1. Health System Strengthening, Planning &
Management,Human resource,Hard to reach
In 20 townships

2. •
•
•
•
•
•
•
•
•
•
•
•
•
Kachin State Mon State
Shan
NayPyiTaw
Bago
Sagaing
Kayah
Kayin
Chin
Yachine
Irrawaddy
Tanintaryi
Yangon
-
Bamaw,Shwegu
Thaton, Mudon
Nyaung shwe, Hsipaw, KyaingTong
Pyinmana, Lewe
Yedarshay, Thayarwaddy
Ye-Oo
Demawsoh
Hlaing Bwe
Hakah
Maungdaw
NgaPutaw
Myeik
Kawmhu

3. Health Systems Assessments in 20 townships
•HSS Assessment Guidelines-training given to all surveyors in
NPT/Ygn
•Conducted during 1st week of May 2010 simultaneously in first
10 townships with 60 Investigators (14 from DOH + 3 from
DHP + 43 from UOPH)
10Townships: Bamaw, Shwe ku, Ye Oo, Hsipaw, Nyaung Shwe,
Mudon, Thaton, Pyinmana, Yedarshay, Tharawaddy
• Conducted in 2011, October to December for second 10
townships. (Lewe, Kawmhu, Ngaputaw, Demawsoh,
Maungdaw, Myeik, Htilin, Hakah, Hlaingbwe, Kyaingtone)

4. Objectives
• To identify health system needs and gaps, with a
particular focus on hard to reach areas
• To provide a baseline for measuring impact of health
system and program investments
• To provide the evidence base for the development of
a Township Coordinated Health Plan

5. 4 main research instruments
• A facility and management questionnaire for Townships
and RHCs
• Infrastructure and essential drug and equipment
questionnaires and inventories.
• Mapping of hard to reach areas
• Use of questionnaires and registers for assessment of
data quality and quality of services at household level.

6. Research Methods
• Collection and analysis of quantitative health system data (e.g.
infrastructure , human resources ratios, population data, essential
drugs lists etc)
• Conducting of in depth interviews with health staff regarding
availability and accessibility of services (hard to reach areas, human
resource issues and motivation, management and planning
supervision etc)
• Conducting of Focus Group Discussion (FGD) with Township Health
Committee in order to understand more deeply issues effecting
community participation and THC function.
• Conducting Data Quality Assessment and Service Quality
Assessment survey

7. Broad findings of Assessments in 20 townships
For description and analysis of health system gaps and bottlenecks at
the Township level the following system areas were surveyed:
Planning & Management
Service Delivery
Human Resources
Community Participation
Infrastructure
Essential Drugs & Logistics System
Transport
Finance & Financial Management
COORDINATED TOWNSHIP HEALTH PLAN
STATION HOSPITAL & RHC COORDINATED PLANS

8. 1. Planning and Management
a) Planning
TMO and staff have no experience in drawing integrated micro plan
for the township health service
Vertical micro plans were drawn for different projects according to
their targets/expectations eg: EPI/ TB/Malaria (Top down)
No experience for drawing costed micro plan; even for EPI they
calculated cost for TA , cold chain maintenance and carrying vaccines
for CRASH program. Calculated by each MW for those costs
The only integrated service mentioned was NID/sub NID with vitamin
A supplementation

9. Supervision
Regular supervision was not seen in all townships except for Mudon
Pyinmana and Hsipaw townships .
TMO reach at least 2-3 RHC/sub RHC which are easily accessible,
no check list was used during supervision (eg- Mudon)
THN/HA1 also tour to RHCs which are accessible, some developed
own checklist; but no tour program at township/RHC levels, no tour
notes written (eg- Hsipaw)
Supervision visit to one RHC per week by HA1 according to tour
plan drawn by TMO. But no support for TA and fuel cost for
supervisory visits (eg- Pyinmana )

10. 2. Service Delivery
Planning for achieving MDG goal 4 and 5 at townships
(Active AN Search Micro plan found in Mudon, Hsipaw, Ye Oo )
With the leadership of TMO, all MWs have drawn a micro-plan for
“Active AN search and Health Talk” ( eg. Mudon, YeOo)
 All midwives have planned dates for health talks ,supervisors were
identified in the micro-plan document
There should be a well set information pamphlet/documents for
Health Education/ some township have vinyl
In the case of referral, some TMO said there are many social
organizations that help people to reach hospital in time
RHC/subcenters have labour room but utilization varies with each
township; TMO were trying to institutionalize RHC/Sub-Center with
labor rooms

