Here is Thingyan reading - a paper on HIV activity coverage by UN staff. You can download your own copy from http://burmalibrary.org/docs4/Increased_coverage_of_HIV-AIDS_in_Myanmar.pdf or download it below.

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Increase coverage of HIV and AIDS services in Myanmar
Conflict and Health 2008, 2:3 doi:10.1186/1752-1505-2-3
Brian Williams (williamsb@unaids.org)
Daniel Baker (baker@unfpa.org)
Markus Buhler (buhlerm@unaids.org)
Charles Petrie (charles.petrie@undp.org)
ISSN 1752-1505
Article URL http://www.conflictandhealth.com/content/2/1/3

Increase coverage of HIV and AIDS services in Myanmar
Brian Williams1, Daniel  Baker2, Markus Bühler1, Charles Petrie3

1UNAIDS, 223 Sule Pagoda Road, Yangon, Myanmar
2UNFPA, 6 Natmauk Road, Yangon, Myanmar
3UNDP, 6 Natmauk Road, Yangon, Myanmar
E-mail addresses:

BW: williamsb@unaids.org
DB: baker@unfpa.org
MB: buhlerm@unaids.org
CP: charles.petrie@undp.org

Abstract

Myanmar is experiencing an HIV epidemic documented since the late
1980s. The National AIDS Programme national surveillance ante-natal
clinics had already estimated in 1993 that 1.4% of pregnant women
were HIV positive, and UNAIDS estimates that at end 2005 1.3%
(range 0.7-2.0%) of the adult population was living with HIV. While a
HIV surveillance system has been in place since 1992, the
programmatic response to the epidemic has been slower to emerge
although short- and medium-terms plans have been formulated since
1990. These early plans focused on the health sector, omitted key
population groups at risk of HIV transmission and have not been
adequately funded. The public health system more generally is
severely under-funded.

By the beginning of the new decade, a number of organisations had
begun working on HIV and AIDS, though not yet in a formally
coordinated manner. The Joint Programme on AIDS in Myanmar 2003-
2005 was an attempt to deliver HIV services through a planned and
agreed strategic framework. Donors established the Fund for HIV/AIDS
in Myanmar (FHAM), providing a pooled mechanism for funding and
significantly increasing the resources available in Myanmar. By 2006
substantial advances had been made in terms of scope and diversity of
service delivery, including outreach to most at risk populations to HIV.
More organisations provided more services to an increased number of
people. Services ranged from the provision of HIV prevention
messages via mass media and through peers from high-risk groups, to
the provision of care, treatment and support for people living with HIV.
However, the data also show that this scaling up has not been
sufficient to reach the vast majority of people in need of HIV and AIDS
services.

The operating environment constrains activities, but does not, in
general, prohibit them. The slow rate of service expansion can be
attributed to the burdens imposed by administrative measures,
broader constraints on research, debate and organizing, and
insufficient resources. Nevertheless, evidence of recent years
illustrates that increased investment leads to more services provided
to people in need, helping them to obtain their right to health care.
But service expansion, policy improvement and capacity building
cannot occur without more resources.

Background

Myanmar is experiencing an HIV epidemic documented since the late 1980s.  The
National AIDS Programme national surveillance ante-natal clinics had already estimated
in 1993 that 1.4% of pregnant women were HIV positive, and UNAIDS estimates that at
end 2005 1.3% (range 0.7-2.0%) of the adult population was living with HIV. While a HIV
surveillance system has been in place since 1992, the programmatic response to the
epidemic has been slower to emerge although short- and medium-terms plans have
been formulated since 1990.  These early plans focused on the health sector, omitted
key population groups at risk of HIV transmission and have not been adequately funded.
The public health system more generally is severely under-funded.

By the beginning of the new decade, a number of organisations had begun working on
HIV and AIDS, though not yet in a formally coordinated manner. The Joint Programme
on AIDS in Myanmar 2003-2005 was an attempt to deliver HIV services through a
planned and agreed strategic framework. Donors established the Fund for HIV/AIDS in
Myanmar (FHAM), providing a pooled mechanism for funding and significantly
increasing the resources available in Myanmar.  By 2006 substantial advances had been
made in terms of scope and diversity of service delivery, including outreach to most at
risk populations to HIV. More organisations provided more services to an increased
number of people. Services ranged from the provision of HIV prevention messages via
mass media and through peers from high-risk groups, to the provision of care, treatment
and support for people living with HIV. However, the data also show that this scaling up
has not been sufficient to reach the vast majority of people in need of HIV and AIDS
services.

