Aging in Myanmar

Abstract

This spotlight provides an overview of the situation of older persons in Myanmar, an understudied country of over-50-million population. Myanmar is of particular interest to researchers and policy makers, given its overall level of poverty and modestly rapid population aging. Research on older persons, while increasing in recent years, remains sparse. Empirical evidence indicates that Myanmar older persons are in relatively poorer health compared to those in neighboring countries. Many live in abject poverty and depend on their families for material support. Coresidence is very common and facilitates reciprocal exchanges across generations. Looking ahead, Myanmar confronts important challenges including demographic shifts that reduce availability of family support for older persons and increasing burden from chronic illnesses. Currently, government measures are essentially absent, although a law on aging was drafted and is in the process to become legislation.

Myanmar was considered one of the most secluded nations until a series of ongoing political and structural reforms were initiated in 2010 (The Lancet, 2012). It is the largest country in terms of area in mainland Southeast Asia with a total population of 51.5 million according to the 2014 census. On the west Myanmar borders on Andaman Sea, the Bay of Bengal, Bangladesh and India, on the north on China, and on the east on Laos and Thailand. Population aging and substantial increases in the numbers of older persons are taking place throughout Southeast Asia including Myanmar although at different paces. According to the 2015 United Nations Population Division estimates, Singapore is the most advanced in population aging with 17.9% of its population aged 60 and older followed closely by Thailand with 15.8%. At the other extreme is Laos with only 6% aged 60 and older. Myanmar is intermediate with 8.9% aged 60 and older (United Nations, Department of Economic and Social Affairs, Population Division, 2015). United Nations projections anticipate that the ranking with respect to population aging among Southeast Asian countries will remain the same through 2050, although in all countries substantial population aging will take place.

The situation of older persons in Myanmar is of particular interest given its level of poverty. Among the 10 ASEAN (Association of Southeast Asian Nations) countries, only Cambodia ranks below Myanmar as measured in terms of per capita GDP (Gross Domestic Product) adjusted for purchasing power parity (International Monetary Fund [IMF], 2015). It also has some of the worst health indicators and a very weak health sector (The Lancet, 2012). Mortality is quite high with life expectancy at birth for 2010–2015 estimated by the United Nations at only 65.6, 5 years below that for Southeast Asia overall (United Nations, Department of Economic and Social Affairs, Population Division, 2015). Moreover, for the period 2010–2015, life expectancy at age 60 is projected to be 16.7 years, almost 2 years less than the 18.4 for Southeast Asia as a whole and below the worldwide average for all countries designated as low income ( United Nations, Department of Economic and Social Affairs, Population Division, 2015).

Demographics of Aging

Population aging is driven mainly by declining fertility but is also affected by improving survival rates as well as international migration, features that have characterized the demographic transition taking place in Myanmar at least since the mid-20th century. Starting in the 1970s, United Nations estimates indicate that total fertility rates (TFR) declined steadily from around 6 births per woman over a lifetime to 2.25 births by 2010–2015, that is, just above the replacement level of 2.1 (see Table 1). Although age-specific survival rates have increased steadily since the middle of the 20th century as indicated by rising life expectancy at birth (e₀), this has actually moderated the extent of population aging rather than contributing to it. The reason for this is that given that the improvements in life expectancy at birth were from the low level of 36 up to the mid-60s, the increases were within a range that disproportionately reflects improved survival rates at infancy and young childhood rather than at older adulthood. Improvements above this level, however, will come disproportionately at older ages and thus contribute to population aging in the future. Life expectancy at age 60 has also improved steadily from 12.2 years in 1950–1955 to 16.7 by 2010–2015. It is more difficult to assess the impact on age structure of the net out-migration that has been taking place at least since the 1980s. Since migrants are typically in younger or middle adult ages, their absence may have slightly increased the share at older ages among the remaining population.

