Accessibility of Essential Drugs in Remote Areas of Laos Sivong SENGALOUNDETH, Bounnao PHACHOMPHONH, Sivixay XAYASAN Khamveuy THAMMAKHANH, Vongchanh PHANOUVONG Facilitated by Chanthakhath PAPHASSARANG & Lamphone SYHAKHANG Supervised and Assisted by Ass. Dr.Rolf Wahlstrom, Dr Bo Erickson, Ass. Dr.Cecilia Stålsby, Mrs Solveig Freudental, Prof. Goran Tomson Problem Statement: To improve the situation of low access to essential drugs for combatting common diseases in remote areas of Laos, revolving drug funds at the village level (VRDFs) have been established since the early 1990s, but poor functioning has recently been reported. Objectives: To assess the accessibility of essential drugs in remote areas in two provinces of Laos, and to explore the views on the performance and sustainability of VRDFs among the VRDF committees and community members. Design: Cross-sectional using quantitative and qualitative methods. Setting and Study Population: A total of 400 household heads were randomly selected from twenty villages in four districts of Khammouane and Champasak provinces. Twenty village health volunteers (VHVs), who administer the VRDFs, were interviewed, and six group discussions were conducted with community members and VRDF committees. Outcome Measures: Percent of selected tracer essential drugs. A checklist, including the existence of a VRDF committee, number of meetings, guidelines for VHVs, report system, monitoring, auditing, the use of benefits from drug sales, etc., was used to assess the performance of VRDFs. The perceptions of people regarding the issues of VRDF sustainability were also explored. Results: The availability of 10 selected essential drugs in the villages was low, with an average availability of 35% in Khammouane district and 38% in Champasak. Of those available, 41% and 37% were expired, and about 44% and 25% were incorrectly labeled, respectively. For three out of four villages, the availability of essential drugs was higher in a village where a private pharmacy existed than in villages with only a VRDF. No regular meetings were held among VRDF committee members. There was a lack of necessary guidelines and equipment for VHVs. The report and feedback system was not available. No regular monitoring, auditing, or supervision of VRDFs by the district level was performed. Only a few training sessions were provided to VHVs. Treatment seeking at VRDFs was low among the villagers, mainly due to the lack of essential drugs at VRDFs, the inadequate experience of VHVs, and the existence of other health providers. Conclusions: There is a need to improve the quality of VRDF services by establishing a comprehensive management system for VRDFs to strengthen the knowledge of VHVs, improve drug procurement and monitoring, and ensure availability and accessibility of good quality drugs for people living in remote areas, as well as to ensure sustainability of VRDFs.

Background and rationale: Since Alma Ata in 1978, “Health for All” goal not reached Widening gap between poor and rich, and between urban and remote areas. Access to Essential Drugs(ED) to combat common diseases in remote areas still a burden in Lao PDR. Few revolving drug fund (RDF) in some remote areas but generally unsustainable. Challenge to meet government policy to alleviate poverty in 2020: –A need to make ED accessible in remote areas, thus expending the RDF. Lack of information on how to improve access of ED in remote areas and how to make RDF functioning and sustainable.

General Objective: To assess the accessibility of E.D of the population in remote areas. To explore the performance and mechanism of sustainability of RDFs. To give information to the MoH for further planning and intervention.

Specific Objectives: To assess the availability of ED based on the existing ED list. To describe where people can get ED, what they know about drug use. To assess the perceived quality and price of ED. To assess and explore the performance and sustainability of the RDFs.

Methods Both quantitative and qualitative methods were used Study type: Cross-sectional Study sample: KMCHP –Sample size of households –Village Health Volunteers1010 –Pharmacies/drugsellers22 –Group discussions33 (5-10 pers.)

Data Collection 20 RDF drug kits were surveyed. 4 Private pharmacies (2 in CPS, 2 in KM) were surveyed. 400 hh were interviewed 6 group discussions were made: 2 male S, 2 female S, 2 RDF Committees. 2 RDF Committees were interviewed

Results 1. Availability of EDs KM % CPS % 110 ED avail3538 2Registered Expired & unknown4238 4correct packaging6475 5Correct label4425

2. Health seeking behaviour KM N=304 % CPS N=369 % 1Provincial hosp11 2District hosp106 3Health Centre Village RDF2334 5TM11 6Private pharmacy1123 7Private clinic101 8Unlicensed Practitioner 318

3. Reasons for not going to RDF KM N=233 % CPS N= 242 % 1Drug are not available at RDF 546 2No drugs as needed251 3Using private providers1813 4Not cured at RDF133 5Serious illness74 6No injection at RDF54 7Poor service at RDF42 8Drugs at RDF expensive43 9VHV not available at RDF 38

4. Prices of drugs in Kips 1 USD = Kip KMCPS 1Ferrous sulfate 60 (10-200) 60 (30-80) 2Ampicilline250 ( ) 181 ( ) 3Chloroquine178 (50-500) 175 ( ) 4Cotrimoxazol370 ( ) 257 ( ) 5Paracetamol 76 (25-250) 52 (35-100) 6ORS ( )

Main findings Low availability of ED at village level with high number of unregistered drugs, expired drugs and poor labeling drugs Drug prices in KM were more expensive than in CHS Inadequate comprehensive management system e.g.organization,poor drug supply system, qualified VHVs, no guidelines, poor incentive system for VHV and RDF committee 23% to 34% utilized village RDF in KM & CHS Performance and sustainability of RDFs are challenging issues

Recommendations Appropriate regulation and guideline of RDF management system should be developed. Regular monitoring from District Health Officer to RDF should be performed The functioning of RDF management committee should be improved. Training on RDF management and drug use should be provided to VHVs. An appropriate incentive system should be developed for VHVs and RDFs management committee. Indicators for regular monitoring system should be developed.