Fighting HIV/AIDS in Myanmar

Knowledge Showcases

Fighting HIV/AIDS in Myanmar August 2015 | Issue 65 OPENING BORDERS Myanmar, a country of about 51 million people,1 "reopened" its borders in 2011 after decades of isolation. The government is implementing ambitious economic, governance, and political reforms. From an enviable endowment of natural resources and geographic location at the intersection of the People's Republic of China (PRC), India, and Thailand, Myanmar is poised to become (again) a regional trading hub and key supplier of natural gas, minerals, and agricultural products. Real gross domestic product is expected to grow at 7.3% a year on average over the period 2015–2020.

Transport is a critical component of economic and social progress, contributing to market-size, networks, performance, productivity, and reliability. Myanmar's road density is still low,2 but a surge in road building is linking the country to Bangladesh in the west, India in the northwest, the PRC in the northeast, and the Lao People's Democratic Republic (Lao PDR) and Thailand in the east. Considering Myanmar's geographic location, these transport corridors will spur connectivity, mobility, and trade in the Greater Mekong Subregion.3 ON HIV/AIDS In Myanmar, the estimated number of people living with HIV/ AIDS (in 2014) ranks sixth highest in Asia and the Pacific, at around 200,000, of whom roughly a third are women.4 While the epidemic remains concentrated in a few key populations, Myanmar's economic and social transitions may lead to increased risks and vulnerability to infections. Increased transport can also be a driver in the spread of HIV/AIDS: it offers economic opportunities that attract migrant workers, commercial retailers, and entertainment industries to previously remote communities.5 Hence, prevention and testing programs continue to be critical.

Health budgets have risen markedly in recent years (rising from 0.2% of GDP in FY2011/12 to roughly 1.1% of GDP by FY2014/15).6 However, such figures remain among the lowest among countries in Southeast Asia and the Western Pacific.7 Meanwhile, many other health issues clamor for attention,

Highlights •

The estimated number of people living with HIV/AIDS ranks sixth highest in Asia and the Pacific.

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Myanmar "reopened" its borders in 2011. A surge in road building is linking the country to its neighbors and will boost mobility and trade. Increased connectivity may make Myanmar more vulnerable to HIV/AIDS, requiring that urgent actions be taken to address expanded risks and vulnerability.

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In 2013, the Ministry of Health and the Asian Development Bank, with $10 million in support from the Japan Fund for Poverty Reduction, partnered to expand coverage and quality of information and services for targeted populations along and near transport corridors in three states of Myanmar.

Myanmar | Health several of which—drugresistant malaria, fake drugs, dengue fever, and tuberculosis—have regional dimensions.

The highest cost of HIV/AIDS is human.

But, there are other layers of economic and Road density in member countries of the social significance: Association of Southeast Asian Nations as a (i) the direct costs whole is about 11 kilometers per 1,000 people, while Myanmar’s is about 2 kilometers. of prevention and Source: ADB. 2012. Myanmar: Transport Sector treatment; (ii) reduced Initial Assessment. Manila. www.adb.org/ documents/myanmar-transport-sector-initial human capital due to -assessment loss of productivity and skills; (iii) distributional effects, whereby some areas, populations, and age groups are more stricken than others—this disproportionately affecting the poor since they have little access to information and even less to services; and (iv) diminished savings and investments, that often have intergenerational repercussions at the household level.

BUILDING CAPACITY FOR HIV/AIDS PREVENTION In 2005, the Government of Sweden helped the Asian Development Bank (ADB) establish the Cooperation Fund for Fighting HIV/AIDS.8 In 2006, ADB leveraged the fund under a regional technical assistance project for fighting HIV/AIDS in Asia and the Pacific. The core outcome or objective targeted by the project was more effective and evidence-based response to the HIV/AIDS epidemic at regional and country levels. In 2008, ADB approved regional technical assistance to reduce the incidence and prevalence of sexually transmitted infections among workers and communities associated with infrastructure projects traversing transport corridors in Cambodia, the Lao People's Democratic Republic, Myanmar, and Vietnam. In Myanmar, interventions involved (i) mapping the geographic distribution of risk in Kawkareik and Myawaddy townships in Kayin State, specifically, conducting operational research on migrant and mobile

___________________ Myanmar's population is young and will grow to about 60 million by 2030.

Road density is the ratio of the length of a country's total road network to its country's land area. In 2005, Myanmar's road density was 4.1 kilometers (km) per 100 square kilometers (sq.km). (Thailand had 35.2 km/100 sq.km in 2006 and Viet Nam had 48.6 km/100 sq. km in 2007.)

