Non communicable diseases (NCDs) are the leading global cause of death and disability. Between and within countries, however, there is still a marked diversity in the causes and nature of this disease transition. In Myanmar, economic and political reforms, and the ways in which these intersect with health, have created a unique public health and development context with major ramifications for public health. Myanmar’s transition creates anl opportunity to learn from the public health and development mistakes made elsewhere, but signs are at present that the rush towards short term economic opportunities is taking precedence. This piece illustrates some of the local dynamics that drive NCDs in Myanmar, and potential entry points for the international community to help address Myanmar’s next major health challenge.
NCDs in Myanmar
Myanmar has the second lowest Human Development Index rating in East Asia and the Pacific, and is still heavily impacted by communicable, and maternal and child, diseases – under five mortality rates are higher than the regional and global averages; while tuberculosis prevalence rates (for instance) are almost twice the regional average and three times the global average.
Myanmar now faces a ‘triple burden of disease’. WHO estimates that around 40% of all deaths in Myanmar are due to NCDs. The Global Burden of Disease report also highlighted the growing impact of NCDs – in Myanmar in 2010, four of the top 10 causes of death were NCDs. Between 1990-2010, stroke rose from approximately 3.9% of all deaths to 6.9%, and deaths attributable to heart disease, diabetes and kidney disease had approximately doubled. Risk factors including tobacco consumption, high blood pressure, and household air pollution are the major sources of disability adjusted life years in Myanmar, with each accounting for over 6% of total share. By contrast, sub-optimal breastfeeding and childhood underweight account for less than 3% of share of DALYs.
Drivers and risks
Over the past few years, political and economic developments in Myanmar have created an environment conducive to the rapid growth of NCDS. Alcohol, tobacco, and soft drink companies have rushed to take advantage of the changing political and economic environment. Faced with collapsing sales in many developed countries, these companies are increasingly targeting developing countries. With the potential for rapid economic growth in Myanmar, and a weak regulatory environment and limited public health lobby groups, Myanmar has become a major priority. While these companies bring revenue and employment opportunities, as has been seen elsewhere the long term health costs of these ‘industrial vectors’ outweighs the short term economic benefits.
Since mid-2012, the Myanmar Investment Commission has approved the establishment of at least six new breweries, including granting licenses for four joint ventures in January 2013 which involve multinational corporations such as Heineken and Carlsberg. The highest tax payer in the country in 2011-12 was Myanmar Brewery Limited, raising the potential of conflict between economic growth and long-term health outcomes.
The same story is playing out with Big Tobacco. In July 2013 British American Tobacco, the world’s second largest cigarette manufacturer, unveiled a $US50 million investment over five years to produce, market and sell its brands in Myanmar. Its factory, to be built on the outskirts of Yangon, will create about 400 jobs. Japan Tobacco, number 3 globally, forged a joint venture partnership in 2012, while China’s largest tobacco producer is also setting up a multi-million dollar joint venture.
A joint venture was also approved recently between Coca-Cola and a local company to resume the domestic production of Coca-Cola. Coca-Cola’s explicit objective of market expansion has raised concerns that both the prevalence of soft drink consumption and the level of consumption by existing consumers will increase. There is significant potential for a conflict of interest between health and economic priorities. The current investment incentive structure in Myanmar allows tax breaks for foreign investors for five years, which has implications for government revenue and also for health outcomes as this may create space for companies to set a low price for products to stimulate demand.
Current NCDs prevalence in Myanmar – and expected acceleration in coming years – require a range of responses by a range of public health and development stakeholders. The National Health Plan 2011-2016 prioritises NCDs, and there have been a number of surveillance mechanisms implemented in the past decade to track the progression of NCDs and risk factors. However, there is still the need for the establishment of a comprehensive NCD surveillance system, and for the promotion of surveillance and comprehensive environmental, policy and program interventions.
The 2012 Health in Myanmar report from the Ministry of Health outlines a number of activities that respond to NCDs including a multisectoral meeting to finalise national policy on NCDs, a workshop for the WHO Package of Essential Interventions for NCDs, and a national policy on tobacco control. Additionally, some long term projects are already in operation, including the Cardiovascular Disease Project which was established in 1981. This project currently operates hypertension clinics in 43 townships in the Yangon division, and plans are being developed to expand it into more districts.
Public sector resource constraints are a significant issue in the context of low government revenue and competing health and development priorities. Human rights concerns are still prominent – particularly treatment of certain minority populations – and these tensions will have implications for the provision and availability of universal healthcare. A recent development that might contribute to improved health outcomes is the trend towards governance decentralisation. This could have positive implications for primary health care and treatment and prevention of NCDs, as local government officials have generally been found to place more emphasis on development priorities.
Civil society has an important to play in addressing NCDs in Myanmar. A core group of local and international NGOs has been operating in the country for decades, and the number of NGOs is increasing in response to recent reforms. There are a number of NCD-specific organisations and initiatives currently operating in Myanmar, including the Myanmar Medical Association, the Doctors and Cancer Foundation and the Myanmar Cardiac Society. There are also a significant number of local NGOs operating at the grassroots level in healthcare and community development that could be mobilised to play a role in addressing NCDs.
As Myanmar’s disease transition continues (and as the understanding of donors and NGOs regarding the impacts of NCDs grows), there will be substantial opportunities for engagement in this area in Myanmar. This engagement won’t only be within the health and medical sectors, though there’s important work to be done here. Much important work will be needed in ensuring that trade acts as a facilitator of good health, not a barrier; that Myanmar learns from some of the challenges (and disasters) that have occurred as its Asian neighbours have developed; and that local organisations committed to addressing NCDs are provided with adequate partnership, funding and capacity building opportunities.
This article is a modified version of a case study in the report Non Communicable Diseases and the International Development Agenda: Addressing the World’s Biggest Killers, written by Sam Byfield and Rob Moodie and published by the Australian Council for International Development in November 2013.
Sam Byfield is the Non Communicable Diseases Coordinator at the University of Melbourne’s Nossal Institute for Global Health. Maeve Kennedy is completing a Master of Development Studies at the University of Melbourne.