While reforms have been underway in many sectors of Myanmar the the nation's Health Ministry's aim of achieving universal health care coverage for citizens over the next 20 years may be too ambitious a goal for a medical system that has spent less than $1 per person under decades of military rule.

Until the civilian reform government can overhaul health care, the burden of payment falls on the patient. At Yangon General Hospital, one of the nation's biggest and best hospitals patients pay for any equipment used during their treatment. In a country where the average person earns about $2.50 per day many have to forego care or seek other options, according to Thailand-based Myanmar news outlet the Irrawaddy

“For [Myanmar’s] public hospitals, which are completely under-resourced by the government, patients often have to pay for everything themselves—IVs, medications, dressings, cleaning, food,” said Dr. Vit Suwanvanichkij, a public health researcher who has worked with migrants from Myanmar on the Thai border for more than a decade and who visited hospitals in Myanmar last year.

“It’s probably the most privatized health system in the world,” Suwanvanichkij added. The government plays an almost negligible role in providing health care. According to National Accounts Data from the Ministry of Health, the ministry was responsible for just 10 percent of all health care spending in 2008 to 2009, while households accounted for about 85 percent, with additional funding from other ministries and NGOs.

There are a few charity hospitals and clinics in Yangon, Myanmar’s biggest city, including the Muslim Free Hospital and the Thukha Charity Clinic that serve patients with limited income for free. The head surgeon of the Muslim Free Hospital, Dr. Tin Myo Win, is the the personal physician of opposition leader Aung San Suu Kyi. The relationship has helped draw donations from abroad and money also comes through religious donations from local Muslims in the city, the Irrawaddy reported.

Patients in the hospital’s surgical and outpatient wings said they avoided public hospitals because they could not afford them, and had heard stories about poor treatment. “I’ve never been to any other hospital because I only trust this hospital,” said U Ne Win, a surgery patient.

The hospital has limited resources despite the esteem of its head surgeon. The surgical unit offers just 25 beds, at least theoretically, and is unequipped to handle some difficult cases like heart, brain and kidney operations.

“Sometimes we have to put [patients] in between the beds, so we can accommodate more than 35 or 40 if necessary,” Dr. Tin Myo Win said, adding that he often performs 10 to 15 surgeries in a single day. “You should only perform about five major operations a day as a surgeon. Sometimes I have to stay late into the evening.”

In rural areas many rely on midwives to perform a wide range of duties.  In some states they are responsible for about 3,000 patients, according to the Ministry of Health. “They’re expected to do everything—primary health care, ante and postnatal care, pediatrics, delivering babies, collecting health data. Rural health-care providers joke that the midwife does everything except have the baby,” said Dr. Suwanvanichkij.

A shortage of doctors drives the problem. Availability varies from about six doctors per 100,000 people in Mon state to about 60 doctors for the same number of people in China state, according to statistics from the Ministry of Health.

The lack of reliable health care in rural regions takes a a heavy toll. Malaria is a leading cause of death and  tuberculosis occurs in more than 500 for every 100,000 people, nearly twice that of the rate of the Southeast Asian region according to 2010 data from the World Health Organization. For HIV, the prevalence is 455 cases per 100,000 people compared to the regional average of 189 cases.

As the country emerges from nearly 50 years of military dictatorship health experts are calling for an overhaul of the health care system. Aung San Suu Kyi has made health and education reforms her two major platforms since winning a seat in Parliament last year and she is spearheading a project to upgrade Yangon General Hospital.

Her personal doctor Win is developing a national health policy with a National health Network that he formed this year, with plans to create a mobile clinic with surgeons, specialists and emergency medical technicians traveling to remote areas.

Starting this year, some public hospitals have begun to offer limited financial aid. Yangon’s North Okkalapa General Hospital began offering aid for patients who could not afford to pay for medicine or IVs, according to an assistant medical officer at the Muslim Free Hospital who completed an internship at North Okkalapa General last year.

In the meantime, the Ministry of Health’s goal of achieving universal health care coverage in 20 years will be difficult with such a limited budget, according to Win.

“For the Ministry of Health, we can understand. With the amount they have in their hands, they are doing quite a good job for the people,” said the doctor. “But how can you [fix everything] with this limited budget?”

According to the latest figures, health care spending still only accounts for about 3 percent of the total national budget, the Irrawaddy reported.