It is clear nevertheless that the net impact of these demographic changes resulted in increased aging of the Myanmar population. For example, the percentage of the population 60 and older rose from under 6% in the 1950s and 1960s to over 8% during the period of 2010–2015. The number of persons 60 and older will rise approximately 250% from 4.8 million in 2015 to about 12 million in 2050 (United Nations, Department of Economic and Social Affairs, Population Division, 2015). The potential support ratio (the number of persons 15–64 per one older person 65 and older) is projected to decline from 12.5 in 2015 to 5 in 2050. It is important to note that the proportions of Myanmar’s oldest old, that is, persons aged 80 and older, have been relatively small (<1%). Nevertheless they have doubled between 1970–1975 and 2010–2015. Moreover, the absolute number of the oldest old is projected to triple within the next 3.5 decades, reaching over 1.3 million by mid-century (United Nations, Department of Economic and Social Affairs, Population Division, 2015). As in all other countries in the region, Myanmar has more women than men among the older population, reflecting the lower female mortality rates that predominate throughout the life span. However, there is little change over time. According to Table 1, the share of women in the older population remains between 55% and 56% throughout the period between 1950 and 2015.

Summary of Research on Aging

Limited research on aging published in English language dates back at least to 1990 although overall it is relatively scarce. In 1990, the World Health Organization (WHO) sponsored the Collaborative Study on Social and Health Aspects of Aging in Five Southeast and East Asian countries that included Myanmar. The survey covered 1,221 respondents aged 60 and older in the three regions of Yangon, Mandalay, and Ayeyarwady. Results are summarized in the overall report (Andrews, 1993). In 2005, a report on the older-aged population was published based on the 1973 and 1983 censuses and household membership listings from several national surveys (Department of Population and United Nations Population Fund (UNFPA), 2005). In 2012, a second report on the elderly population was published (Department of Population and UNFPA, 2012). In the absence of any survey targeting Myanmar’s older population, the analysis provided in the 2012 report is based on the 1973 and 1983 censuses and household listings from the 1991 Population Changes and Fertility Survey and the 2001 and 2007 Fertility and Reproductive Health Surveys. This report concluded that aging is not as dramatic in Myanmar as in other Asian countries but nevertheless is still crucial to prepare now for the challenges and opportunities in response to population ageing.

In the last few years, more extensive research on aging in Myanmar has occurred, thanks in part to the efforts of HelpAge International which sponsored two major representative surveys focused on older persons. The first was the 2012 Survey of Older Persons in Myanmar and is commonly referred to as the Myanmar Aging Survey or MAS. It was based on a nationally representative sample of 4,080 persons aged 60 and older except for the exclusion of Kachin state for security reasons (Knodel, 2014a). The aim was to provide a comprehensive picture of the situation of older persons in the country including their social characteristics, economic activity and income, material well-being, family support and intergenerational exchanges, and health. The second survey was the 2016 Survey on Accessing Healthcare by the Older Population, Myanmar (Rajan & Sreerupa, 2016). It targeted 1,000 elderly respondents in one township in each of five major geographic areas of the country. The content focused on health status, risk factors, health seeking behavior, and access and utilization of health services among older persons.

Several journal articles focus on aging in Myanmar or on comparative analyses that include Myanmar (Knodel, 2014b; Knodel & Nguyen, 2015; Knodel & Pothisiri, 2015; Moe, Tha, Naing, & Htike, 2012; Teerawichitchainan & Knodel, 2015a; Teerawichitchainan & Knodel, 2016; Teerawichitchainan, Knodel, & Pothisiri, 2015; Teerawichitchainan, Pothisiri, & Giang, 2015). These articles address a broad range of topics in social gerontology including health disparities and health seeking behaviors among older adults, how families provide support for older persons in terms of living arrangements and long-term care, how family support impacts upon the well-being of older adults, and reciprocal intergenerational exchanges such as caring for grandchildren by grandparents. In addition, recent medical research provides some emphasis on noncommunicable diseases (NCD) (P. Morrison, personal communication, August 27, 2016). Although not specifically focusing on older persons, such research is a relevant development given that older persons are more prone to NCD than other age groups.