The operating environment constrains activities, but does not, in general, prohibit them.
The slow rate of service expansion can be attributed to the burdens imposed by
administrative measures, broader constraints on research, debate and organizing, and
insufficient resources. Nevertheless, evidence of recent years illustrates that increased
investment leads to more services provided to people in need, helping them to obtain
their right to health care. But service expansion, policy improvement and capacity
building cannot occur without more resources.

The scope of the HIV epidemic

Myanmar is one of South-East Asia's countries hardest hit by the HIV epidemic. At the
end of 2005, UNAIDS and WHO estimate that 1.3% (range 0.7-2.0%) of the adult
population were infected by HIV [1]. This percentage results in an estimated 360,000
people (range 200,000-570,000) living with HIV.  Epidemiological analysis suggests that
the HIV epidemic may be levelling off since the early part of the decade [2] (See Table
1).

An HIV sentinel surveillance system has been in place since 1992. It found that 1.4% of
sampled pregnant women attending ante-natal care services were infected with HIV in
1993 [3]. From an initial nine surveillance sites, the system has progressively expanded
to 30 sites in 2005 carrying out sentinel surveillance for women receiving ante-natal care
and people attending services for sexually transmitted infections. HIV surveillance for
specific high-risk groups is also undertaken, including injecting drug users (four sites),
tuberculosis patients (nine sites started in 2005) and female sex workers (two sites). The
present surveillance systems does not allow for analysis by site as the sample size is too
small. Regional differences in the epidemic cannot therefore be further assessed.
Protocols are being introduced in 2007 to include men who have sex with men, to add
additional sentinel sites for sex workers, to increase sample sizes and to improve
sampling methodology [4].

Concerning knowledge, the latest published behavioural surveillance report of the
National AIDS Programme  [5] contains data for the general population (15-49 years of
age) and youth (15-24 years of age) in 2003. Over 90% of the respondents had ever
heard about HIV. Knowledge of three effective prevention methods (abstinence, being
faithful to one uninfected partner and consistent condom use) ranged from 21% among
youth to 42% among the population aged 25-49. The level of knowledge among women
of all ages was generally lower than among men.  In a 2005 survey on knowledge of
reproductive and sexual health the Department of Health Planning surveyed 14,400
households sampled from 86 townships which were part of a UNFPA funded
reproductive health programme. It was found that the proportion of the adult respondents
(aged 15-49) who could correctly identify at least three ways of preventing HIV
transmission was 50.7%. This figure is more than 10% higher than that of a 2002 study
by the Department of Health Planning using the same methodology in the same area.
[6].

With respect to condom use, in the behavioural survey of the National AIDS Programme,
60% of young men (15-24 years) reported consistent condom use with sex workers [3].
This figure, which some epidemiological models suggest is already high enough to have
a significant impact on the spread of the epidemic [7], is largely consistent with data from
studies conducted by non-government actors [8].  In an unpublished, national condom
market study conducted by Population Services International at the end of 2004, 85.4%
of young people (15-24 years) reported condom use the last time they had sex with a
sex worker. Another unpublished NGO study in 2004 among youth 15-24 years old and
living in Kayin and Mon states found that 82% reported condom use at last sex with a
sex worker. Other non-governmental service providers are known to also collect
behavioural data for programme monitoring and evaluation purposes but these remain
unpublished as official approval for publication has not been sought or granted.

