township, Dooplaya District/southern Kayin State (interview received in November 2016)[37]

In addition to a lack of supplies and staff, due to a lack of consistent funding and oversight by the Myanmar government or the authority responsible for the construction, some newly constructed healthcare facilities never open[38] or are defunct as soon as the opening ceremony has been completed.[39] One KHRG researcher from Thaton District reported to KHRG in 2014:

“We [the community] need more healthcares [professionals] in this area [ThatonTownship].The Myanmar government built clinics in many places but there are no nurses or medics.There are no people who look  after these buildings so some of the buildings were destroyed and some became goat pens.”

Situation Update written by a KHRG researcher, Thaton Township, Thaton District/northern Mon State (received in July 2014)[40]

Access to healthcare: communication and coordination

Given both the lack of access and void in rural areas of functioning and culturally appropriate Myanmar government healthcare facilities, villagers have consistently relied on a number of different actors to fill the gaps in service provision. Most of these services are provided by Karen healthcare CBOs and the Karen Department of Health and Welfare (KDHW) under the KNU administration, neither of which could operate openly under conflict for risk of being accused of supporting Karen EAGs through their work.[41] However, one villager in Hpa-an District reported in 2014 that the Myanmar government has not given the option for healthcare services to be KNU- led or self-reliant and community-led, asserting its presence in areas where villagers state their preference for services provided by local actors instead of the Myanmar government:

“[W]e heard that they [the Burma/Myanmar government] came and built hospitals in Klaw Ga Di village and Shan Ywa Thit village. But they do not allow Karen [KNU] to build a 50 bed or 100 bed hospital in Paingkyon Town.”

Saw A--- (male, 36), C--- village, Nabu Township, Hpa-an District/ central Kayin State (interviewed in May 2014)[42]

Since the 2012 ceasefire, there has also been an increase in health CBOs operating in rural southeast Myanmar. While these CBOs often provide essential vaccinations and basic medical supplies to villagers in rural areas, villagers have raised concerns over the unpredictability of their services due to a lack of consultation and communication between villagers and the healthcare provider. This lack of communication and consultation is evident in many services that are provided in southeast Myanmar,[43] and has resulted in confusion among villagers and an overlap in services in some areas whilst a void continues in other areas. For example, a KHRG researcher from Dooplaya District reported in 2014:

“There are two township clinics that were opened by the KNU which are free of charge. Although each township has [Burma/ Myanmar government] Anti-Malaria Teams, there are [additional] government organisations and association sentering the community [other than the] Anti-Malaria Team, including Mother and Child Care and Polia Protection and Immunisation and Anti-Tuberculosis. Villagers do not know which injection they should get and they also worry that they will not get the right injection. In 2013 a medical complication arose after a villager had an injection for elephantiasis. [44] Because of the 2013 medical complication, villagers were concerned with which health teams [or organisations] will arrive news to give help.”

Situation Update written by a KHRG researcher, Win Yay Township, Dooplaya District/southern Kayin State (received in November 2014)[45]

As the above report suggests, healthcare providers have been active in increasing health awareness trainings to villagers after the preliminary ceasefire, although many areas remain poorly serviced and lack permanent healthcare staff.[46] Additionally, villagers have found that they are not consulted on their health priorities with regards to the trainings that are available, and do not know the schedule of when these mobile teams will return to their community.[47]

However, the presence of KNU medics and CBOs has provided essential, if not consistent or extensive, healthcare for villagers particularly in more remote areas and for villagers who face financial barriers to traveling and accessing Myanmar government hospitals, easing some villagers’ health concerns. According to one KHRG community member from Thaton District in 2015:

“Those who live near towns go to town for treatment. Those who have insufficient money for treatment, theyfindtheir own ways of treating their illnesses. In KNU side [KNU-controlled areas], BackPack[48] has setup clinics in every area. Therefore, those who cannot afford to go to town [for treatment] try to go to the KNU side [clinics], where they also receive enough medicine”

Situation Update written by a KHRG researcher, Thaton Township, Thaton District/northern Mon State (received in November 2015)[49]

The reliance on CBOs and local Karen medics due to inadequate Myanmar government services is evident throughout KHRG’s 25 years and the presence of these local organisations has been life-saving for villagers in hiding or immobile due to severe movement restrictions and poor infrastructure.[50] However, even with these various actors providing services in rural areas, many villagers have suffered over 25 years from inadequate access to healthcare facilities and services. The recent improvement in quantity of healthcare buildings has done little to improve the health of villagers on the ground if the services remain unstaffed, without medicine, and without coordination or consultation by different service providers.