Secondary Data Sets

Like most middle- and low-income Asian countries, Myanmar has only one nationally representative survey of older persons, namely the 2012 MAS (Teerawichitchainan & Knodel, 2015b). However, the 2016 Survey on Accessing Healthcare by the Older Population, Myanmar provides detailed information on older persons’ health (Rajan & Sreerupa, 2016).

Important data sources not specifically interviewing older persons are the censuses. The 1973 and 1983 censuses have been used by researchers as the basis for information on population aging (Department of Population and UNFPA, 2005, 2012). Myanmar’s most recent population census enumerated in 2014 serves as the basis for an upcoming report focused on population aging. In addition to census data, the first and second Integrated Household Living Conditions Assessment Surveys (IHLCA) (2004–2005 and 2009–2010), the 1991 Population Changes and Fertility Survey, and the 1997, 2001, and 2007 Fertility and Reproductive Health Surveys conducted by the Department of Population are also useful for analyses related to older persons. This is because all of these surveys have household-level data files with at least basic information of all household members including older-aged members.

Access to the above-mentioned secondary data sets is limited but available upon request to the organizations that conducted/sponsored the surveys.

Key Research Institutions

At present, there are only limited numbers of researchers specialized on aging research in Myanmar. Key players are from universities in Myanmar (e.g., the University of Public Health Yangon, Yangon Institute of Economics particularly its Demography Department), government agencies (e.g., the Department of Population, Ministry of Immigration and Population; Department of Social Welfare, Ministry of Social Welfare, Relief and Resettlement; Ministry of Health), and international organizations (e.g., UNFPA, WHO, HelpAge International). A small, yet growing, group of researchers based outside Myanmar with expertise on the social gerontology of the Myanmar population exists.

Main Research Issues

Material Well-being and Income Security

Since a series of reforms was introduced in 2010, Myanmar’s economy has been growing swiftly with a GDP growth rate of 7.2% in 2015 and is estimated to grow fastest in Southeast Asia in the next few years (Asian Development Bank [ABD], 2016). Despite significant economic development, 70% of the total population still lives in rural areas and poverty remains widespread (Department of Population, 2015). This is evident in the 2012 MAS, which shows that older people in Myanmar are quite poor in terms of material well-being. A large proportion of older adults live in houses made with nonpermanent materials (e.g., bamboo). A third (34%) lack access to electricity and over half (56%) lack running water. These situations are particularly common in rural areas where 44% of older persons have no electricity and 63% have no running water. On average, the households of older people have few possessions even when including items that belong to other household members. Only 40% of Myanmar elders live in households with a television, while under one tenth are in households with a phone in 2012. The 2014 census reveals improvements in material well-being of the overall population. For example, half of all households have televisions, whereas one third have a mobile phone. Improved material well-being is likely indicative of improved standards of living. Increased access to phone, for instance, can be particularly crucial for older persons in maintaining social contact with adult children who migrate and for communicating when urgent matters arise.

According to the MAS, a majority of Myanmar older adults, specifically those in the bottom 60% of wealth distribution, live in abject poverty as measured by household possessions and quality of housing (Teerawichitchainan & Knodel, 2015a). The bottom two quintiles live in particularly materially deprived households, and the middle (third) quintile does not witness much improved material conditions either. It is only among the top two quintiles that household possessions and housing amenities typical in middle-income Southeast Asian countries become more evident.

Older people in Myanmar typically live in low-income households. The analysis of MAS shows that almost 10% report that their household monthly income is no more than 25,000 kyat, or less than US$1 per day and just over 60% are in households with income no more than US$3 per day. Only 55% feel that their income is adequate to meet their daily needs on a regular basis. Less than one in five older persons have savings in the form of money or gold.

Work is one potential source of material support for older persons. Most older men and women in Myanmar (94%) have been economically active during their lifetime. Of these, 60% were primarily engaged in agriculture, while 10% were engaged in nonagricultural labor and 11% formal-sector jobs. Interestingly, compared to neighboring Thailand, Myanmar older adults are considerably less likely to have worked during the preceding year (30% vs. 43%) (Knodel, 2014b). The difference may likely reflect poorer health among older persons in Myanmar compared to Thailand where the government provides universal health insurance and the economy is more advanced (Sasat & Bowers, 2013).