Support to National AIDS Planning, Coordination and Resource Mobilization
The national response to HIV and AIDS was slow to take off during the 1990s, despite
increasing evidence that HIV prevalence was rising. A number of factors constrained the
range of services available for HIV activities during the first ten years of the epidemic.
Myanmar has an under-funded public health system and limited political support was
expressed in support of HIV services. There were few national civil society organisations
with HIV programmes, and the formation of civil society in general, outside of those
linked to the government, remains problematic.  Among the limited number of
international non-governmental organizations present in Myanmar, a few started HIV
prevention programmes on a limited scale after 1995 and initiated critical advocacy
work. UNICEF began supporting services for HIV as early as 1994. As one of the few
donors present in Myanmar during that period, UNICEF supported a range of
interventions in HIV prevention. The World Health Organisation (WHO) provided training
and technical assistance for HIV surveillance, the management of sexually transmitted
diseases and the prevention of mother to child transmission of HIV. The United Nations
Development Programme (UNDP) provided support to the National AIDS Programme as
well as local civil society organisations.  Activities supported included condom promotion
and supply, provision of test kits to the national blood safety programme as well as the
production of information, education and communication materials.

By the turn of the millennium, interest in expanding work in the area of AIDS had grown,
but there was no formal mechanism coordinating such efforts.  More international NGOs
had been able to establish operations in Myanmar and a few parastatal national
organizations had begun discussing HIV and AIDS.  The National AIDS Programme,
though continuing to be based largely around health sector activities, added some nonhealth
 sector HIV prevention and awareness-raising work [9], albeit with very limited
funding.  The Ministry of Health budget for AIDS in 2004, for example, was 78.05 million
kyats  [10] (this corresponds to $90,000 using the average UN exchange rate for 2004 of
880 Kyats per US dollar) as compared to $1 million in Cambodia, $5.6 million in Viet
Nam and $92.8 million in Thailand in 2004 [1].

Early into the new decade, the United Nations agencies present in Myanmar increased
their level of investment and began advocating collectively, both within and outside of
the country, for increased, concerted action on HIV.  A United Nations Joint Action Plan
(2001-2002) was developed, and the Joint United Nations Programme on AIDS opened
an office. In 2002, a United Nations Expanded Theme Group on AIDS with membership
including organisations outside the United Nations system was established and it
developed the Joint Programme on AIDS in Myanmar 2003-2005, negotiated with the
Government, the National League for Democracy (the leading opposition party) and
donors.

The Joint Programme articulated a multi-sectoral framework into which all constituencies
(Government departments, United Nations agencies and national and international
NGOs) could position themselves and which increased the focus on specific
vulnerabilities around the purchase of sex by men and drug use [11].  Technical
coordination mechanisms were established.  Harmonized indicators were negotiated,
providing a basis for collecting annual, comparable data from all partners working on
AIDS and assembling a picture of national progress.  The United Nations Expanded
Theme Group governed the Joint Programme, a body including three representatives
from the Ministry of Health, six United Nations agencies, five donors, and three
international and three national non-government organisation representatives.  While
normal practice in many countries, it demonstrated the ability to craft structures in
Myanmar, to discuss HIV programme issues and provide a basis for accountable
delivery of international assistance.

The Fund for HIV/AIDS in Myanmar (FHAM) was created by three donors – expanded to
six by 2006 – to finance the Joint Programme.  In the end, the FHAM programmed
approximately $26 million over four years starting from 2003, financing the work of 35
implementing partners. UNAIDS Myanmar estimates that the FHAM contributed to
roughly 30% of the total funding on AIDS in 2005.  The FHAM was itself a product of
United Nations collaboration, relying on UNDP to manage the finances and
administration of contracts, while the UNAIDS Secretariat mounted a programme
support team and chaired a management committee to oversee the use of FHAM funds.
The FHAM programme support team monitored all partners' activities on the basis of
quarterly progress and financial reports as well as annual reports. During its four years,
the Fund undertook a total of 35 field monitoring missions in 62 locations across
Myanmar.

Service delivery expansion: evidence

As a result of the increased investments in AIDS programming, advocacy efforts in
favour of a stronger and more coordinated response, and Government steps to improve
the enabling environment, prevention and care service provision for HIV grew.  By 2005,
these investments had started to pay off and significant increases in service provision
were reported by implementing partners [8] [12] [13].

In 2005, the National AIDS Programme and 15 non-governmental organisations reported
reaching a total of 25,500 female sex workers by targeted HIV prevention services. The
services were spread over a substantial part of Myanmar with a more concentrated effort
in the large urban centres (see Figure 1). Sex work is illegal in Myanmar. The Ministry of
Home Affairs issued an unpublished internal directive in 2001 instructing police not to
use possession of condoms as evidence of prostitution.  More recently, the National
Strategic Plan underlines the importance of reaching sex workers in a supportive
environment.  Unpublished reports of implementing partners highlight the concern of
continuing arrests, however.

