The Future of Myanmar’s Mental Health Policy Landscape: Applying Casual Layered Analysis (CLA)

Author: Rosalinn Win

Advisor: Pobsook Chamchong

Problem Statement

In the face of an evolving world, mental health crises have risen with undermining factors around the world. To prioritize, prevent, and protect mental health burdens in line with human rights, the Comprehensive Mental Health Action Plan from 2013 to 2030 was launched by the World Health Organization (2021). Following WHO’s guidelines, many nations, mostly developed countries, have regulated national mental health policies or strategies with intended goals, objectives, and legislation to strengthen mental health and treatment for mental health disorders. However, attempts to prevent mental health disorders through implementing mental health policies have often remained behind the state’s agenda, including allocation of resources and budgeting for mental health. Therefore, Kovacevic et al. (2023) claimed that most states can be identified as “developing” countries simply because they are beyond addressing the incidence of mental health problems.

Similarly, Myanmar is vulnerable to mental health burdens, and the previous Lunacy Act 1912 was outmoded and no longer appropriate to respond to the current and future mental health burdens. Nevertheless, no separate mental health policy has been cultivated, and it was designed to encompass the overall National Health Plan until 2020. Led by the elected civilian government, the National Mental Health Policy and Strategic Plan for Mental Health from 2021 to 202  was inaugurated in August 2020 and was approved in 2021. Lamentably, the subsequent military coup in February 2021 impeded its practical application following the collapse of the overall health system in Myanmar. On the one hand, the number of mental health disorders is growing amid ongoing armed conflicts and humanitarian crises in Myanmar (Tol et al., 2023). Thus, establishing a robust mental health policy by implementing strategies, goals, and cooperation to resolve mental health issues productively is worth mentioning. To the best of my knowledge, no previous studies have been conducted on foresight tools to reflect and evaluate the future of the mental health policy landscape in Myanmar. Hence, this study aims to investigate a deeper understanding of mental health-related hidden paradigms and uncover the provision of a plausible future for mental health policy in Myanmar.

Policy Analysis

The Causal Layered Analysis (CLA) future thinking approach introduced by Inayatuallah is adopted as the main conceptual framework in this study. Inayatuallah (2004) added that using the future thinking tool CLA is not for predicting the future but for building more transformative, inclusive, sustainable, and effective policy through the creation of alternative futures. There are four levels, and these levels are intertwined as one level of analysis has an impact on another level: the litany, systemic causes, worldview, and myths (Fan and Nee, 2014). To gain a comprehensive understanding of the future mental health policy landscape in Myanmar through this framework, this study analyzed how the obstacles exist at each layer of analysis and proposed policy recommendations.

The primary data were gathered from 8 key informants’ interviews, representatives from NGOs/INGOs, including Jue Jue’s Safe Space Organization, to unpack findings and obtain rich and deep information for the future of Myanmar’s mental health policy landscape. By ensuring triangulation of the findings, the collection of secondary data from government and international organization reports, and literature-based research is followed.

Rising Statistics, Resource Scarcity, and Policy Vacuum

The analytical results strongly suggest a remarkable rise in various types of mental disorders in Myanmar. In prior years, instances of mental health issues proved to be infrequent, with a seemingly low presence in public spaces. Currently, many individuals, including youngsters, are exposed to mental disorders because they are observed in public areas muttering to themselves, appearing to be severely mentally ill, or slowly losing their mental capacities to cope (P1). Likewise, almost 99 out of 100 community members seemed to suffer from anxiety due to their daily struggles to meet the routine basic needs (P4). Furthermore, post-traumatic stress disorder (PTSD) and depression are the most noticeable mental disorders among young people due to the consequences of natural and man-made disasters in Myanmar (P4). These findings aligned with the research explored by Fan et al. (2024) that PTSD, anxiety, and depression are the common mental health categories among adults in Myanmar.

A further illustrious impediment to the provision of mental health policy within Myanmar is the demonstrable scarcity of adequately trained or skilled mental health professionals. Statistical data from WHO (2022) indicates a disparity in the average density of mental health personnel, with Myanmar reporting a mere 0.2 psychiatrists, 0.6 nurses, and 0.1 social workers per 100,000 population. A substantial demand exists for expanded facilities and human resources capable of delivering primary-level care within mental well-being. Specifically, in the case of mild or moderate mental health conditions, there is a greater distinguishable need for a greater number of trained mental health counsellors to address a wide range of emotional and mental health challenges (P8). The international communities (including WHO) are raising Mental Health and Psychosocial Support (MHPSS) in Myanmar; however, it is still challenging to have coverage for all mentally health vulnerable populations across the country.

