As Myanmar’s nationwide ceasefire negotiations continue, peace in many formerly war-torn regions has allowed state-run lifesaving services to gradually expand. But their provision is intensely politicized, and carefully crafted access strategies are vital, experts warn.
Protracted violence combined with what The Asia Foundation (TAF), an international development NGO focused on Asia, called the central government’s “extreme deficit in legitimacy” in ethnic regions meant that social services were often designed and implemented directly or indirectly by ethnic groups engaged in hostilities with the Burmese army.
However, service providers have begun to adjust by “converging” programmes, or attempting to align and unify the main elements of government and ethnic health organizations’ systems - service delivery, governance and leadership, workforce, and information systems - in an effort to increase impact while allowing the peace process to continue.
In 2011 President Thein Sein instituted reforms, stoking unprecedented encouragement from international donors; aid money jumped from US$355 million in 2010 to $504 million in 2012. But ceasefire negotiations with some opposition groups continue, and even peaceful ethnic regions remain mired in deep, complex poverty.
A UN Refugee Agency (UNHCR) report pointed to Myanmar’s “new aid paradigm” of “moving towards the approach seen elsewhere in the world, where donors work with the government and fund projects at local level”.
Nyunt Naing Thein, deputy chief of party for the Project for Local Empowerment, a programme run by the International Rescue Committee in Thailand, told IRIN: “As humanitarians, we are providing crucial services in a politically tense environment, so we have to be very careful with sequencing our own changes so that we don't jump the service provision aspects ahead of the politics.”
Myanmar’s Ministry of Health said that while there is no single national convergence policy “progress has been made… at the local and state levels, for example with training and [the] provision of vaccines and commodities.”
Experts say it is crucial that everyone from donors to practitioners see convergence as a matter of necessity, but carry out the process with patience. As services are scaled up and formalized in impoverished and isolated corners of the country, survival strategies developed during decades of violence and intimidation continue to be important.
Healthcare workers have been targeted by the government or army in some locations. “Community health organizations have filled the service gap left by the state, but work has often proved dangerous… The direct targeting of healthcare workers has included kidnappings by the Tatmadaw [Myanmar army], while government restrictions on movement prevented patients and healthcare workers accessing clinics. Individuals who contravened restrictions risked being shot on site by Tatmadaw forces,” said Katherine Footer, a research associate at the Johns Hopkins University School of Public Health in a November 2014 article on violence against healthcare workers in eastern Myanmar.
Footer argued that healthcare workers’ experiences in tense areas led to the development of important survival tactics: “In the presence of chronic insecurity, development of self-protection strategies by [healthcare workers] and the communities they serve has been essential to maintaining a shadow healthcare system in eastern Burma and ameliorating, if not eliminating, restrictions to access.”
Myanmar researcher Ashley South argued in a 2010 Chatham House paper that “such local approaches to protection are particularly important in situations where international humanitarian actors have limited access - and especially in cases where the state is one of the main agents threatening vulnerable populations.”
International agencies supported many such efforts by setting up offices across the border in Thailand which, according to a 2012 article published by the Overseas Development Institute’s Humanitarian Practice Network (HPN), forged relationships between aid agencies and opposition organizations.
“As cross-border aid is often the only way to help highly vulnerable communities, agencies working in zones of ongoing armed conflict have little choice but to accept some form of relationship with insurgent groups,” the HPN paper explained, arguing that international agencies should do more to understand local protection strategies these workers used.
“This will not be a straightforward undertaking in south-east Myanmar, where the humanitarian agenda is highly politicized,” HPN researchers argued, however insisting that “local humanitarian activities can mobilise communities and help to build trust and capacity, and international donors can engage positively with such initiatives.”
Vaccinations, for example
“We have to strike a balance,” says Nyunt Naing Thein, pointing to vaccinations as an example of a crucial service that can be expanded through proper convergence.
“Sending government healthcare workers [to administer vaccines] won't make sense because they won't be accepted there by the communities or the ethnic armed groups that still control some territories,” he explained. “Sending ethnic health workers makes more sense, but they are not certified by the central authority or Ministry of Health,” he said, calling it “a situation where we want to get services like vaccinations expanded to people who need them, and we also want to respect the central government’s requirements to train and certify people who can administer vaccines.”
To solve this problem, the Project for Local Empowerment developed an accreditation partnership between a Burmese university and a Thai university.
“The ethnic health workers were much more comfortable accessing the training [in Thailand],” Nyunt Naing Thein told IRIN. “And the fact that the government agreed to do this, signals some respect for the work these people have been doing as humanitarians for decades, and a willingness to engage in supporting people everywhere in the country.”
Nyunt Naing Thein emphasized that all such processes should be carried out in a way that builds trust among the parties concerned.
Kim Jolliffe, a researcher who authored the TAF report, warned: “In areas where trust is slowly being built but ceasefires remain fragile, rapid expansion of government presence can damage confidence and must be done with caution and better consultation.”
Jolliffe told IRIN that social services and peace processes are interdependent: “Convergence of state and ethnic armed organization-linked systems should not be viewed as a strategy that can be pushed through, as it is dependent on the peace transition and will take time.”
He explained that convergence efforts could have long-term impacts on how government-run social services are shaped and reformed in conflict-affected areas, adding that: “It is crucial that support is maintained to existing structures on which hundreds of thousands people depend, particularly as ceasefires could break.”
Myanmar was ruled from 1962 to 2011 by a repressive military government that crushed dissent and fought protracted armed conflicts in the country’s border regions where ethnic minorities live. Social services in remote and contested areas were provided by everything from local NGOs linked to ethnic opposition groups to cross-border mobile teams - some of whom were known as “Back Pack Medics.”