Drug use is illegal. This poses a number of constraints on programmes addressing the
prevention of HIV transmission through contaminated injecting equipment as well as the
operation of methadone maintenance programmes. Despite these constraints, current
programmes now cover many of the essential elements of a comprehensive harm
reduction strategy. The services for injecting drug users had likewise seen a substantial
increase. In 2002 only one drop-in centre was in operation; by 2006 a total of 16 drop-in
centres, run by NGOs or the United Nations, were operating with high numbers of drug
users.  In addition to these centre-based services, outreach and peer education teams
established in these centres provided prevention and referral services. A total of 11,500
injecting drug users of an estimated total of 60,000 were reported as having received
services in 2005 in many of the drug producing areas for Myanmar including Shan and
Kachin States, as well as urban centres [8].

Needle exchange and distribution also showed a steep increase in numbers. From
210,000 clean needles distributed in 2003, the reported numbers climbed to 1,162,000
needles distributed in 2005 [8].

Preparation for the roll out of methadone maintenance therapy started in 2004. By the
end of 2006 more than 200 people were enrolled in this programme. The methadone
programme is implemented in the drug treatment centres of the Ministry of Health. One
non-government organisation collaborates with public health services in dispensing
methadone. This collaboration between public and non-government sectors is
considered crucial to ensure a comprehensive approach in support of patients.

HIV prevention efforts for men who have sex with men are a relatively recent
occurrence. Nevertheless, during 2005 at least 22,000 men who self identified as having
sex with other men had received tailored health education, mostly through peer
education and outreach programmes of non-governmental organizations' [8].

The prevention of mother to child transmission (PMTCT) programme was launched in
2000 by the National AIDS Programme with the assistance of United Nations agencies,
and was functioning in 89 out of the 324 townships and 37 state, divisional and other
hospitals by the end of 2006. In 2005, a total of 629 mother-baby pairs received
Nevirapine (an anti-retroviral drug) prophylaxis through the National AIDS Programme
as well as three non-governmental organisations.

The Ministry of Education has introduced life skills training that includes HIV education in
the national curriculum for the primary school and in selected secondary schools. The
programme has been ongoing since 1998 and the Ministry reports that 46% of the
secondary schools are covered by the programme reportedly reaching 900,000 children
aged 10 to 16 years in 2005. However, a recent review noted that the quality, coverage
and impact of the school-based life skills programme require continued attention [14].

Prevention efforts for specific, targeted groups have been accompanied by advocacy
and HIV prevention campaigns for the general population. The mass media have
increasingly carried HIV-related message from the government, United Nations agencies
and international non-governmental organisations. Population Services International, a
non-governmental organisation, reported that 250 HIV-related television spots were
shown in 2005. In 2006 this increased to 438.  UNAIDS Myanmar tracks HIV media
coverage in 10 popular newspapers and journals and found an increasing frequency of
HIV and AIDS related reporting since the beginning of 2004 [8].

The availability of condoms either through social marketing or free distribution has
increased greatly. With 11.1 million condoms distributed in 1999 compared to 39.9
million by the end of 2005, the figures have risen nearly fourfold over a period of six
years [8]. Over half of these condoms were sold at highly subsidized prizes through
social marketing, the rest through free distribution. With slightly less that one condom
available per capita per year, the figures in Myanmar remain lower than in other South-
East Asian countries [8].  These figures do not include commercial sales, roughly
estimated as 4.3 million in 2005 by the National AIDS Programme based on informal
consultations with partners.

Concerning treatment, care and support, the beginning of anti-retroviral treatment (ART)
in Myanmar dates from 2003, when Médecins Sans Frontières Holland first introduced
treatment. Since, they have expanded progressively and additional organisations have
begun providing treatment, including through the public health sector launched in 2005,
resulting in a substantial scale-up (Table 2). Home-based and community-based care
has also grown, from 3,800 people living with HIV receiving some sort of support at the
end of 2004, growing to 10,900 people at the end of 2005 [8].  A number of self-help
groups and networks of people living with HIV have formed over the last years, and
there is now representation of people living with HIV in planning events and coordination
forums.  Further capacity building of localized self-help groups and networks is required,
however, to ensure that representatives of people living with HIV have a structure
through which they can effectively communicate with their constituents.