In Myanmar, adult children are the most common source of material support for older persons. Over 80% of older persons report receiving some type of material support from children according to the MAS. Moreover, 59% report children as their main source of income, while only 24% report work (by self or spouse). As income from work declines with advancing age, support from children becomes increasingly crucial.

Pensions are uncommon as a source of income for Myanmar’s older-aged population. Overall, 8% report any income from a pension and only 3% indicate a pension as their main source of income. In addition, pensions are largely limited to older persons in urban areas. Only 3% of older adults in rural areas report any pension income and only 1% indicate it as their main source. Almost no one surveyed in the MAS report receiving welfare support from government or nongovernmental agencies.

In response to old-age income insecurity and limited social protection mechanisms presently available in Myanmar, the Department of Social Welfare in collaboration with HelpAge International started in 2015 piloting an old-age social pension scheme in two townships in Kachin State and Ayeyarwady Region. Under this pilot scheme, older persons receive a cash transfer of 10,000 Kyat (US$8) paid on a quarterly basis for a 12-month period. However, no program evaluation or findings have been released at the time of this writing. It is important to note that there was a scheme funded by government leaders to periodically provide one-off cash transfers to Myanmar centenarians. More recently, the scheme has been expanded to include elders aged 90 and older and funded by the government.

Health

After years of political turmoil, economic hardship, and poor living conditions, many older persons in Myanmar appear to bear grave old-age health outcomes. Comparison with the neighboring middle-income country, Thailand makes this striking. Only a third of older persons in the MAS reported that their health was good or very good compared to 43% of their Thai counterparts (Knodel, 2014a; Knodel, Teerawichitchainan, Prachuabmoh, & Pothisiri, 2015). The percent reporting that their health is poor or very poor among Myanmar older adults increases steadily as age advances rising from 17% among those aged 60–64 to 31% among persons 80 and older. Furthermore, 28% of older persons in Myanmar reported problems with eyesight, compared to 18% in Thailand. Regarding physical functioning, Myanmar older persons scored worse on every functional limitation and ability to carry on activities of daily living (ADL) than Thai older adults. Physical difficulties increase sharply with age in Myanmar. Compared to those in their 60s, persons in their 70s reported 2.5 times as many functional limitations on average and four times as many ADL difficulties. Almost 90% of those aged 80 and older reported at least one difficulty in physical functioning and on average they experienced nearly six specific difficulties. The trends and patterns of physical difficulties in Myanmar imply that acute needs for long-term care (LTC) will increase in the future in Myanmar as the numbers of older adults at advanced ages continue to rapidly increase.

Evidence further indicates gender and economic disparities in health among older persons in Myanmar. Older women are more likely than their male counterparts to report problems with various aspects of health. According to the MAS, almost a quarter of older women compared to 19% of men reported their health as poor or very poor. Likewise, 57% of women compared to 40% of men reported at least one functional limitation while 19% of women versus 13% of men reported they had at least one ADL difficulty. Research also indicates that older persons who are economically better off reported better self-assessed health, less sensory impairment, and lower functional limitations than economically disadvantaged counterparts (Teerawichitchainan & Knodel, 2015a). Noteworthy is that differences in health between older persons in the bottom and second wealth quintiles are clearly evident, which suggests that relative economic inequality matters even among those who are very poor.

Myanmar is facing the emerging challenges of a growing geriatric population (WHO, 2014). The country is experiencing the double burden of communicable and noncommunicable diseases. Deaths caused by stroke, heart disease, diabetes, and kidney disease doubled during 1990–2010. Approximately 40% of all recent deaths in Myanmar are due to NCD (WHO, 2011). A recent study shows that the prevalence of hypertension was 34% among the sampled adult population in Yangon Division, with 32% of the hypertensive respondents currently taking medication and only 11% having their hypertension controlled (Zaw, Latt, Aung, Thwin, & Myint, 2011). Given chronic nature of NCD, the rise in proportion and absolute number of older persons who are at risk of chronic illnesses and LTC needs can potentially impose heavy burden on Myanmar’s health system and the families who care for them.