Acceptability of healthcare: inadequate staff and skill

In addition to concerns with regard to lack of access, villagers have consistently raised their concerns over quality of healthcare services. In recent reports, notably since 2014, when clinics and healthcare services are staffed, villagers also report that the quality of the services provided by Myanmar government health workers is poor. The lack of trained medical staff, generally supplied by the Myanmar government, will take longer to overcome than the lack of a physical building or well-stocked medicine cabinet. The training that both KNU medics and Myanmar health workers receive is too brief to secure the knowledge and skills necessary to provide quality healthcare services to villagers. As a result, when healthcare services are available, insufficiently trained health workers can often do little to address villagers’ health concerns and simply refer sick villagers to other clinics which are further away:[51]

“The health workers were elected to work for the health service but they are not well trained or qualified to treat serious patients so, the villagers have to face challenges. For the villagers who face serious   diseases, most of them go to town for the medical treatment.”

Saw Eh--- (male, 24), Ei--- village tract, Thaton Township, Thaton District/ northern Mon State (interview received in November 2016)[52]

In addition to not being well trained or qualified, villagers report that these health workers often fail to communicate effectively with their patients and results in many villagers currently not knowing their health options and being uncertain whether it is safe to take certain medicines, such as in the area of reproductive health, with serious health consequences:

“[There is a] lack of health awareness at the Township level. […] In ruralareas, women do not want to use contraceptive pills because they are afraid to use them. There is no effective awareness [conducted]. If  there is effective awareness, there would be no big concern [for them to use contraceptive pills]. In Kyaukkyi Town, many women had not given birth to their child successfully [they have faced birth complications]because they lack access to [health] awareness. They do [not] have knowledge on what to do and what not to do [when getting pregnant and giving birth]. Moreover, there are few health workers. In Karen State   [southeast Myanmar], [pregnant] women in the villages are not well taken care by the [health workers]. Because women have a lack of knowledge about reproductive health, about what to do and what they should not do, about one third of women who got married after [they turned] 18 years old have lost their baby [in childbirth or infancy].”

Naw Ej---- (female, 38), Ek---- section, Kyaukkyi Township, Nyaunglebin District/ eastern Bago Region (received in February 2016)[53]

Problems of poor communication between health workers and patients, a lack of awareness for patients about their health options, and poorly trained medical staff, are evident also in recent cases where healthcare providers have denied patients treatment for no evident reason,[54] failed to communicate how to safely and effectively use prescribed medicine and medical supplies,[55] acted negligently by failing to discuss potential side effects of treatment with patients,[56] and been unable to offer effective treatment to patients in need.[57] This is aggravated by the lack of culturally appropriate staffing in southeast Myanmar, with many Myanmar government-appointed healthcare staff being unable to speak Karen and therefore unable to communicate with patients effectively.[58]   For  this  reason,  villagers  have  reported  serious  side  effects  after  receiving vaccinations from insufficiently trained health workers, and lack trust in some Myanmar government health workers to work in the best interests of the patient.[59] These experiences do little to empower villagers to respond to their own health needs. Furthermore, reports of poor communication do little to encourage villagers to access Myanmar government services where they are made available.