11. 2. Hard To Reach Villages
Hard To Reach villages
Health Unit
including
MCH
No of
villages /
Wards
Physical
%
Economic
%
Social B
%
Bamaw
6
114
13
11.4
47
41.2
17
14.9
Shwegu
6
89
17
19.1
35
39.3
0
0
Demawsoe
9
162
28
17.3
76
46.9
22
13.6
Hlaingbwe
9
307
108
35.1
92
29.9
86
28
Hakha
5
74
36
48.6
29
39.2
30
40.5
Thaton
5
192
26
13.5
59
30.7
0
0
Mudon
7
58
0
0
9
15.5
0
0
Maungdaw
NyaungShwe
10
430
103
23.9
150
34.9
147
34.2
8
462
66
14.3
21
4.5
18
3.9
Kengtong
6
589
164
27.8
48
8.1
3
0.5
Township

12. 2. Hard To Reach Villages
Health
Unit No of villages /
Township
including
Wards
MCH
Hard To Reach villages
Physical
%
Economic
%
Social B
%
Hsipaw
6
519
273
52.6
227
43.7
141
27.2
Ye-U
7
189
37
39.4
8
8.5
0
0
Pyinmana
6
137
29
21.2
24
17.5
20
14.6
Lewe
8
221
32
14.5
32
14.5
9
4.1
Htilin
6
92
50
54.3
22
23.9
11
11.9
Yedeshay
9
325
70
21.5
42
12.9
4
1.2
Thayawady
8
287
12
4.2
31
10.8
14
4.9
Kawhmu
6
130
33
25.4
9
6.9
4
3.1
Ngaputaw
6
230
33
14.3
0
0
1
0.4
Myeik
6
152
21
13.8
121
79.6
31
20.4
139
4759
1151
24.2
1082
22.7
558
11.7
Total

13. 2. Mapping Hard to Reach Villages

14. Hard To Reach Villages

15. Mapping hard to reach noted the following barriers in
access to health:
• Physical Barriers was found to be more in Hakha, Hsipaw, Ye U,
Htilin, Hlaingbwe and Pyinmana
• Social barriers like language barrier and some religious beliefs
restraining from seeking health was found in Maungdaw, Hakha,
Hlaingbwe, and Hsipaw
• Economic barrier was found in almost all townships, highest in
Myeik and lowest in Nyaung Shwe.
• This information is based on the group discussion with the Basic
Health Staff including midwives from the sub RHC.

16. Physical barriers- Pyinmana, Bamaw :
• In Pyinmana, half of the RHCs are situated in hard to reach areas
where roads are dusty in mountainous areas which become muddy
roads during rainy season.
• In Bamaw, HTR as BHS have to cross the rivers/streams by boat and
continue on foot but these areas are accessible through out the
year.
• Midwives could not go there during the hot and dry season when
the rivers/streams have dried up and have to walk on foot on the
dust road.

17. Physical barriers- Tharawaddy, ShweGu, Yedashay:
 Roads are dusty road/ become muddy road during rainy season and only
transportation mean is by bullock cart at that time.
 Midwife has to walk three to four hours to reach this area for immunization.
• In rainy season, there are streams formed from water falling from the mountains
(taung kya chaung) and could not accessible to the villages beyond the
streams/rivers as water is running turbulently. Dry season-have sand islands in
middle of river (Thaung)
• If the people living in Bago Yoma areas want to go to Yedarshay , it will take (3) to
(4) hours by boat to pass through the Swa Dam. From Yedashay to the areas such as
Myayoe Yone and ChinYu villages, they have to cross the streams for (32) times.

18. •
•
•
•
Physical barriers- Hsipaw: Nyaung Shwe, YeOo:
Hard to reach areas are those areas where there are many hilly region and
deep mud roads during rainy season/accessible by trailer jeep.Dusty road
which become muddy road during rainy season/only transportation mean is
by bullock cart at that time.Boats are only means for midwife to reach the
community around the lake.
Paluzawa RHC is HTR that needs (8) hours to get to that area by car/ trailer
jeep for all seasons. Roads are very rough and cannot access during rainy
season. Only transportation mean is by Bullock carts.