Myanmar’s health system has been severely underfunded (Grundy, Annear, Ahmed, & Biggs, 2014). According to the World Bank’s World Development Indicators database, the Myanmar government spends 2.3% of its GDP on health in 2014, compared to 6.5% among countries in the East Asia-Pacific region and 5.7% among other low-income countries (World Bank, 2016). This equates to a health expenditure of 103 international dollars per capita. Shortages of health personnel and infrastructure are also evident. There are only 100 nurses/midwives (2014) and 60 hospital beds (2006) per 100,000 population. The share of payments for health services that are out-of-pocket in Myanmar is considered relatively high, accounting for 51% of the total health care expenditure compared with 25% in the East Asia and Pacific region and 37% among low-income countries. Although physician service and equipment at public health facilities are theoretically free-of-charge, depending on location and treatment, patients are sometimes expected to give gifts for medical professionals who treat them and to pay for medicines and supplies used in treating them (Rajan & Sreerupa, 2016; Shobert, 2013). In addition to high level of private financing of health care, other barriers include reduced accessibility due to geographic and infrastructure factors. The lack of paved main roads in Myanmar and security issues in some regions further hinders access to health services (Perlez, 2014).

The country’s strong economic growth in recent years is contributing to poverty reduction and improvement in livelihoods and living standards in certain segments of the population (World Bank Myanmar, 2016). This change has put inequality into a sharp relief, as evident in research findings on unmet needs in LTC (Teerawichitchainan & Knodel, 2016). Myanmar older persons from the poorest households are more likely than others to experience unmet need for care and even when they receive care, they tend to experience inadequate care. Gaps in LTC decline in an almost linear gradient with increased household wealth.

Extensive reforms since 2010 have led the Myanmar government to increase public spending on health. At present, there is a strong government commitment in allocating more resources to rural primary health care, infectious disease control, and maternal and child health (WHO, 2014). Myanmar’s 2014–2018 health strategy addresses the importance of controlling the growth of NCD burden but does not specifically target health care for older persons or long-term care. Although there are a few health policies focusing on the older-aged population, few resources and limited capacity have curtailed their success (Han, 2012). For example, the Healthy Aging Project initiated by the Ministry of Health since the early 1990s covered 161 townships or only about half of 330 townships nationwide by 2014 (Tin, 2014).

Currently, LTC policies do not exist in Myanmar. Nevertheless, the government is keen to invest in social protection programs directed to the most vulnerable in society, including frail older persons in need of LTC. The National Social Protection Strategic Plan launched in 2014 by the Ministry of Social Welfare, Relief and Resettlement is particularly promising. It incorporates two programs directed to older adults involving establishing social pensions and promoting Older Person Self-Help Groups (OPSHGs). The latter program is relevant to community-based care. It supports OPSHGs at the village level with key objectives to meet economic and health needs of older persons. Community-based care for older persons is to be delivered by trained volunteers recruited from OPSHGs. These programs are not yet effective nationwide. At present, the OPSHG program remains in the pilot stage, covering less than 1% of the population aged 60 and older (Ministry of Social Welfare, Relief and Resettlement, 2015).

Intergenerational Support

Older people in Myanmar are generally surrounded by family at home. The MAS provides extensive information about exchanges of material, emotional and social support as well as services between generations within the same family. Average household size of persons 60 and older approaches five and 86% live in households with two or more generations including 77% that coreside with at least one of their own children. Such multigenerational arrangements facilitate intergenerational exchanges. Among those that live with a married child, coresidence with a married daughter is more common than with a married son. This reflects a flexible bilateral kinship system but with a tendency of grown daughters to play more prominent roles within the family than sons. Given the previous slow pace of economic development in Myanmar associated with its relative seclusion, internal labor migration in the past has been modest. Thus many older-aged parents not only have an adult child coresiding with them but also living nearby further facilitating intergenerational exchanges of material support and personal services. Normative support for filial obligations to aging parents is widespread. The vast majority of older persons believe that children should provide financial support and personal care to their parents in old age. In practice, this appears to be the situation. Two thirds of adult children of older persons provided parents with at least some material support and just over one fourth provided the equivalent of at least US$60 during the year prior to the MAS. From the parents’ perspective, this translates into over 90% having received material support from one or more of their children including almost two-thirds that received at least US$60 or more.