Access to and uptake of voluntary and confidential counseling and testing remains very
low. In order to increase the number of people undertaking HIV testing, provision by an
increased number of partners, including NGOs, has been recommended [14].  Recently,
two international NGOs have received official permission to launch HIV testing activities.

Discussion

Service coverage

The establishment and expansion of AIDS services since 2000 demonstrates that
international resources can increase availability of services for populations that would
otherwise lack access.  In many areas of prevention and care, the number of townships
where programmes have been initiated is growing, for example in prevention of mother
to child transmission (89 townships in 2006), townships with any kind of sex worker
outreach or peer education programme (273 townships in 2005), or townships with HIV
programmes for drug users (24 townships) [15].  However, the breadth and depth of
service coverage is still alarmingly low when compared to estimated sizes of most at risk
populations [16] (see Table 3). Indeed, the number of townships covered does not
necessarily translate into significant percentages of people gaining access to services.
Less than 20% of injecting drug users are being reached with outreach or tailored health
education programmes; in the case of female sex workers this may reach as high as
50% of sex workers, while well under 10% of men having sex with men have access to
any service.  Only 8% of the estimated number of HIV positive pregnant women is
offered services to prevent the transmission of HIV to their babies during birth. Only 10%
of people living with HIV estimated as needing anti-retroviral treatment are currently
receiving it.

Further challenges for program implementation and scaling up
As a result actions by the Ministry of Health and the National AIDS Programme and
advocacy by international actors, the environment has allowed actors to expand their
work on AIDS.  At the same time, the overall operational setting remains unpredictable
and constrained, without being broadly prohibitive.

Carrying out health and humanitarian programmes in Myanmar is characterized by a
high level of administrative control.  Obtaining approvals to establish an organization and
a programme – whether national or international – can take a year or more.
Memorandums of Understanding with detailed workplans must be negotiated annually
down to the township level.  Approval by a cabinet-level body is required for every
international staff member to be posted in Myanmar.  All domestic travel by foreigners
requires approval, usually with at least three weeks notice, from both the technical
counterpart ministry as well as the Ministry of Defence; foreigners cannot visit projects
sites, and not even those under their own direct management, without being
accompanied by a government official.  Approval for importing commodities is slow to be
obtained, and international and national NGOs do not benefit from exemptions provided
in other countries for the tax-free importation of vehicles and other project supplies.
Much of the procurement funded by international sources has been undertaken by
various members of the United Nations system.  Difficulties related to coordination of
roles and timeliness of procurement have in some instances further delayed programme
implementation.

Activities are also constrained by limits of the capacity of the implementers and limits
that the national health services can influence other government bodies.  The external
review of the National AIDS Programme undertaken in April 2006 highlights many of
these issues [14]. Capacity for action by non-health ministries, critical for HIV prevention,
is also weak.  While the Ministry of Health has been successful in mobilizing high level
endorsement of its National Strategic Plan, more non-health ministries will have to be
mobilized if HIV prevention is to achieve the goal of universal access and be
sustainable.

Characteristics of the broader operating environment also hamper, rather than facilitate,
HIV prevention and care.  Discussion of cultural values and roles, much of which must
explore traditional norms about sexual behaviour, often for the first time in the public
domain, is essential for sustainable HIV prevention.  The meaningful participation of
people living with HIV and other civil society actors is essential for such discussions and
requires an ability to form self-help groups and formal networks across the country.
More research from a variety of viewpoints, including from outside the government, is
needed to inform debate which best takes place in an atmosphere of a free exchange of
ideas.  While such cultural discussion is occurring in the growing (but censored) press,
as well as through small informal networks of people living with HIV, its expansion is
slow and requires a more conducive environment.

Access to populations in need of services remains difficult and in some cases
impossible.  Some sensitive border regions, other areas containing large numbers of
mobile populations, such as mining camps, and conflict areas are off-limits to
international NGOs and United Nations agencies.  Some progress has been made, but
the HIV epidemic in these areas can only be reliably reversed with full access to all parts
of the country.

