02. Oct 2018

In Myanmar, midwives gain a new role – fighting NCDs

Gwendolyn Carleton
A WDF project that teaches midwives to screen for NCDs is improving prevention and care for thousands.
Myanmar visit
Midwife Daw Khin Ohnmar Htoon (right) conducts a health check in Myaung Tagan. Photo by Jesper Westley.
It’s a warm weekday afternoon in Myaung Tagan, and midwife Daw Khin Ohnmar Htoon is back in her home village. But she’s very much at work – dressed in her red and white uniform, with her NCD bag in hand, she’s here to check on her neighbours’ health.
Daw Khin Ohnmar Htoon is one of the seven midwives who staff the Myaung da Gar primary health centre. The health centre is a source of basic care for 140,000 people, and Daw Khin Ohnmar Htoon’s village outreach is part of an ongoing effort to make it more effective. Her task: to check local residents for signs of diabetes and other NCDs, and invite those with risk factors or symptoms to attend the health centre’s newly established weekly NCD clinic.  
The outreach is one outcome of a partnership between WDF, Help Age International, several Myanmar universities and the country’s Ministry of Health. The project, Expanding access to primary health care for NCDs in Myanmar (WDF15-1286), is rolling out WHO’s Package of Essential NCDs (PEN) in 83 of the country’s 330 townships. Its goal is to to diagnose and treat 10,000 people with diabetes and 47,000 with hypertension before its completion in 2019.
(PEN is a set of cost-effective interventions for early detection and management of diabetes and other NCDs that can be delivered in resource-poor settings.)
Midwives are the backbone of Myanmar’s health care system and are key to the project’s design.
“In most countries, the role of midwives is screening and health promotion, and then they refer patients to doctors for diagnosis and treatment. This model doesn’t work in Myanmar because of the lack of doctors in rural areas,” explains Professor Ko Ko, Professor/Head of Myanmar’s Dept of Diabetes and Endocrinology at University of Medicine-2 and a project co-partner. “So we have trained midwives for screening, diagnosis, treatment and referrals, as well as health promotion and follow up.
"Some people ask whether there are quality issues – it’s important to note that the midwives have been well trained, with a manual book and guidelines and now tablets. They are well-supervised, with precise indications for referrals.”
Hanne Strandgaard, Head of WDF’s Programme Department, adds: “NCDs affect millions of people in Myanmar, yet essential NCD care is virtually non-existent at the primary health care level. So when Help Age approached us with this proposal, we were intrigued - teaching midwives new skills is an effective and sustainable way to improve care for thousands.”
New patients every week
In Myaung Tagar, Daw Khin Ohnmar Htoon meets Daw Ni Ni Win, a young mother, outside her wood and bamboo hut. The midwife explains her mission, and Daw Ni Ni Win sits on her front step to have her blood pressure measured as her curious son looks on. 
When Daw Khin Ohnmar Htoon’s checks reveal risk factors, she refers the patient to the new NCD clinic. Each week, from 30 to 50 people visit the clinic, and a handful are registered as new patients. The clinic now has more than 100 patients registered. Between 5-10% are referred to the township hospital for treatment, while the rest are managed by the clinic. 
The government provides midwives with NCD kits, helping them conduct their outreach and signalling official commitment to the project.
The government provides midwives with NCD kits, helping them conduct their outreach and signalling official commitment to the project. Photo by Jesper Westley.
Commitment + pragmatism = sustainability
Local residents seem to have welcomed the new service, says Ms Strandgaard, who visited several participating clinics in November 2017. 
“For example, one woman told me she was grateful that the NCD clinic has opened as she could get her medications for free, there was shorter distance for her to travel, and during her visits, she could also receive health education and counselling,” she says.
Participating healthcare professionals also support the project, as do Myanmar’s health authorities. The government of Myanmar has committed to providing equipment – including the red NCD kits carried by midwives into the villages - consumables and drugs to all health care facilities as part of the national roll out of the PEN model.  
“Strong government commitment, combined with pragmatic use of existing health resources, is something we really like to see and encourage,” Ms Strandgaard says. “This combination will create access to care for many people, and bodes well for the future.”