RANGOON — Burma’s health ministry has deployed an emergency response team to Arakan State following the suspension of Médecins Sans Frontieres (MSF) operations there, but concerns are growing over a sudden gap in medical care for hundreds of thousands of people who previously depended on the humanitarian organization’s services.
MSF Holland, which began operating in the restive western state 20 years ago, claims to be the single biggest provider of health care there. Last year it conducted over 400,000 consultations, including in camps for internally displaced people (IDPs) and in hard-to-reach areas of the state, which has seen communal violence between Buddhists and Muslims since June 2012.
Other NGOs and UN agencies also offer health services in Arakan, but on a smaller scale. Burma has depended largely on outside medical assistance in the aftermath of the violence, due to limited funding and resources at the Ministry of Health.
Ye Htut, a spokesman for President Thein Sein, said the government was moving to fill the gap in care after deciding late last month not to renew MSF’s agreement to operate in the state. However, the medical response appeared limited for the time being.
“The Ministry of Health already sent an emergency response team with eight ambulances to Rakhine [Arakan] to fill MSF’s operation,” he told The Irrawaddy in an email last Thursday, without elaborating, when asked whether the ministry planned to open additional clinics or to send more doctors and nurses to the state.
He did not respond to further requests for comment when asked whether the government’s response would be sufficient to handle the needs of patients who previously sought treatment with MSF, including over 10,000 malaria patients and almost 850 people with HIV. He also declined to comment on whether the government was considering allowing other international medical aid organizations to boost their presence in the state.
Before their operations were suspended, MSF employed more than 500 staff in Arakan, mainly medical staff, who provided primary health care, reproductive services, referral services and treatment for malaria, HIV and tuberculosis. They worked at over 30 sites in eight townships in the state, with a total program worth over US$9 million.
“Humanitarian organizations are very concerned about the potential humanitarian impact in Rakhine [Arakan] State following the government’s request to MSF Holland to temporarily stop its activities,” Pierre Peron, a spokesman for the UN Office for the Coordination of Humanitarian Affairs in Burma, told The Irrawaddy. “Replacing the MSF operation would be very difficult due to the scale and complexity of the operations that MSF has built up over many years, particularly in the northern part of Rakhine.”
Allegations of Bias
MSF Holland announced on Feb. 28 that it had been ordered by the government to halt all its operations in Burma—not only in Arakan, but also in Kachin and Shan States, as well as Rangoon Division. The government justified its decision partly by accusing the aid body of providing preferential treatment to favor the Rohingya, a Muslim minority group that has borne the brunt of violence in Arakan State and is largely denied citizenship in the country.
Rights groups and foreign governments responded critically, and within days the government said MSF could reopen its clinics everywhere except Arakan State. In addition to allegations of preferential treatment, the government accused MSF of violating certain conditions in its memorandum of understanding (MoU), including by employing more foreign staff in the state than agreed, and by running a medical care clinic for newborns without approval.
In the days before the suspension, Arakanese Buddhists had protested in the state capital Sittwe against MSF operations, accusing the aid group of bias and urging Thein Sein to cancel its MoU. The protests appeared to have been sparked by MSF’s claim that it treated 22 patients for injuries in the aftermath of an alleged massacre of Rohingyas in Maungdaw Township. While the UN said it received “credible evidence” to indicate that Arakanese villagers and state security forces were involved in the alleged violence, the government repeatedly denied the killings had occurred and accused MSF as well as international media of misreporting events.
Aye Maung, a lawmaker and chairman of the Rakhine Nationalities Development Party (RNDP), said he supported the suspension of MSF operations in Arakan State. “It was what the people of Arakan wanted. My party respects the people,” he told The Irrawaddy. “A very small amount of medical care was for the Rakhine [Arakanese] people. They should have worked for both the Rakhine community and the Muslim community, but they discriminated, so most of the Arakanese suffered.”
MSF has denied to comment publicly as it continues negotiations with government officials in Naypyidaw, but the aid group has long rejected allegations of bias, saying it operates on the basis of medical need.
Since 2012, Rohingyas have lacked access to health care and other basic services in Arakan State because they have been subject to government-imposed movement restrictions that make it difficult if not impossible for them to travel to medical centers. Certain public hospitals in the state have also been accused of denying them admission for treatment.