The operational environment remains difficult to predict.  In February 2006, the Ministry
of Foreign Affairs, the Ministry of Home Affairs and the Ministry of National Planning and
Economic Development, issued new draft guidelines to the international community –
United Nations agencies and NGOs alike – for the coordination of organisations
undertaking humanitarian work [17].  Partners have raised concerns that a rigid
application of these guidelines could compromise their work.  The United Nations
Resident Coordinator, on behalf of the humanitarian community in Myanmar, sent a
letter to the government in March 2006 stating standard humanitarian principles that
would be required for successful delivery of assistance to Myanmar.

Resource constraints

Sufficient and predictable resource flows are critical for planning and service delivery.
Government health expenditures in 2005 were reported to be $0.37 per person [18]
(using the average UN exchange rate for 2005 of 1,030 Kyats per US dollar against
reported 376 Kyats expenditures per person) and the percentage of general government
expenditure on health in 2003 was 0.5% of gross domestic product, compared with
Thailand 2.0%, Cambodia 2.1% and Vietnam 1.5% [19].  Government investment in
health care needs to be dramatically scaled-up if the HIV epidemic is to be rolled back.

From the international community, Myanmar receives a very low level of financial
support considering its development profile.  Total official overseas development
assistance in the country was estimated as $2.4 per capita in 2004, as compared to $47
for Laos, $35 for Cambodia and $22 for Viet Nam [19]. For HIV alone, in 2005 donor
commitments to partners working in Myanmar amounted to approximately $25 million,
whereas Cambodia the same year, with a similar epidemic but only a fifth of the
population, received approximately $45 million [20].  In 2007, overall resources available
for HIV are expected to remain flat (including the anticipated contribution from the three
Diseases Fund), handicapping efforts to scale up the response. (see Figure 2).

The highly politicized context of operating in Myanmar requires any potential donor to be
very committed to its investment.  All grants are closely scrutinized by a variety of
political actors both inside and outside the country, who in other circumstances might not
pay detailed attention to HIV funding.  Donors can expect public commentary on the
appropriateness of their investments from the government, the National League for
Democracy, Myanmar political groups based outside of Myanmar, and international
organizations with a principle focus on political affairs in Myanmar.  Large grants can
become political issues in and of themselves, testified to by the extensive commentary
preceding and following the termination of the Global Fund to Fight AIDS, Tuberculosis
and Malaria, Round 3 AIDS grant [21, which occurred in August 2005 for the stated
reason that the operating environment did not meet the Fund requirements.

New Directions in HIV Programming

While partners were slowly expanding services, several motivating – and complicating –
factors led to a further evolution of HIV strategic planning and coordination efforts.  In
line with the "Three Ones" principles being advocated for AIDS programmes worldwide,
the government argued for its own leadership role in the national response to AIDS while
acknowledging that international standards militated in favour of more participatory
practices in strategy design and coordination [22].  An independent mid-term review of
the Joint Programme and the FHAM also encouraged the establishment of more
complex mechanisms separating out roles of leadership and ownership of national
plans, technical support provision by international organizations, and decision-making by
investors [23].  Prior to its termination, accommodating the requirements for Global Fund
Round 3 also served as motivation for creating participatory coordination structures.
The termination in August, 2005, threw planning efforts into turmoil requiring still more
adjustment.  In early 2006, the government requested an external review of the health
sector by a team of international and national experts. The review made a number of
recommendations to address the identified short-comings [14].

Reflecting these reviews, events, and evolving views, extensive discussions among all
stakeholders led to a new configuration.  Continuing the provision of key HIV prevention
and care services for the people of Myanmar remained the unifying motivator.  The
United Nations supported the government in developing a National Strategic Plan 2006-
2010 and a targeted, prioritized and budgeted Operational Plan 2006 – 2008 [3] [16].
This process involved the government, United Nations agencies as well as international
and national NGOs, and was supported by external consultants.  Among the advances
contained in the new National Strategic Plan include greater coherence among the
various actors; a focus on most at risk populations including sex workers and clients,
drug users, and men who have sex with men, a participatory coordination structure,
more multi-sectoral involvement, an explicit mention of human rights, and a greater
emphasis on outcomes (beyond activity outputs) [3] . The Ministry of Health now chairs a
Technical and Strategy Group on AIDS which involves representatives from the
community of people living with HIV, from other selected ministries, national and
international NGOs and United Nations agencies.

