LAOS COUNTRY REPORT UNICEF
I. Background
The Women's Development Program (WD) was been carried out by the Lao Women's Union with support from UNICEF for the past five years, 1992 to 1996. The program was established in five provinces (Houaphan, Xiengkhouang, Khammouane, Savannakhet and Champassak), including seventeen districts and 391 villages.
The objectives of the WD were:
1. to build women's capacity at different levels in planning and management, and to enhance women's self-image and confidence by providing them with opportunities to participate in decision-making processes, and
2. to improve the health and nutrition status of rural women and their children through health education and improved access to basic health education service.
In 1995, village revolving drug funds (RDF) were established as a part of the Women's Development Program. The RDF component was seen as a key entry point for the improvement of community health care, information dissemination and practice in basic household hygiene, sanitation, maternal and child care and access to essential drugs at village levels on a cost recovery basis.
II. Overall Goals and Objectives of the Revolving Drug Fund
・ Contribute to the reduction of under-five mortality and morbidity due to diarrhea, acute respiratory infections, and other common diseases
・ Reduce inappropriate use of drugs in the treatment of diseases causing diarrhea and acute respiratory inflections and other common diseases in children under five years of age
・ Contribute to strengthening the health system through development of vertical and horizontal linkages between local communities, public and private social sector staff (Health, Education, Information and Culture, Lao Women's Union etc.) to reduce health problems among women and children
Specific objectives:
・ Continue to strengthen and expand the operation of community drug revolving fund systems in five provinces currently involved in the project
・ Promote malaria prevention at community levels through the use of impregnated mosquito nets and mosbar insecticide soap
・ Provide access to essential drugs at less than market price
・ Improve correct dosage and use of basic drugs
・ Increase community participation in improving children's, women's and family health
III. Activities Completed
1. Consolidated village RDFs with community health monitoring and evaluation systems
2. Conducted a mid-term review of the implementation of village RDF systems at central, province and district levels
3. Conducted a second workshop for sixty-eight trainers in facilitation and workshop design based on the village health workers training curriculum
4. Conducted a second round of training (update) for 135 village RDF health workers:
〜 treatment and prevention of malaria, diarrhea, acute respiratory infections
〜 community/household hygiene and sanitation
〜 nutrition (breast-feeding, iodized salt, vitamin A)
〜 safe birth practices
〜 communication skills and use of health education flipcharts
〜 dissemination of eleven basic health messages based on Facts for Life
5. Collected household and community health data from 391 villages, processed and analyzed data; based on data, identified priority problems and made plans for action at the village level
6. Trained and established self-monitoring and planning system to be carried out by villagers
7. Developed, pre-tested, revised, printed 3000 copies and distributed 1500 copies of RDF manual
8. Provided new sets of essential drugs for 135 new and 256 old revolving funds
9. Provided cupboards and supplies for 135 villages in expanded RDF project in districts and villages
10. Provided five computer sets for each provincial RDF operation unit, sixteen motorcycles and eighty bicycles for monitoring and supervision teams and village health workers
11. Trained 270 VHWs and 135 village heads in RDF operations, simple diagnosis and rational use of essential drugs in villages where the project was newly expanded
12. Provided one tuk-tuk for Khammoaune Lao Women's Union and one Toyota 4 WD Hilux pickup for Houaphan Lao Women's Union to support drug replenishment, monitoring and supervision
13. Established system of replenishing drugs in each of five provinces:
〜 At village level, on the 1st to the 5th of the month, village health workers report drug amounts sold and money received to the head of the RDF district; money is turned over to the head of the RDF district
〜 At district level, on the 6th to 10th of the month, the RDF district head summarizes all village reports (the amount of drugs sold and money received) and sends the summary to the RDF provincial head
〜 At province level, on the 11th to 15th of the month, the RDF provincial head summarizes the reports from the districts and the amount of drugs sold and money received and deposits the money in the provincial bank
〜 On the 16th to the 20th of the month (once every three or four months), the RDF provincial head orders/purchases drugs from pharmaceutical factory in Vientiane Munipality. At the same time s/he deposits the money to the factory account.
〜 On the 21st to the 25th, the pharmaceutical factory sends drugs to the province
〜 At the time each report is submitted at the above levels, the new drugs are received and taken to the district or village to replenish the RDFs
IV. Achievements
By the end of the 1997, village level revolving drug funds were operating in 391 villages in seventeen districts of five provinces. Village leaders and community members report that the current village RDF system is effective because it provides villagers with timely and simple treatment of common diseases and quality basic medicines that are low cost. People no longer waste money and time traveling outside the village for necessary medicine. The system has provided people in the community access to essential drugs on a cost recovery basis as well as information on their use.