19. (b)
Economic
barrier

20. Economic barrier
• People in some remote villages are poor yet the midwives said they
give services sometimes free/ sometimes within their affordability
(such as 1000 kyats per visit for minor illness). They earn 1200 kyats
per day and for them to reach the hospital transportation cost was
35,000 k.
• The main economic problem in this area is high transportation cost
that hinders the referral of patients to the hospital.
• Even though there were mechanisms in the communities as
providing cash to those in need in case of emergency, the bearer has
to repay all the costs after recovery.
• Poor people being unable to access to health care and use to rely on
traditional medicine. Even in geographically easily accessible areas
like peri-urban slum poor people cannot reach to health care
facilities due to financial problem

21. (c) Social barrier
Language barrier found in
• Maungdaw (Yachine, Bingale), Demawsoe (Kayah) , Hlaingbwe
(Kayin)
Hsipaw (Shan, Kokant, Wa, Lahu), Bamaw (Kachin, Chinese)
Mudon (Mon),Nyaung Shwe , KyaingTone(Shan), Myeik
Traditional belief in health care
Shrines everywhere in Hsipaw
Bamaw -traditional, spiritual belief in healing in remote areas
Yedarshay- People in the community have faith in the traditional
healers such as Shwe Yin Kyaw gang /they do not want to take early
treatment with health personnel.
Nyaung Shwe- In the Inle lake there are a lot of quacks and people
are still sticking to spiritual healing procedures.

22. Assessment Maungdaw
Demawsoh
Social Barrier
Myeik

23. Mapping Hard to Reach
EPI
Fixed/Outreach
-Mudon, Kawmhu, NgaPutaw
Fixed/Outreach/Mobile- Shwegu, Yedarshay, Nyaung Shwe,
Bamaw, Thaton, Demawsoh, Maungdaw,
Hakah, Myeik, Lewe, Htilin
Fixed/Outreach/Mobile/Crash- Hsipaw, Pyinmana, Tharawaddy,
Ye Oo, Kyaingtone, Hlaing Bwe

24. HTR
Mone tai
pin RHC
EasyTR
Kwin ohn
RHC HTR
HTR
ETR
Tamindwin
RHC HTR
MCH

25. Easy To
Reach
HTR
HTR
Easy To
Reach

26. •There are large in equities in human resources distribution as
is 1:10000 - 1:14000 in some places of some Townships
Midwife: population
•
Increase in workload of Midwives has to be taken care of by other BHS such as
HA, LHV, PHS 2 and even by some neighborhood midwives. This issue has to be
put up as solving the HR problem in coordinated township health planning.
•
The health care coverage which could be solved by using volunteers in the
community.

27. MW : PHS 2 ratio
HR analysis
MW
PHS2
11%
89%
Midwife: PHS II ratio is many variation 43:10 to 22: 2 according
to appointed staff, but in total 20 townships , it was 10 : 1.
TMO suggested increasing PHS II posts so that there will be
balance between the two categories and PHS II might take up a lot
of workload from the midwife

28. Skill Mix MW : PHS2 in 20 Townships
Township
Township
MW
PHS2
MW
PHS2
Hsipaw
19
2
Ye-U
32
4
Pyinmana
17
5
Lewe
38
4
Htilin
28
1
Yedeshay
31
2
Thayawady
33
15
Bamaw
27
1
Shwegu
23
0
Demawsoe
41
5
Hlaingbwe
47
1
Hakha
24
1
Thaton
43
0
Kawhmu
24
1
Mudon
35
10
Ngaputaw
29
1
Maungdaw
32
2
Myeik
32
2
Nyaung-Shwe
35
3
Total
624
62
Kengtong
34
2
Ratio
10: 1

29. Objectives of FGD
To identify the community participation level at the township as
regards THC in future development of CTHP
Themes of FGD
1. Function of THC
2. Perception on health by community
3. Health Care coverage
4. Accessibility of health care services
5. Availability of health care services
6. Utilization of health care services
7. Quality Services
8. Involvement in Township Health Planning
9. Role of THC
10.Future perspectives of THC
11.Communication and supervision
12.Suggestion for forming budgetary sub committee

30. FGD in Maungdaw
Tharawaddy
Pyinmana
Hsipaw

31. Functions of Township Health Committee
• THC members thought it was to carry out the tasks assigned by the
TMO/local authority
Representative from
• Local authority- giving down the line instructions to village heads to
carry out prevention and control of d/s
• Development Affairs , MCWA , Red cross and NGOs
• Designated duties by the committee and if possible to assign
separate staff to implement the administrative work such as
recording and reporting.
• THC members also helped in supervision / field visits of TMO and
BHS at every level.
• After Discussion in Township Health Committee, unanimous
decision was set up to use the seed money as the Hospital Equity
Fund for poor mothers and children