Beginning 2006, six donor countries have worked to establish the Three Diseases Fund
(www.3dfund.org), responding both to the termination of the Global Fund grants and the
imperative to continue the service provision that the FHAM had begun.  The Three
Diseases Fund's structure more formally divides national strategy making from financial
allocation decisions.  It provides an incentive for participatory planning and coordination
while keeping final decision-making on resource allocation – and the ultimate
responsibility for performance – clearly with the donors.  It incorporated the United
Nations Country Team's statement on principles for the provision of humanitarian
assistance into its programme document [24].  It has committed to investing $100 million
over five years and will operate through the United Nations Office of Project Services
(UNOPS) as its fund manager.

Conclusion

Since the start of the decade, the provision of HIV prevention and care services has
expanded significantly as a direct result of advocacy by internal and external actors
concerned about HIV in Myanmar, increased investment of international resources and
increased recognition by the Ministry of Health of the issue. Although programme
implementation is characterized by high transaction costs and long delays, the
environment has not prevented partners from delivering HIV services to people in need
but the restrictions have limited geographic coverage and hampered timely
implementation.  These findings support arguments made as early as 2004 that
additional resources can lead to more pragmatic approaches by government [25].

Despite the turbulence created by the Global Fund termination and the generally
politicized atmosphere, actors both inside and outside the country have demonstrated
that carefully negotiated agreements on HIV and AIDS programming are still possible.
The new National Strategic Plan on AIDS 2006 – 2010 currently reflects international
best practice in many areas, highlights most at risk populations for HIV, and was
developed in a much more participatory manner than any preceding plan.  Six donors
have crafted an accountable, independent and transparent structure to fund service
delivery, using the National Plan as an important reference.

Early indications suggest these new structures offer a way forward in the Myanmar
context, yielding benefits for people living with HIV and the population as a whole.
Programme output data demonstrates that increased resources and policy engagement
can result in increased services for people in need and facilitate the evolution of HIV
policies.  However, more capacity building of the public health system and NGOs, more
operational and behavioural research, more policy discussion, and more partners are all
needed to build on this foothold of successful programming.  Without more investment,
from the Government as well as international sources, the road towards universal
access to HIV prevention and care will be much longer than it needs to be.

Competing interests
The authors have no competing financial interest. BW, DB, MB and CP are based in
Myanmar and work for United Nations agencies. This article was written in a personal
capacity and does not necessarily reflect the view of UNAIDS or any other United
Nations organisations.

Authors' contributions
BW and MB led in writing the manuscript.  MB also researched background data,
prepared tables and charts.  DB and CP participated in manuscript preparation.

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  21
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[15] UNAIDS: Matrix of Township Service Providers. Yangon; 2006.
[16] Ministry of Health Myanmar: National Strategic Plan on HIV and AIDS: Operational
Plan April 2006-March 2009. Yangon; 2006.
  22
[17] Government of the Union of Myanmar: Guidelines for UN Agencies, International
Organizations, NGOs / INGOs on Cooperation Programme in Myanmar. Yangon; 2006.
[18] Ministry of Health Myanmar: Health in Myanmar 2006.Yangon, 2006.
[19] United Nations Development Programme: Human Development Report 2006. New
York; 2006.
[20] Country Coordinating Committee Cambodia: Fifth Call for Proposals – Country
Coordinated Proposal – HIV/AIDS. Phnom Penh; 2006.
[21] International Crisis Group: Myanmar: New Threats to Humanitarian Aid. 2006
[22] UNAIDS: The "Three Ones" in action: where we are and where we go from here.
Geneva; 2005.
[23] Scott A, Jenkins C, Mathai D, Panda S: Joint Programme for HIV/AIDS: Myanmar
2003-2005 – Mid Term Review Findings and Recommendations of the Review Team.
Yangon; 2005
[24] UNOPS: Proposal – Three Diseases Fund. Bangkok, 2006.
[25] International Crisis Group: Myanmar: Update on HIV/AIDS Policy. 2004.

Figures and Tables in the orginal document