3 Transport corridors that link to production networks—otherwise called economic corridors—is an important means to strengthen the manufacturing sector and create jobs. There is, for instance, talk of a large Bangladesh–(People's Republic of) China (PRC)–India–Myanmar Economic Corridor, planned to run from Kunming in the PRC to Kolkata in India, and link Mandalay in Myanmar to Dhaka and Chittagong in Bangladesh.

4 There is a 19% prevalence among people who inject drugs, a 10% prevalence among men who have sex with men, and an 8 % prevalence among sex workers. Source: HIV and AIDS Data Hub for Asia-Pacific. 2015. HIV Estimates and Projections: Asian Epidemiological Model—Myanmar 2010–2015. aidsdatahub.org/ 5 The Asian Development Bank (ADB)'s Sustainable Transport Initiative incorporates HIV/AIDS prevention into transport projects. For the Greater Mekong Subregion, ADB has also formulated guidelines to standardize HIV/AIDS prevention programs within transport projects.

6 International Monetary Fund. 2014. Staff Report for the 2014 Article IV Consultation. Washington, DC7 International Monetary Fund. 2014. Staff Report for the 2014 Article IV Consultation. Washington, DC. 7 Nominally, health care is free. In reality, patients pay for services, even in public clinics and hospitals (that often lack basic facilities and equipment).

8 The fund aims to support and strengthen efforts to develop comprehensive responses to the HIV/AIDS epidemic.

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populations and their vulnerability to HIV/AIDS infections; (ii) community-based program in Tachilek township in Shan State for awareness-raising on HIV/AIDS and other social and health issues and for positive behavioral changes for key affected population and local communities along the transport corridors; and (iii) capacity assessments and drafting of a framework and strategic plan for institutional development of the National AIDS Program at central, state, and township levels.9 Later, Myanmar requested ADB support for a follow-on, country-specific project.

From this, in 2013, ADB extended a $10 million grant to Myanmar for Greater Mekong Subregion capacity building for HIV/AIDS prevention, its first large-scale project in the health sector since reengaging with the country in 2012. The project, financed by Table: Outline Phasing Arrangements Phasing Phase 1 (1–2 years)

Transition

Arrangement 1. Service agreements are signed between MOH, ADB, and the implementing partners.

2. ADB funds the construction or refurbishment of health facilities identified by the government and the procurement of essential equipment and commodities.

3. ADB contracts the implementing partners using ADB’s Guidelines on the Use of Consultants with stop–go clauses and signals intention to novate to MOH 1–2 years hence.

The contracts set milestones and benchmarks for the transition to Phase 2.

4. The implementing partners deliver agreed services, subcontracting also (with stop–go clauses) local nongovernment and community-based organizations.

5. ADB fields review missions every three months.

1. MOH and ADB conduct transition review—establish basis for Phase 2 change in implementation—agree on novated arrangements.

2. MOH (re)negotiates contracts with implementing partners and adapts, extends, or re-lets linked subcontracts.

3. MOH resources the project management units to assume full executing agency roles; relevant accounts are reviewed or established.

4. Novation is declared effective.

Phase 2 1. MOH ensures provision of essential equipment and (3–4 years) commodities to the constructed or refurbished health facilities.

2. State-level township health offices sustain functional operations and maintain the constructed or refurbished health facilities with annual operational plans and budgets.

3. MOH takes over management of novated contracts with implementing partners.

4. MOH manages procurement, etc.

5. ADB continues to field review missions every three months for first six months then moves to standard six-monthly reviews.

ADB = Asian Development Bank; MOH = Ministry of Health.