Most importantly, the vast majority of participants mentioned that the absence of a strategic mental health policy in Myanmar has ultimately led to negative impacts on the individuals, community, and country as a whole. Due to the policy vacuum, there are no rights or regulations for the individuals affected by mental health, as well as mental health trained workers in Myanmar, resulting in prolonged suffering and preventing recovery with the lack of quality care from trained experts (P8). Moreover, untreated mental health amid high rates of mental health issues may correlate to loss of productivity and affect the country’s economic productivity in the long term. WHO (2023) report estimated that US$6 trillion annually will be projected to cost due to productivity losses linked to mental health conditions affecting people across their lifespan. Hence, the regulation of comprehensive mental health policy is of paramount importance to overcome both visible and unforeseen obstacles related to mental health.

Intertwined Systemic Drivers

Continuation of conflicts and instability for nearly seven decades, not only overlooked the overall mental healthcare system but also the mental health policy implementation has been ignored in Myanmar. After the military coup in February 2021, these have even worsened in a poor resource setting. A majority of participants in this study indicated that the protracted political turmoil has been a consequential driver of diverse mental health issues ranging from mild to severe and has impeded the implementation of strategic mental health policy in Myanmar. Particularly, human rights violations, pervasive violence, and the constant experience of insecurity have contributed to the development of childhood trauma, anxiety, depression, collective PTSD, and even more major mental health issues. Besides, the following military junta’s conscription law after the political crisis has generated widespread anxiety, insecurity, and depression among adults and young people, tragically leading some individuals to take their own lives. The current political climate echoes the previous era of military suppression and military coups, causing past mental struggles to resurface (P1).

Myanmar is listed as a low-middle-income country according to the World Bank, and the middle class has shrunk together with socioeconomic downfall as a consequence of the political crisis. In the meantime, it culminated in widespread poverty and an increase in the burden of mental health in Myanmar. The United Nations Development Programme (2024) revealed that the percentage of people living in poverty, which illustrates nearly half of the populace is living in deprivation, is fueled by the likelihood of mental health impairment in Myanmar after the military coup. What is more, economic adversity in Myanmar has triggered high unemployment rates, loss of income, and inability to afford basic needs, contributing to stress, depression, and anxiety. With fewer jobs available, people are finding it hard to afford basic daily needs, and some people even have no choice but to go a whole day without food, surviving only on water (P2). Myanmar people will encounter food insecurity and a reduction of accessibility and availability to food due to the continuing political and social crisis in Myanmar (Hasyim et al., 2024).

Further, under the prolonged military regime with consecutive military officials, people have been denied in order to access to social protection, including basic human rights such as healthcare, education, and employment security that grant healthy standards of living. The International Labor Organization (ILO) estimated that a majority of the Myanmar population, approximately 98%, has no access to the requisite social protection and social safety. Instead, people are living under the exploitation of social protection that eventually results in anxiety, stress, and depression.

Meanwhile, Myanmar is documented as being at high risk of natural disasters such as floods, earthquakes, and landslides. Severe floods and the recent earthquake have left many survivors with double burdens and layers of trauma about their mental health well-being. Due to the different environmental disasters, Myanmar has experienced loss of lives and properties, and severe injuries, which have resulted in anxiety, depression, grief, and PTSD. The climate-affected communities are struggling to survive their lives or to cope with their grief daily, because some people have already lost all their family members in the tragic events of climate disasters. Nonetheless, the failure to prepare a system and strategy for disaster-related responses has caused many people to be vulnerable to psychiatric problems.

Dominant Discourse and Stigma

Mental health is mostly portrayed with different dominant paradigms by the family, community, and political leaders in Myanmar. Suffering from mental health conditions appears insignificant and has always seemed “a shameful issue or useless” to the family and community. Even among health professionals, mental health is a minor issue and fails to explore the diverse range of mental health causes and conditions adequately (P3). The timely recognition of an incipient mental health disorder holds the potential to alleviate individuals suffering from severe psychiatric diseases and facilitate the prompt initiation of appropriate support or treatment interventions. With the upholding of hidden assumptions like “don’t air your dirty laundry in public” by society and family, mental health-affected individuals are prohibited from seeking professional support (P1). Pernice‐Duca (2010) claimed that a positive correlation was observed between receiving a family support network and greater recovery experiences, with more hopeful attitudes by mental health individuals. Nevertheless, the deficit in mental health literacy in society or families frequently results in inadvertently contributing to mental health challenges, neglecting to pursue professional assistance, or encountering indifference from the broader community or even within the family unit itself. It is profoundly saddening to observe family members abandon those facing mental health illness, leaving them on the street without support and ending their relationships with them (P1).

