18 April 2014

Photo: A landmine warning hangs outside a clinic near the Thai border in Karen State, Burma (Alex Bookbinder)

Over six decades of civil war in Eastern Burma, civilians have fled en masse over the border to Thailand in search of basic necessities – physical security, food, medicine.

But now, glimmers of hope are shining through back home. A nationwide ceasefire process is underway, and the government has signed ceasefires with the vast majority of the country’s ethnic armed groups. To be sure, the durability of these accords is far from assured. Conditions in some parts of the country remain violent and tense, but Karen State — where the majority of the refugees in Thailand originate — is experiencing what is perhaps the calmest period in its modern history.

Although high-level negotiations are still underway, health services for tens of thousands of people living in territories controlled by the Karen National Union (KNU) are steadily improving, a corollary of the peace process that is already palpable.

“We can conduct our activities safely, and we have more access to our communities,” says Gyi Gyi, an official with the KNU’s medical relief arm, the Karen Department of Health and Welfare (KDHW), who conducts cross-border relief work from his regional headquarters in Mae Sariang, Thailand. “When we met with the SPDC soldiers [in the past], they would shoot our medics. But now, according to the ceasefire process, our medics can [travel] freely.”

The KDHW provides the only front-line health care available to residents of KNU-controlled areas of Karen State, and other Karen-majority territories further afield. The Burmese military classified these areas “free fire” zones when hostilities were active, rendering impossible any hope of offering permanent health services across vast swathes of the state.

Although a finalised peace accord is still elusive, the KDHW has taken steps to increase its presence in areas where fighting historically limited its ability to operate. In the past, the KDHW operated most of its brick-and-mortar clinics at a distance from populated areas likely to come under attack; the core of its operations were based around ten-man “mobile clinics” that moved from village to village, able to pack up and leave on short notice.

As perceived security has increased, the KDHW has transformed these mobile clinics into 35 “village-tract health centres,” physical bases of operation from where medics can travel to more remote locations. “Some clinics that we built in remote areas, we have now moved to villages, which acts as a centre for other villages,” Gyi Gyi said.

The village-tract health centres offer basic front-line health services, including immunizations, malaria treatment, nutrition programmes and trauma care, and serve populations of between 3,500 and 5,000 each. But despite the advantages inherent to not having to move around, facilities are rudimentary and health outcomes are still poor.

Poor healthcare is not unique to Karen State, but rather a nationwide phenomenon. In 2011, Naypyidaw allocated just US$2.90 per person for healthcare, less than almost any other government on earth.

But despite the government’s own limited provision of health services, cooperation is on the agenda. The KDHW opened a dialogue with their counterparts in the Karen State health department one year ago, a development that would have been implausible just months before. “Now, the KDHW is still talking with the government,” Gyi Gyi said. “We have talked with the state health department seven times.”

The KDHW seeks official recognition as the main healthcare provider for areas outside the reach of the government in Karen State, and wants to cooperate with the government on a range of initiatives, including maternal health, malaria eradication, and infrastructure projects, such as improving access to water and sanitation. To facilitate communication, it recently opened a branch office in Hpa-An, the capital of Karen State. It is also seeking official accreditation for the KDHW’s medics, who undergo much more rigorous training than do government employees.

State-level negotiations have been extremely positive, Gyi Gyi claims, but true decision-making power is out of the local government’s hands. “They need to send all information to the union health level, and then if the union health level says we can proceed, we will,” he said.

While the KDHW still receives the bulk of its funds from border-based organisations, it is now able to receive funds from Rangoon-based donors through the Myanmar Peace Centre, the government’s one-stop clearinghouse for peace negotiations and the allocation of funds associated with it.

For the KDHW, it’s a welcome change, but not one that it’s entirely accustomed to yet. “When you build peace, you need to adjust many things,” Gyi Gyi said. “At least, we now have channels: Even if we cannot go directly to the government, we can go through the peace centre, which coordinates between us and the government.” Eventually, he believes, the KDHW will receive funds directly from the government, but “it’ll be better to negotiate that after a [peace] agreement is signed.”

 For all the tangible progress made on health in Karen State, the gains witnessed over the past two years could be eradicated if the peace process were to turn sour. A long-postponed third round of peace talks is set to be held in Hpa-An in May, but there can be no assurances it will go smoothly. “While we see there’s no fighting, both sides, especially from the military, should sign onto a code of conduct, but that [agreement] hasn’t been reached yet,” Gyi Gyi said.

Yet the positive ties forged between the KDHW and the government may serve as a bellwether for the future of the peace process writ large. “We are looking forward to the next KNU meeting with the government. It’s very important for us, to be able to work for our people in the future,” Gyi Gyi said. “This process has progressed very far in one year, but we will see how things will be in 2015 about Burma.”

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