V. Improvement of Community Hygiene
Preventive health: The project did not just emphasize treatment. The project stressed preventive health by increasing household knowledge and practice of good sanitation, hygiene, and nutrition, and there were positive changes among household members. For example, people of the village who follow the advice of village health workers sleep under mosquito nets, drink boiled water, use clean water and latrines, eat nutritious food, use iodized salt, and use the correct techniques for breast-feeding starting immediately after birth. These interventions contributed to the overall improved health of women, children, and families in villages where these activities were supported by Lao Women's Union and UNICEF.
Staff capacity building: The project also emphasized capacity building for various levels of health staff, Lao Women's Union staff, and village health workers (VHWs). In each province, a team of VHW educators was trained.
The Province and district health staffs are now capable of working as teams for project planning, management monitoring and supervision. VHWs also gained skills through the project's daily operation. Most VHWs are able to use the RDF manual and can make simple diagnosis, prescribe essential drugs, and practice correct case management. Based on reports, the number of serious cases needing treatment in hospital has declined. This is attributed to the fact that early detection and treatment is now available. The Women's Development Program, in its operations, closely coordinates with the health sector, since all technical support and management procedures for drug selection stages, reporting and monitoring systems, utilization and replenishment are under the provincial and district health services guided by the Ministry of Health. Hence, UNICEF assisted the government to develop an operational framework for RDF implementation in the target provinces. Based on village health workers' records of disease patterns and occurrences, there seems to be a decline in malaria, diarrhea, and ARI cases in many communities. Data on diseases patterns will continue to be collected resulting in a data base for study over a longer period.
VI. Project Constraints and Solutions
In the initial phase, there was inadequate understanding of the concepts of RDF operation by both province and district health and LWU staff. This was because of lack of experience and knowledge about RDF operations. The problems are now resolved as the government staff has gained experience in RDF operation.
Lack of vehicles for transport
There is a shortage of vehicles for supervisory teams, especially for district teams which need to make regular visits to the villages. To resolve this problem, the project made provisions (car, tuk-tuk, motorcycles and bicycles) to province and district RDF teams to facilitate travel to the villages. However, there is still inadequate transportation to cover now RDF areas.
Shortage of personnel for project management and supervision
Shortages of Lao Women's Union and provincial and district health staff for management and supervision is a major constraint. It can only be resolved by ensuring that the village RDF committees are strong and understand the work of self-monitoring and supervision. This would reduce the need for additional province and district staff.
Inadequate government budget for operational costs
The government budget is very small and services do not have adequate funds to sustain operational costs, e.g. travel money for government staff, fuel for monitoring and supervision, stationery and supplies for reports etc. The project is providing partial support for monitoring costs to ensure effective project supervision. This is needed during the pilot phase of the project in order to build up government experience in RDF operation.
Integration into policy framework of government
There are no Bamako Initiative-type programs in the Lao RDF. Community-based RDF operations are still relatively new. Besides this project, there are some similar pilot projects sponsored by NGOs, and these experiences are still being studied carefully by the government. The government is at present conducting studies on health care cost recovery and is developing a policy framework on revolving drug funds within the health system. Once this policy framework is established, the community-based RDF systems will be officially integrated into the government health system and may be taken to scale as appropriate. UNICEF used funds from the Nippon Foundation to adapt the village RDF model developed by JICA as the base for the Women's Development Project as a pilot project. UNICEF has provided technical and managerial support to the program and has shared this experience with government partners. The Nippon Foundation sponsored its consultants from Tokyo University, to visit Vientiane where they provided suggestions to UNICEF for how to improve the RDFs.
VII. Monitoring and Supervision
The project was closely monitored by the government and by UNICEF field staff. The government staff visited the villages regularly to provide guidance and to ensure that the RDF operational system is functioning well. UNICEF technical staff, central LWU staff and MOH staff have also carried out independent field monitoring to all provinces and districts and to nearly all villages. In addition various monitoring instruments and self-monitoring is carried out from district to villages to ensure that there is adequate reporting and monitoring at these levels of the project and also by the communities themselves.
VIII. Conclusion
The project has completed its pilot phase. Based on feedback from assessment, the project has been successful and has generated support and enthusiasm from every level. More importantly, the project has responded to the needs of people at the community level and has decreased health problems for children, women, and communities.
It has restored some degree of confidence among people towards the health system. The project has built the capacity of the health staff and strengthened the health system so that health cost recovery strategies can be implemented to sustain health services in the future.
IX. Future Plans
At the end of the five year program, five provinces, seventeen districts and 391 villages were served by revolving drug funds. Support for RDFs will continue during the new program cycle (1998-2002) in cooperation with the government of Laos. UNICEF RDFs will be extended to the three provinces (Sekong, Saravanh and Attapeu) in approximately nine districts including 330 new project sites.
Thank you, Nippon Foundation, for supporting revolving drug funds in Laos's villages.