In addition, “mental health is not an important matter” or “not yet the right time to consider,” compared to physical health, and the state’s priorities are the deep narratives framed by political leaders on mental health. Sarmiento et al. (2024) claimed that the population of Myanmar has never had psychosocial well-being given priority in terms of national development or policies. The frames have halted mental health policy execution and delayed effective responses to mental health problems. Importantly, with the immense suffering of mental health crises in Myanmar, the prioritization of mental health necessitates immediate integration aligned with other critical agendas, such as the implementation transformative and effective mental health policy is equally as crucial and worthwhile to exercise in parallel along with the state’s agendas.

Weight of Myths and Beliefs

Mental health is symbolized as deep-rooted stories and narratives by the society in Myanmar. These characterizations detrimentally affect both the mental health of individuals and professionals, by and large. The Burmese words, such as “yin-yin-lay-yu”, “kyat ma pyay”, and “a-yu” tend to normalize as implanted traditional narratives of mental health (P1). The hidden meaning of these words ranges from mild to severe mental health conditions, which can also be described as abnormal intelligence or a lack of intelligent abilities, without attempting to understand mental health conditions and their causes. Due to continuing to perpetuate these narratives by the society, some people are afraid of being called “a-yu,” meaning “craziness” by the community, and this inhibits them from seeking professional help or treatment interventions (P2). Stigma surrounding mental health often prevents those in need from accessing mental support or treatment (Newsom, 2014). Therefore, it is vital to acknowledge and reframe ingrained traditional beliefs about mental health to encourage individuals affected by mental health illness to be free from stigma and seek professional assistance. Along with the deep-seated stories of mental health, society used to imply that the person who pursued a mental health-related degree, skills, or knowledge, as “a-yu-pyin-nyar”, meant “useless knowledge”. As a result, many people who were interested in mental health-related knowledge were restricted by their family from pursuing their education and were disdained after receiving their degree by the community due to hidden stories of mental health.

Further, different religious myths have been explored concerning mental health based on the religious identities and communities, such as “wut-na-kan-na,” meaning “sinful or cursed illness”, illustrating mental health due to a sin from the past. Leaving everything to “karma or fate” might somehow seem good in temporary; however, in the long run, this narrative might not be able to heal the root causes of mental health, instead, it can even worsen without understanding and treatment of the underlying problems (P1). Interestingly, the diverse perspectives on religion-related myths and beliefs have been observed among the respondents. In regard to religious beliefs on mental health, positive aspects outweigh negative ones because religious practices like meditation or prayer assist people to stay calm amid uncertainty (P6). Equally, religious beliefs are symbolized mental health as a “lack of faith” or “religious weakness”. According to these beliefs, individuals are being demoralized by the demon due to their deficiency in religious practices. Some researchers and clinicians have a concern that religious beliefs may restrict persons with mental illness from receiving proper healthcare services (Subu et al., 2022).

Policy Recommendation

The following policy recommendations are proposed for a plausible future of Myanmar’s mental health policy based on the analysis and presenting findings through the conceptual framework of CLA for each layer.