ADB. 2013. Grant Assistance to Myanmar for Greater Mekong Subregion Capacity Building for HIV/AIDS Prevention. Manila. www.adb.org/projects/documents/greater-mekong-subregion -capacity-building-hiv-aids-prevention-gar

the Japan Fund for Poverty Reduction and implemented by the National AIDS Program in the Ministry of Health, aims to increase access to and quality of health and HIV/AIDS services—specifically, prevention, treatment, and care—along fast-developing transport corridors in Kayin State, Mon State, and Shan State, which collectively border Thailand, the PRC, and Lao PDR.10 To build synergies with centers of excellence, the Ministry of Health and ADB joined hands with the Joint United Nations Programme on HIV/AIDS (UNAIDS) as well as the International Organization for Migration and Malteser International, which work in association with local nongovernment and communitybased organizations.11 Feeding into that overall objective, the project targets three core outputs:12 • Strengthened planning and management capacity at national, state or regional, and township levels; • Enhanced capacity to provide quality and accessible services; and • Improved access to community outreach among target populations.

The project is in the early stages of implementation.

Notwithstanding, it is characterized by an innovative, sequential approach structured around three distinct but interconnected phases: this deserves attention in a very challenging context that calls for long-term engagement by both state and non-state actors, framed by the Myanmar National Strategic Plan and Operational Plan on HIV and AIDS, 2011–2015 and subsequent updates.

Related Links • ADB. 2006. Regional Technical Assistance for Fighting HIV/AID in Asia and the Pacific. Manila. www.adb.org/projects/documents/fighting-hiv-aids-asia -and-pacific • ADB. 2008. Regional Technical Assistance for HIV Prevention and Infrastructure: Mitigating Risk in the Greater Mekong Subregion. www.adb. org/projects/documents/hiv-prevention-and-infrastructure-mitigating-risk -greater-mekong-subregion-financ • ADB. 2010. Regional Technical Assistance for Evidence-Based Advocacy for Fighting HIV/AIDS in Asia and the Pacific. www.adb.org/projects/ documents/evidence-based-advocacy-fighting-hiv-aids-asia-and-pacific -regional-hiv-aids-data • ADB. 2010. Practice Guidelines for Harmonizing HIV Prevention Initiatives in the Infrastructure Sector: Greater Mekong Subregion. Manila. www.adb. org/publications/practice-guidelines-harmonizing-hiv-prevention-initiatives -infrastructure-sector-greate • ADB. 2012. Health and Economics: Focus on HIV/AIDS in Myanmar. www. adb.org/features/focus-hiv-aids-myanmar • ADB. 2013. Grant Assistance to Myanmar for Greater Mekong Subregion Capacity Building for HIV/AIDS Prevention. Manila. www.adb.org/projects/ documents/greater-mekong-subregion-capacity-building-hiv-aids -prevention-gar • British Broadcasting Corporation. 2014. World Aids Day: Tackling HIV in Myanmar. www.bbc.com/news/health-30244390

___________________ To note also, in 2010, regional technical assistance for evidence-based advocacy to fight HIV/AIDS in Asia and the Pacific, established the regional data hub at aidsdatahub.org/, which covers also Myanmar, and built capacity for national and regional data collection and analysis.

10 The project targets 739 villages in five townships: Mawlamyine in Mon State; Kawkareik, Hpa-An, and Myawaddy in Kayin State; and Tachilek in Shan State.

11 The International Organization for Migration and Malteser International had earlier helped execute the Myanmar component of the 2008 regional technical assistance.

12 To note, monitoring and project management will absorb 22% of project funds to offset initial capacity shortcomings in the Ministry of Health.

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KNOWLEDGE CONTRIBUTORS Barbara Lochmann (blochmann@adb.org) is a senior social sector specialist in ADB's Southeast Asia Department.

The Knowledge Showcases Series highlights good practices and innovative ideas from ADB technical assistance and other operations to promote further discussion and research. www.adb.org/knowledgeshowcases www.adbknowledgeshowcases.org

Olivier Serrat (oserrat@adb.org) is a principal knowledge management specialist in ADB's Sustainable Development and Climate Change Department.

The Asian Development Bank (ADB) is dedicated to reducing poverty in the Asia and Pacific region.

The views expressed in this publication are those of the author(s) and do not necessarily reflect the views and policies of ADB or its Board of Governors or the governments they represent.

Creative Commons Attribution 3.0 IGO license (CC BY 3.0 IGO) © 2015 ADB. The CC license does not apply to non-ADB copyright materials in this publication.

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