MSF offered services in IDP camps and operated mobile clinics that went to Rohingya communities in remote areas, especially in the northern townships, but it also treated local Buddhists and says the majority of its malaria patients in 2013 were Arakanese.
Identifying the Treatment Gap
It is possible that more medical aid groups will face trouble in Arakan State in the coming months. The state legislature is now considering a proposal to block unregistered NGOs from operating in the region, to prevent them from “causing bigger problems” between Buddhists and Muslims, according to a report by Radio Free Asia.
The proposal was submitted by another RNDP lawmaker, Aung Win, on Friday. “There are some INGOs and NGOs that have caused bigger problems between the two communities and some are creating a bad image of the country. Also, we have seen some organizations act disrespectfully to the local people,” he told RFA.
The news agency reported that only 19 international and local NGOs had been approved to operate in the state since 2012, although 70 groups had applied. It said local authorities in the past allowed NGOs to work without formal registration, in an effort to help the more than 140,000 people living in IDP camps and others affected by the communal violence.
For medical aid, various UN agencies fund a wide range of health care services, often collaborating with the government as well as local and international NGOs.
Beyond these programs, about 15 international and local NGOs were offering health services in the state as of late last year, according to the Myanmar Information Management Unit, which assists the UN country team in Burma. Including MSF, only a handful of these offered basic health services, and their programs were much smaller. Other organizations focused on mental health, reproductive health, women’s and children’s health, malaria prevention, HIV treatment and health education.
Few groups offered health services in the northern townships, according to Malteser International, a relief agency of Malta which assists tuberculosis patients and supports local health staff in the area.
“Overall, our intervention is of course much smaller than that of MSF. In northern [Arakan], I think they were the biggest player, partly because they have a lot of funding,” said Johannes Kaltenbach, a spokesman for Malteser in Burma. He said his organization employed about 200 staff in the state, compared to more than 500 staff at MSF.
He said the suspension of MSF operations was unfortunate, particularly for the beneficiaries in the northern townships.
“Still, in magnitude, when it comes to the actual impact it might have, I think we will only feel it in the coming weeks or months. In Sittwe, it might be different,” he added, referring to the state capital, around which many IDP camps are located.
He said he had not heard of government plans to boost care in the state, nor had Malteser been approached to scale up its activities. “We hope MSF will see some return to normalcy. For us, we will wait, the same as other organizations, and see,” he said.
The International Committee of the Red Cross (ICRC), which also supports health services in Arakan, said the removal of any substantial humanitarian provider would have a major impact, but agreed that it was not yet clear how big the treatment gap would be. Michael O’Brien, a spokesman for the ICRC in Burma, said his organization was not planning to expand its reach in the state in the short term.
“At the moment we’re structured to perform the functions that we perform as efficiently as we can. Like most organizations, we wouldn’t have an enormous amount of spare capacity—that doesn’t mean we couldn’t try to provide assistance, but if we’re talking about major health sector assistance, with the structure that we have at the moment, that would be pretty well beyond us in the short term,” he told The Irrawaddy.
“We haven’t been asked to do that either, and I’m not sure at this point that the gap has actually been fully identified. It’s still quite a fluid situation, and so until somebody can be specific about what they would need and then a request comes to us, it’s quite a hypothetical situation.”
Burma’s national health system has been chronically underfunded for decades, as the former military regime prioritized defense spending over social services.
Like in other rural areas across Burma, midwives provide the bulk of health services in Arakan, one of the poorest states in the country. A single midwife is responsible for thousands of patients, and since the outbreak of violence, some midwives have stopped traveling to certain rural villages due to security concerns.
Foreign governments have voiced concerns over the suspension of MSF operations in the state.
“We understand that the Union Government and Médecins Sans Frontières (MSF) are in discussions and want to encourage and fully support their efforts to find a solution that will ensure continued life-saving health services for those in Burma that need it most,” a US Embassy spokesman told The Irrawaddy last week.
“We reiterate the vital importance of allowing the provision of unhindered and regular access to urgently needed health care services and other humanitarian support to communities in need of such assistance, regardless of ethnicity.”