An Assessment of Available Evidence on NCDs and their Risk Factors in Myanmar Report on Main Findings HelpAge International Myanmar, University of Public Health and University of Medicine-2 September 2016 Contents Page No Abbreviations: i Acknowledgements: v Summary: vi Introduction and background to report: 1 Purpose of the report: 2 Overview of the research methodology: 2 Synthesis of available evidence on prevalence and risk factors for NCDs in Myanmar identified by study: 6 - Summary of evidence on prevalence of NCDs in Myanmar: 7 - Summary of evidence on risk factors for NCDs in Myanmar: 7 - Summary of evidence on selected interventions to address NCDs or risk factor in Myanmar: 8 The scope of NCDs and risk factor research to date: 15 Importance of research on NCDs: 16 Limitations identified in research on NCDs and risk factors: 16 Assessment of gaps in research against a framework of evidence needs: 19 Recommendations for prioritisation of research and next steps: 27 Conclusions: 28 Limitations of review: 28 References: 28 Annexes: 30 Annex 1: Outline of literature review methodology 30 Annex 2: List of title identified in literature review 35 Annex 3: Aviliable evidence on morbidity and mortality due to NCDs and their risk factor in Myanmar 55 Annex 4: List of current, recent and planned research related to NCDs and mental health through National Ethics Review Committees 92 Annex 5: Qualitative report on perceptions of key stakeholders on the research gaps related to the burden and risk factors of Chronic Non-communicable Diseases (NCDs) in Myanmar 117 Annex 6: Key NCD policies and strategies underpinning evidence needs 189 Abbreviations ACDS Anterior Chamber Depths AL Axial Lengths ANC Antenatal care ARIs Acute Respiratory Infections ATS Amphetamine type stimulant BL Blindness BMI Body Mass Index CA Cancer CCs Corneal Curvatures CFR Case Fatality Rate CHD Coronary Heart Disease CI Confidence Interval CIN Cervical Intraepithelial Neoplasia CMR Crude Mortality Rate CO Corneal Opacity COPD Chronic Obstructive Pulmonary Disease CP Cerebral Palsy CRD Chronic Respiratory Diseases CRS Congenital Rubella Syndrome CVD Cardio-vascular disease CVS Cardiovascular system DALY Disability-Adjusted Life Year DG Director General DM Diabetes Mellitus DMFT/dmft Decayed, Missing, Filled Teeth I DMR Department of Medical Research DyDG Deputy Director General FGDs Focus Group Discussions GI Glycaemic Index GP General Practitioner HAI HelpAge International HDL High Density Lipoprotein HIV Human immune-deficiency virus HMIS Health Management Information System HR-HPV High risk type Human Papillomavirus IHD Ischemic Heart Disease IMR Infant Mortality Rate INGO International Non-government Organizations KII Key Informant Interviews LBM Lean Body Mass LDL Low Density Lipoprotein MCH Maternal and Child Health MDA Malondialdehyde MGH Mandalay General Hospital MMA Myanmar Medical Association MoHS Ministry of Health and Sports MSG Monosodium glutamate NCDs Non Communicable Diseases NGO Non-government Organizations NO Nuclear opalescence OOP Out of Pocket Payments PAC/S Primary angle-closure/suspects ii PAP Papanicolaou PEN Package of Essential Non-communicable Disease Interventions PHC Primary Health Care PXF Pseudoexfoliation QALY Quality-Adjusted Life Year QOL Quality of Life RE Refractive Error REE Resting Energy Expenditure RHC Rural Health Centre RTA Road Traffic Accidents SBP/DP Systolic Blood Pressure/ Diastolic Blood Pressure SDG Sustainable Development Goal STEPS STEPwise approach to surveillance SVI Severe Visual Impairment TBA Traditional Birth Attendant TT Trachomatous Trachiasis UHC Universal Health Coverage UM2 University of Medicine 2 U5MR Under 5 Mortality Rate UPH University of Public Health VCDs Vitreous Chamber Depths VI Visual Impairment WDF World Diabetes Fund WHO World Health Organisation WHR Waist to Hip Ratio WHS World Health Survey WTP Willingness to Pay iii YGH Yangon General Hospital YLL Years of Life Lost iv Acknowledgements This report synthesises work undertaken by a number of individuals, including staff at HelpAge International and partners, and consultants working on the qualitative research and literature review. We would like to thank all those who took part in the planning and conduct of the qualitative study and literature review and helped with their time and insights, in particular those involved in the interviews, and those who helped in identifying literature. This report is based on a qualitative study and literature review conducted by two consultants Nang Mo Hom and Fiona Campbell commissioned by HelpAge International. We express thanks to Fiona M. Campbell, Nang Mo Hom, Khin Thiri Maung, Dr. Soe Myint, Dr. Tej Ram Jat, Charlotte Aberdein, and Stephen Himley for their contribution at various stages of the assessment. Any mistakes or misinterpretations in the current report are the responsibility of the authors. The analysis is presented as a first step in an on-going process. It is hoped that the report will be used as a basis for further discussion and development