UHC is for everyone

You will not be surprised to hear that I completely disagree with this Comment piece on NCDs and the elderly in Myanmar in the Lancet. I thought at first that it was a parody article in which the word young had been replaced by the word old.

Most of the sixty per cent of deaths that occur because of NCDs in Myanmar are in the elderly. But the DALYs lost due to NCDs are in all ages. Universal health coverage is, as its name suggests, universal. Focusing first on the elderly deprives Myanmar of the opportunity to develop a health system that serves all people who live inside its borders. There are few geriatricians in the country but enough health care providers to serve everyone.

I can think of no more absurd way to end a comment letter than by saying: "a health-care system that is good for older people is a system that is good for all". It sounds like something you might find in Orwell's Animal Farm. More identity politics is not what is needed during the transition in Myanmar.



Can Myanmar's older people lead the way to universal health coverage?
Nazaneen Nikpour Hernandez and Soe Myint
The Lancet
14 January 2017

The unique prospects in Myanmar, created by its emergence from years of isolation, reflect a country that is in the early stages of capacity building bolstered by renewed governmental commitment. This inspires an exciting potential for new strategies to be adopted for universal health coverage (UHC) by 2030. We suggest the health and social needs of older people should be targeted as an approach to tackle the high burden of non-communicable diseases (NCDs) and create a strong health system. This approach might seem counter-intuitive at first, in terms of achieving the most benefit, but in view of the rapid development in Myanmar it would show admirable foresight. Lower birth rates and longer life expectancy will create new challenges in the future that can be anticipated now while concurrently tackling multiple Sustainable Development Goals (SDGs).

59% of deaths in Myanmar are caused by NCDs and the numbers are projected to increase in view of the known effects of globalisation on health behaviours, which arise from increased GDP and greater exposure to NCD risk factors.1, 2 The number of people older than 60 years in Asia is expected to rise 66% by 2030 and will account for 60·2% of total world elderly population.3 Myanmar itself is expected to see an increase in population proportion of its older people from 8·9% (4·7 million people) to 13·2% (7·9 million people).4 The existing health barriers in the country are not unlike other developing countries, such as high out-of-pocket expenses, rural–urban disparities and unequal access to health-care services, as well as a lack of communication between public and private health sectors to achieve coordinated health coverage.5, 6 There are persistent human rights challenges, especially in some areas of the country where occasional conflict further complicates the country's stability and progress. At the same time, in the hopes of fostering peace and national unity, newly elected leaders have moved away from censorship and autocracy towards more decentralised decision making. This move has created an unusual transition period and an opportunity where people at the local level need encouragement to use their voices to direct the change around them.

The benefits of focusing interventions on care of the elderly in Myanmar include investment in a longer-living healthy workforce, preventing marginalisation, and tackling poverty, hunger, and other SDGs at once. Implementation of health programmes for people older than 60 years will also be aided by the high cultural respect towards older people.

Another particularly important advantage for Myanmar is that services for the elderly could help bridge the rifts between public and private health care, given that community and higher NCD care will need to be integrated. For example, specialist training from state NCD specialists could attract private family doctors to work in community based clinics, taking on basic NCD care at the community level and thereby reduce burden on hospitals. However, formal high-level representation from geriatric medicine experts is lacking. Very few doctors have any formal training in geriatric medicine, and those with an interest in this age-group often travel to UK to obtain their diploma of geriatrics. Undertaking of qualifications in the UK is not uncommon for all Myanmar doctors and highlights the need to develop local, affordable and culturally appropriate speciality exams.

For Myanmar, a strategy of engaging older people also makes good economic sense; 85% of those aged over 60 years live with family, and of these, more than half contribute to household income. Additionally, older people provide child care allowing adult children the freedom to move away for work for income.7

The former government had already taken positive steps towards securing the health of older people and signed the Association of South-East Asian Nations (ASEAN) Kuala Lumpur declaration on ageing in 2015 committing to adapt health and social care to meet the emerging challenge of the ageing population. HelpAge International, a donor focussed on advocacy for older people, has been building capacity within the Ministry of Health through public health workshops and funding to help set a national policy to tackle NCDs.

Myanmar has an immense challenge ahead and not least in its capacity to embrace change; to move away from top-down decision making and encourage inclusive discussion. As the country draws a new NCD Strategy for health, questions remain around how the policy can be translated into interventions. A focus on older people, who represent the most complex health needs in the country, would supply an innovative approach that will require integrated social and medical interventions to create a resilient, bottom-up system—a health-care system that is good for older people is a system that is good for all.8

We declare no competing interest.

References are included in the original comment.



  1. Paul says:

    Hi Jamie,
    Do appreciate your opinions on this - but will have to respectfully disagree. Universal Health Care would be ideal - and needed for all people in all countries. Instead we have a push towards Universal Health Coverage - and within that, we need to ensure vulnerable population groups get a look in. Otherwise, we will see widening gaps in who has vs who does not have. And while a number of govt documents talk to providing 'care' for older adults, actions to support this are slim on the ground. Agree whole-heartedly with the need for care for all - but also think some groups may need a bit more support as we move towards that.

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