Rising Statistics, Resource Scarcity, and Policy Vacuum	To enact Mental Health Act: The Lunacy Act 1912 was outdated and the new Mental Health Act that adhering to human rights’ principles should enact to protect mental health individuals, family and community. To establish Mental Health Research and Information Center: Research and information unit is mandatory not only to prevent mis-dis information about mental health but also be able to keep ethical and privacy, and to be able to response precise and effective prevention, interventions and treatment across mental health affected population and regions in accordance with different mental health conditions. To strengthen and recruit qualified Human Resources: delivering up-to-date training (including AI and technology-led approaches), supporting professional development by ensuring National Mental Health Licensing and support financial incentives for dedication to work in public sector or underserved areas
Intertwined Systemic Drivers	To create transformative, innovative and inclusive Mental Health Policy: The strategic mental health policy (2021-2025) should modify flexibly based on the contexts, needs and preferable futures by collecting voices and collaboration of state and non-state actors, e.g. consider visions, missions and strategic responses for unforeseen natural and man-made crisis or advancement in the future. To formulate public-private partnership and collaboration Body: State and non-state actors (including institutions) should cooperate together to effectively prevent and protect mental health and secure accessibility of mental health services by all ranges of population To implement MHPSS in Transitional Justice: conflict-affected community and victims should be supported and grant justice through MHPSS services from state, district, township and village levels (e.g. public meetings, private group/individual discussion) starting from now.
Dominant Discourse and Stigma	Promote public awareness: systemic and innovative awareness raising and campaigns should organize widespread to break dominant discourse, stigma, and stereotype that have impact on mental health (e.g. state’s broadcast, public figure advocacy or brand ambassadorship) To foster community-based mental health program: ensuring diverse range of population in the community acknowledge mental health, prevent and protect mental health in their community, and support individuals from recovery process
Weight of Myths and Beliefs	To regulate school-based mental health education and support: standardized, up-to-date and age-appropriate mental health education should introduce in schools and university by train and assign mental health teacher or professional for schools and university. (e.g. appoint mental health focal teacher or counselor)

 

References

[1]   World Health Organization. (2021). Comprehensive mental health action plan 2013–2030. Comprehensive mental health action plan 2013–2030.

[2]   Kovacevic, R., Garcia, J. N. B., & Gordillo-Tobar, A. (2023, October 10). With mental health conditions on the rise, countries must prioritize investments. Retrieved from https://blogs.worldbank.org/en/health/mental-health-conditions-rise-countries-must-prioritize-investments

[3]   Tol, W. A., Le, P. D., Harrison, S. L., Galappatti, A., Annan, J., Baingana, F. K., … & van Ommeren, M. (2023). Mental health and psychosocial support in humanitarian settings: Research priorities for 2021–30. The Lancet Global Health, 11(6), e969-e975.

[4]   Inayatullah, S. (2004). The causal layered analysis (CLA) reader. Theory and case studies of an integrative and transformative methodology, 1, 1-52.

[5]   Fan, G., & Nee Wey Khng, J. (2014). The futures of the Singapore association of social workers: an analysis using CLA and the “Futures Triangle”. Foresight, 16(4), 329-343.

[6]   Fan, X., Ning, K., Ma, T. S., Aung, Y., Tun, H. M., Zaw, P. P. T., … & Ni, M. Y. (2024). Post- traumatic stress, depression, and anxiety during the 2021 Myanmar conflict: a nationwide population-based survey. The Lancet Regional Health-Southeast Asia, 26.

[7]   World Health Organization. (2022). Addressing mental health in Myanmar. Retrieved from https://iris.who.int/bitstream/handle/10665/364882/9789290210207-eng.pdf?sequence=1&isAllowed=y

[8]   World Health Organization. (2023). Mental health conditions in the WHO South-East Asia region. Retrieved from https://www.who.int/publications/i/item/9789290210788

[9]   United Nations Development Programme. (2024, April 11). Middle class disappearing and poverty deepening in Myanmar. Retrieved from https://www.undp.org/press-releases/middle-class-disappearing-and-poverty-deepening-myanmar

[10]  Hasyim, S., Syafii, M., & Tanjung, A. A. (2024). The Effect of Economic Growth, Imports and Exports on Food Inflation in ASEAN Countries: Case Study of Timor Leste, Laos, Cambodia, and Myanmar. International Journal of Sustainable Development & Planning, 19(9).

[11]  Pernice‐Duca, F. (2010). Family network support and mental health recovery. Journal of marital and family therapy, 36(1), 13-27.

[12]  Sarmiento, C. B., Ford, B., Htay, Y. Y., & Martínez, A. (2024, January). Myanmar’s army’s war against mental health and psychosocial support. United States Institute of Peace.

[13]  Newsom, A. W. (2014). The effect of meritocratic worldviews on mental illness stigma (Doctoral dissertation, Marquette University).

[14]  Subu, M. A., Holmes, D., Arumugam, A., Al-Yateem, N., Maria Dias, J., Rahman, S. A., … & Abraham, M. S. (2022). Traditional, religious, and cultural perspectives on mental illness: A qualitative study on causal beliefs and treatment use. International journal of qualitative studies on health and well-being, 17(1), 2123090.

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