Adult children also provide important services besides material support to their older-aged parents, particularly parents who are frail or ill. Among older persons who receive assistance with daily living activities, daughters provided main care for about half overall and for about 60% of those who were no longer currently married.

Older-aged parents only infrequently give financial support to their children on a regular basis. Just 20% that lived with a child gave or loaned money to the child during the past year and only 6% who had one or more non-coresident children provided money to at least one of them. However, over half of aging parents that live with children report that they or their spouse contribute to household economic support even if not in the form of cash (e.g., participating in family productive activities).

Moreover, aging parents that live with children typically provide important services. These include over half that help with housework and over a third with house maintenance. Another important service that parents provide is through grandchild care thus facilitating the ability of their adult children to work outside the house. Over one third of older persons that have grandchildren provide care for at least one including grandchildren whose parents have migrated elsewhere to work. Almost three-fourths of older persons who currently provide grandchild care consider it to be mainly enjoyable and only 5% consider it mostly burdensome with the remainder indicating it is both enjoyable and burdensome.

Conclusion

Population aging and its ramifications are among several pressing issues currently facing poverty-stricken Myanmar. After decades of political turmoil and social upheavals, Myanmar is rebuilding peace and nationhood. The country is vulnerable to natural disasters, including hurricanes, floods, and even earthquakes which tend to dampen economic and social development. Nevertheless, economic growth has accelerated since the recent political and structural transition. Myanmar confronts important challenges in reconciling ethnic tensions, balancing economic growth, eradicating poverty, ensuring social equity and justice, and providing social protection for its population, including older persons. Rapid economic development, increased urbanization and migration, and shrinking family size may result in the erosion of family support for older persons and thus, adverse impacts on their quality of life.

A review of the current situation reveals that there has been little social welfare provision for Myanmar’s older-aged population leaving individuals and families on their own to fend for the health and well-being of older persons. However, Myanmar adopted international guidelines toward the social and economic protection of the older population in its Action Plan on Aging in 2014 under the former government of Myanmar (Williamson, 2015). The plan advocates establishing the National Steering Committee on Aging (comprising most senior representatives from line ministries and led by the Minister for Social Welfare, Relief and Resettlement) and the National Advisory Committee on Aging (comprising representatives from line ministries, international agencies, United Nations agencies and local nongovernment organizations). A law on older people was drafted and has been approved in August 2016 by the recently elected Myanmar Parliament’s upper house. Under the new government, the Ministry for Social Welfare, Relief and Resettlement is currently seeking consultations regarding Myanmar’s national policy on aging which is expected to be completed in early 2017. A revised action plan on aging is likely to follow. These institutions will lay the groundwork for implementing policies and programs for older persons in the future.

Looking ahead, key questions for Myanmar include whether the country will get old before getting affluent enough to provide adequate social protection for its older-aged population and what are appropriate and sustainable roles of the state, communities, and families in addressing the needs of older persons. At present, poverty and inequality are pervasive in Myanmar as evidenced in disparities in material well-being, health, and quality of life among older persons. While intergenerational support remains strong and significant for the well-being of family members including older persons, structural changes may impose significant challenges in maintaining the traditional forms of old-age support. For the immediate future, Myanmar needs a holistic national strategy addressing all aspects of aging to ensure effective implementation and coordination of programs for older persons. To guide the national strategy, there is a need to promote aging research in Myanmar from biomedical, economic, and socio-behavioral perspectives, to encourage empirical assessment of the situation of older persons, and to utilize empirical evidence to inform policy formulation and program designs for older populations.

References

Author notes