of a priority research agenda on NCDs in Myanmar. v Summary HelpAge International Myanmar is working with the University of Public Health (UPH) and the University of Medicine 2 (UM2) in Myanmar, and Thammasat University of Public Health in Thailand, on a programme to support evidence-based NCD policy and improved NCD services in Myanmar. As part of the programme, HelpAge International and partners commissioned a review of the available evidence on the burden of NCDs and their associated risk factors in Myanmar. The review encompasses three complementary components: 1) a review of published literature 2000-2015 on NCDs and their risk factors; 2) qualitative interviews with key actors engaged in NCD research in Myanmar; and 3) additional reviews of Myanmar ethical committee inquiries and post- graduate research on NCDs in Myanmar. This report outlines the key findings from the three components including a synthesis of the key outcomes from the literature review and qualitative interviews, and an assessment of the gaps in the evidence against a framework of evidence needs. The review identifies limitations in the current research on NCDs in terms of quantity and quality. In particular, there is limited evidence on the prevalence of NCDs in Myanmar with only small numbers of studies available in any individual disease category. In addition the evidence on risk factors for NCDs in Myanmar is also limited, although the STEPs study is acknowledged as providing important insights into risk factors for NCDs over time. There are limited studies looking at interventions to address NCDs in the country, and in particular those targeted at the population level. An analysis of the available evidence against key information needs highlights gaps across the evidence base. A number of implications of the research gaps on policy development/policy makers and priority needs are identified. A series of next steps are proposed to take forward the process of addressing these gaps. vi Introduction and Background to the Report HelpAge International (HAI) Myanmar is working with the University of Public Health (UPH) and the University of Medicine 2 (UM2) in Myanmar, and Thammasat University of Public Health in Thailand in support of the programme “Strengthening public health capacity to respond to Myanmar’s disease transition”. The overall goal of the programme is to contribute to equitable and universal health care through improved support to evidence-based Non-Communicable Disease (NCD) policy and improved NCD health services. As part of the programme, HelpAge International and partners commissioned a review of available evidence on the burden of NCDs and their associated risk factors in Myanmar. The aim of the review was to identify gaps in the current evidence base on NCDs, and to suggest priority actions to address these gaps in support of the longer term design and development of programme and policy interventions to address NCDs in the country. Myanmar is identified as one of 23 high burden countries with respect to NCDS (Alwan et al, 2010). Data points to a significant burden of NCDs (WHO, 2014a) and to a potential increase in exposure to risk factors associated with key NCDs (Byfield and Moodie, 2013). The WHO 2nd Global Status report on NCDs (WHO, 2014b), estimated 59% of total deaths in Myanmar are due to NCDs, with a 24% probability of dying from one of the 4 main NCDs between the ages of 30 and 70 years. The report also highlights a growing concern with several risk factors for NCDs including hypertension and overweight/obesity. This concern has been strengthened by the results of the national survey of diabetes mellitus and risk factors for non-communicable diseases in Myanmar, published in November 2015, which found that over 90% of participants had at least one risk factor and almost 20% of the study population had 3-5 risk factors (MoHS, 2015). Data from the 2015 Global Burden of Disease report also points to an increase in premature death1 from causes attributable to NCDs over the period between 1990 and 2010. Four NCDs (stroke, Ischaemic Heart diseases, cirrhosis and congenital anomalies) are in the top 10 causes of Years of Life Lost (YLL) in 2010 (IHME, 2016). The challenge posed by NCDs has been recognised in-country for some time. A commitment to addressing the burden of NCDs and their risk factors has been outlined in the National Policy on NCD Prevention and Control (available in draft). This policy builds on a number of previous publications and links Myanmar’s actions to wider regional and global efforts (WHO, 2013; WHO, 2011). The new government, elected in November 2015, has further emphasised the need to tackle the burden of NCDs in the country in its Programme for Health Reforms (NHN, 2016). In the Programme, a reduction in the incidence of selected NCDs is identified as a key aspect of the vision 1 The term premature death/mortality is used here as per IHME definition where “YLL are the estimated number of years lost based on the highest life expectancy in the deceased’s age group”.