Access to healthcare: livelihood and financial insecurity

An additional concern with regard to access to healthcare for villagers in southeast Myanmar is their livelihood and financial insecurity. For villagers able to access Myanmar government health facilities such as those located in larger towns, particularly in the post-ceasefire era, the cost of healthcare services and prescribed medicines have been described as unaffordable.[60] This financial barrier has been present throughout KHRG’s 25 years reporting period. Villagers throughout the reporting period have faced debt in order to pay for the cost of medicine and medical treatments for their family members[61] while some have sold personal possessions to cover these expenses.[62] According to Saw PP--- from Dooplaya District in 2016:

“For some widows, they do not have money therefore they sell their land or borrow money from others and they are in a situation of debt. They receive medical treatment and have to repay their debts as well, so they cannot be safe from debt.”

Saw PP--- (male, 37), Win Yay Township, Dooplaya District/ southern Kayin State (interview received in November 2016)[63]

Poorer villagers who struggle to pay for the cost of healthcare services identify a further barrier in accessing adequate services, reporting that they are discriminated against with regard to priority health treatment or are not treated at all. This is the case with both private and public health workers who have discriminated against poorer patients.[64] In this case, poorer patients report that they are ignored by health workers,[65] feel pressured to pay more money to receive better treatment,[66] and receive sub-standard care due to their financial status.[67] The benefits of good quality healthcare therefore remain inaccessible to villagers who do not have sufficient finances. This has significant impacts, as noted by one KHRG researcher in Thandaunggyi Township, 2014:

“There is one thing; naturally, some medics only look for their self-profit and they do not fully sacrifice or show their benevolence to the patients [by treating poorer patients]. For the rich people, as they have money, they do not have to face big problems [to access medical  treatment]. Because of having a shortage of medicine, [villagers] have to face problems in many ways and some people have lost their lives for nothing [because they could not afford treatment or access medicine].”

Situation Update written by a KHRG researcher, Thandaunggyi Township, Toungoo District/northern Kayin State (received in July 2014)[68]

These financial concerns over both access and acceptability of treatment are raised in a context where many villagers report recurring livelihood insecurities and financial instability. Villagers’ livelihood insecurities have been present throughout 25 years of KHRG reports and have continually impacted their basic health and survival, as villagers have been forced to pay for basic medicines which should have been supplied by Myanmar government for free:

“The SPDC [Tatmadaw / Myanmar government], when it does allot money to build a clinic, will not provide medics with training, nor give the village money for medicine. In many cases medics must buy medicine for the village with their own money, then rely on the villagers to pay them back. When supplies are short villagers must cope with saline injections and Paracetamol as the only available treatment unless it is serious enough to make a journey to the nearest hospital, often many days’ journey by foot.”

Report written by a KHRG researcher, Dooplaya District/ southern Kayin State (published in March 2000)[69]

Additionally, through abuse by armed actors, namely Tatmadaw, villagers according to KHRG reports have been forced into states of poverty and financial insecurity, directly impacting their health. Due to constant demands for forced labour evident in KHRG reports between 1992 and 2012, with some districts reporting cases of forced labour ongoing in 2015 and 2016, villagers have often been left with little time to devote to their farms and other income generating activities, negatively impacting their livelihood, finances and food security.[70] These concerns have been compounded by Tatmadaw’s direct theft and destruction of land, food stores, and means of food production during village attacks in the 1990s most commonly, but also in the late 2000s.[71] The abuses of theft, looting, extortion, land confiscation and forced labour have weakened traditional livelihood subsistence, directly impacted villagers’ food security, financial security and, therefore, their physical health. As such, villagers throughout KHRG’s reporting period have been left with little money to spend on health services or medications, forced to go without treatment or to sell their remaining possessions for treatment.[72]

Serious livelihood struggles have been heightened in cases of severe health problems caused by abuse, and the right to health is repeatedly identified by many villagers as essential in order to secure their own livelihood.[73] For example, villagers who have been left disabled after being shot or maimed by landmines have reported the difficulty of securing their livelihood after the abuse.[74] This concern is intensified by the lack of adequate support services that can support survivors of serious abuse, and in some cases during KHRG’s reporting period has led villagers to take their own lives, such as 18 years old Saw Ed--- from Ee--- village, Toungoo District, in 2007: