District health programmes and health-sector reform: case study in the Lao People's Democratic Republic

The Lao People's Democratic Republic (Lao PDR) is classified by the World Bank as a low-income country under stress. Development partners have sought to utilize effective aid instruments to help countries classified in this way achieve the Millennium Development Goals; these aid instruments include sector-wide approaches (SWAps) that support decentralized district health systems and seek to avoid fragmentation and duplication. In Asia and the Pacific, only Bangladesh, Papua New Guinea and the Solomon Islands have adopted SWAps. Since 1991, a comprehensive primary health care programme in the remote Sayaboury Province of Lao PDR has focused on strengthening district health management, improving access to health facilities and responding to the most common causes of mortality and morbidity among women and children. Between 1996 and 2003, health-facility utilization tripled, and the proportion of households that have access to a facility increased to 92% compared with only 61% nationally. By 2003, infant and child mortality rates were less than one-third of the national rates. The maternal mortality ratio decreased by 50% despite comprehensive emergency obstetric care not being available in most district hospitals. These trends were achieved with an investment of approximately 4 million US dollars over 12 years (equivalent to US 1.00 US dollars per person per year). However, this project did not overcome weaknesses in some national disease-control programmes, especially the expanded programme on immunization, that require strong central management. In Lao PDR, which is not yet committed to using SWAps, tools developed in Sayaboury could help other district health offices assume greater planning responsibilities in the recently decentralized system. Development partners should balance their support for centrally managed disease-specific programmes with assistance to horizontally integrated primary health care at the district level.     

H5N1 influenza viruses in Lao People's Democratic Republic

A prospective surveillance program for influenza viruses was established in Lao People's Democratic Republic (PDR) in July of 2005. We report isolation of H5N1 virus genetically distinct from H5N1 circulating in 2004, which indicates reintroduction of H5N1 into Lao PDR after its disappearance (i.e., no virologic or serologic evidence) for 2 years.     

Promoting safer sexual practices among expectant fathers in the Lao People's Democratic Republic

Men's decisions and behaviours influence the sexual, reproductive and maternal health of women and the health of their families, but men are rarely included in reproductive and maternal health care services. Men's attendance at antenatal care has the potential to prevent women from becoming infected with HIV during pregnancy and post-partum, when they are more vulnerable to infection and have a high risk of transmission to the infant. Greater involvement of men requires an understanding of social, cultural and organisational barriers in different contexts. In 2006, the Burnet Institute undertook fieldwork to inform a pilot project to encourage expectant fathers to attend antenatal care. A local Lao team conducted focus group discussions and interviews in Vientiane with expectant fathers, pregnant women, older women and health care providers. It was found that myths about the dangers of sex during pregnancy and women's decreased desire resulted in periods of sexual abstinence. Participants reported that unprotected extramarital sex was common but difficult for couples to discuss. Men lacked knowledge about sexually transmitted infections, including HIV. Men wanted information so they could better protect the health of their partners and babies during and after pregnancy, and reported being willing to attend antenatal care when invited. Our findings have useful implications for policy and implementation.     

Promoting safer sexual practices among expectant fathers in the Lao People's Democratic Republic

Men's decisions and behaviours influence the sexual, reproductive and maternal health of women and the health of their families, but men are rarely included in reproductive and maternal health care services. Men's attendance at antenatal care has the potential to prevent women from becoming infected with HIV during pregnancy and post-partum, when they are more vulnerable to infection and have a high risk of transmission to the infant. Greater involvement of men requires an understanding of social, cultural and organisational barriers in different contexts. In 2006, the Burnet Institute undertook fieldwork to inform a pilot project to encourage expectant fathers to attend antenatal care. A local Lao team conducted focus group discussions and interviews in Vientiane with expectant fathers, pregnant women, older women and health care providers. It was found that myths about the dangers of sex during pregnancy and women's decreased desire resulted in periods of sexual abstinence. Participants reported that unprotected extramarital sex was common but difficult for couples to discuss. Men lacked knowledge about sexually transmitted infections, including HIV. Men wanted information so they could better protect the health of their partners and babies during and after pregnancy, and reported being willing to attend antenatal care when invited. Our findings have useful implications for policy and implementation.     

Critical interactions between Global Fund-supported programmes and health systems: a case study in Lao People's Democratic Republic

In Lao PDR, investment by the Global Fund to Fight AIDS, Tuberculosis and Malaria has played an important role in scaling up the response to HIV and tuberculosis (TB). As part of a series of case studies on how Global Fund-supported programmes interact with national health systems, we assessed the nature and extent of integration of the Global Fund portfolios within the national HIV and TB programmes, the integration of the HIV and TB programmes within the general health system, and system-wide effects of Global Fund support in Lao PDR. The study relied on a literature review and 35 interviews with key stakeholders using the Systemic Rapid Assessment Toolkit and thematic analysis. In Lao PDR, the HIV and TB programmes remain vertical and mostly weakly integrated with the general health system. However, Global Fund investments have extended the network of facilities delivering care at local level, resulting in greater integration with primary care and improved access for patients, particularly for TB. For HIV, as the prevalence remains low, services primarily target high-risk groups in urban areas. Less integrated functions include procurement and drug supply, and monitoring and evaluation. HIV and TB programmes are only starting to coordinate with each other. Global Fund-supported activities are generally integrated within the national disease programmes, except for monitoring and evaluation. Synergies of Global Fund support with the health system include improved access to services, institutional strengthening and capacity building, improved family planning (with wider condom distribution through HIV/AIDS social marketing programmes), and the delivery of add-on interventions, such as vaccinations and health education, alongside Global Fund-supported interventions at community level. Unintended consequences concern the lack of alignment between national stated priorities (maternal and child health) and the strong focus of external partners, such as the Global Fund, on financing communicable disease programmes.     

Species composition of mosquitoes of Attapeu Province, Lao People's Democratic Republic

A list of mosquitoes collected from Lao People's Democratic Republic (Lao PDR) from May 2002 to August 2004 is presented. A total of 8,945 mosquitoes belonging to 14 genera and 57 species was collected. The genera recorded were Aedes, Anopheles, Armigeres, Coquillettidia, Culex, Diceromyia, Downsiomyia, Fredwardsius, Mansonia, Neomelaniconion, Ochlerotatus, Paraedes, Stegomyia, and Verrallina. Seventeen species are first reports for LAO PDR.     

Improving tuberculosis case detection rate with a lay informant questionnaire: an experience from the Lao People's Democratic Republic

PROBLEM: In many countries, the tuberculosis (TB) annual case detection rate is below the target of 70%. In the Lao People's Democratic Republic in 2005, it did not exceed 55% APPROACH: The DOTS strategy promotes passive case detection of TB. In order to increase the detection rate, we validated a questionnaire targeting lay informants at village level to notify patients with chronic cough and assessed the relevance for TB case-finding. A three-item questionnaire was sent through the district health departments to all villages in six districts in six provinces. The village headmen were asked to notify chronic cough patients. Answers were validated in a door-to-door survey (20 villages/district). In a sub-sample (four villages/district) all confirmed patients were screened for TB and paragonimiasis. LOCAL SETTING: Attapeu, Luang Namtha, Luang Prabang, Saravane, Savanakhet and Vientiane provinces in the Lao People's Democratic Republic. RELEVANT CHANGES: Lay informant questionnaires sent from district health offices to villages are cost-effective and foster interaction between the health services and remote and underserved communities. Although the correct detection of patients is highly dependent on direct respondents, a substantial number of new TB and paragonimiasis cases were consistently diagnosed in chronic cough patients. LESSONS LEARNED: Out of 456 questionnaires, 295 were returned (65%). Return rates were highly variable between districts (48-87%), questionnaires' sensitivity (56-98%), positive predictive value (34-88%) and correlation between number of notified and confirmed patients (r: 0.26-0.78). In sub-sampled villages (13,541 population) 19 (5.1%) TB and 26 (7.0%) paragonimiasis cases were detected in 374 chronic cough patients. This quick questionnaire approach proved motivating for district authorities and village key informants, although no incentives were provided. The highly operator-dependent approach yielded a consistent detection rate of TB and paragonimiasis cases. This approach brings health services and populations in need in close contact, which is particularly crucial in remote and underserved areas.     

Real world pharmacy: assessing the quality of private pharmacy practice in the Lao People's Democratic Republic

The private sector is a dominant actor in the provision of pharmaceuticals, particularly in developing countries. Private provision of drugs has been associated with risks regarding availability, affordability, rational use and drug quality. Ensuring an effective regulatory framework is therefore a major challenge for governments, yet the capacity of regulatory authorities is often outstripped by private sector growth. In the Lao People's Democratic Republic (Lao P.D.R.), a poor, landlocked country in South East Asia, the private provision of drugs has increased dramatically since the liberalisation of the economy in the late 1980s. This paper aims to describe the quality of the private pharmacy services in the Savannakhet province of Lao P.D.R. In order to do this, a monitoring instrument which serves to make the concept of Good Pharmacy Practice (GPP) operational was developed and applied to a sample of pharmacies. Service quality, as measured by three facility-specific indicators, showed a tendency to be lower in the most distant districts. Poor dispensing practices were manifest by a lack of information about drugs sold in 59% of cases, drugs not being labelled in 47% and different drugs being mixed in the same package in 26% of cases. The prices of four sample drugs were slightly higher in the remote districts. A 10-fold price difference for the same drug was recorded in one district. After reporting the findings, the paper discusses the possible influence of district and pharmacy variables on the quality of services, and goes on to discuss the price differences. It is concluded that further government interventions are needed in order to improve the quality of services and to focus regulatory action on a limited number of aspects, to ensure that drugs can be traced before trying to establish a comprehensive regulatory system.     

Initial stage of hospital contamination with methicillin-resistant Staphylococcus aureus in Lao People's Democratic Republic

Monitoring drug-resistant Staphylococcus aureus has been carried out in Lao People's Democratic Republic (Lao PDR) since 1993. No methicillin-resistant S. aureus (MRSA) strains were detected until 2001 when two isolates were found: 01LP40, which was coagulase type IV, enterotoxin non-productive, and SCCmec (staphylococcal chromosome cassette mec) type III; and 01LP63 from a different hospital, which was coagulase type II, enterotoxin productive, and the SCCmec belonged to a new type. In 2002 four MRSA isolates similar to the latter were detected, 02LP211, 02LP214, 02LP217 from the same hospital as 01LP63, and 02LP100 from a third hospital. This appears to be the initial stage of a MRSA epidemic in Lao PDR. Careful monitoring and intensive monitoring and precautions are recommended.     

The spread of drug abuse in rapidly urbanizing communities in Vientiane, Lao People's Democratic Republic

To determine the prevalence of drug abuse in city neighborhoods in a developing country undergoing rapid urbanization, we performed a household survey on the spread of drug abuse in Vientiane, Lao People's Democratic Republic. A total of 1497 households from 17 villages were selected by the stratified random sampling method from urban districts in the city of Vientiane. Participatory style research was employed to increase both the sensitivity of detection and the reliability of information gathered. Local key players shared in the participatory process in this study. We worked with national and city officers and community leaders, as well as with neighborhood leaders who had received previous training for this survey, and conducted household surveys using face-to-face interviews. We inquired about the spread of drug abuse by asking if the families interviewed recognized drug abuse problems in their community. To examine the extent of urbanization of individual villages, the urban index was calculated by principle component analysis from the following eight indicators: income, occupation, parents' educational histories, diffusion of telephones, ownership of livestock, diffusion of plumbing for running water and distance from the Vientiane city center to the village. Distance was calculated by the Geographic Information System. Among the 17 villages included in the study, the average percentage of recognition of drug abuse in the community was 63.2%. The relationship between recognition of cases of drug abuse in the community and the urban index showed a significant correlation, with a Spearman coefficient of 0.650 (p < 0.01). The high reliability of participatory style surveys is also discussed. In conclusion, city neighborhoods in a developing country undergoing rapid urbanization showed evidence of the spread of drug abuse, which was associated with the urban index. Participatory style research activity was recommended to help raise awareness of community participation in anti-drug-abuse activities.     

A cross-sectional community study of post-traumatic stress disorder and social support in Lao People's Democratic Republic

Objective

To estimate post-traumatic stress disorder (PTSD) symptoms in those injured and not injured by landmines or unexploded ordnance (UXO) in rural Lao People''s Democratic Republic and to determine whether the perception of social support was associated with PTSD symptom severity.

Methods

A community survey was conducted among 190 people injured by landmines or UXO and 380 age-, sex- and neighbourhood-matched non-injured individuals in the Sepone district of Savannakhet Province, the part of the Lao People''s Democratic Republic most heavily bombed during the Viet Nam War. Using the Harvard Trauma Questionnaire and the Medical Outcomes Study Social Support Survey, trained health-care workers conducted face-to-face interviews to assess PTSD symptoms and level of perceived social support. Multiple linear regression was performed to explore the association between social support and other factors and PTSD.

Findings

The prevalence of PTSD was higher among the injured (10%) than among the non-injured (4%), but the level of perceived social support was not significantly different between the two groups. A higher level of perceived social support was associated with milder symptoms of PTSD. Women, older people and those with a formal education were more often and more severely affected by PTSD.

Conclusion

The perception of strong social support might help to alleviate the symptoms of PTSD among people injured by landmines or UXO in rural parts of the Lao People''s Democratic Republic. Psychosocial interventions should be incorporated in assistance for the injured because they have more severe and longer-lasting symptoms of PTSD than the non-injured.     

Soil-transmitted helminth infections and risk factors in preschool children in southern rural Lao People's Democratic Republic

The current widespread school-based control of soil-transmitted helminth (STH) infections is also advocated for preschool children. The objective of this study was to assess infection with STHs as well as their determinants in preschool children (<60 months) in southern rural Lao People's Democratic Republic (Lao PDR). A cluster survey was carried out from October to December 2006 in three districts of Savannakhet Province. The prevalence of Ascaris lumbricoides, hookworm and Trichuris trichiura was 27.4% (95% CI 27.0-27.6%), 10.9% (95% CI 10.7-11.0%) and 10.9% (95% CI 10.7-11.1%), respectively. Of the children studied, 28.4% had a monoparasitic infection and 9.3% had a polyparasitic infection. Older children had a higher risk for hookworm infection [odds ratio (OR) = 1.75, 95% CI 1.03-3.01; P = 0.041] and multiple infections (OR = 1.81, 95% CI 1.01-3.20; P = 0.044). Low socioeconomic status was associated with A. lumbricoides (OR = 0.61, 95% CI 0.38-0.98; P = 0.043) and monoparasitic infections (OR = 0.62, 95% CI 0.38-0.99; P = 0.049). In Lao PDR, deworming of preschool children is warranted. Preventive measures should address important risk factors. Health education regarding personal hygiene, appropriate water management and the construction and proper use of latrines are additional essential elements.     

Vaccine introduction in the Democratic People's Republic of Korea

The feasibility of mass vaccination campaigns for Japanese encephalitis and Haemophilus influenzae type b infections was explored in the Democratic People's Republic of Korea using pilot vaccination studies. The experiences from these initial studies were then used to support larger vaccination campaigns in children at risk of these infections. We discuss the challenges and requirements for the inclusion of additional vaccines into the existing expanded program on immunization in the country.     

Paris on the Mekong: using the aid effectiveness agenda to support human resources for health in the Lao People's Democratic Republic

Background  

This study examines the potential of aid effectiveness to positively influence human resources for health in developing countries, based on research carried out in the Lao People's Democratic Republic (Lao PDR). Efforts to make aid more effective – as articulated in the 2005 Paris Declaration and recently reiterated in the 2008 Accra Agenda for Action – are becoming an increasingly prominent part of the development agenda. A common criticism, though, is that these discussions have limited impact at sector level. Human resources for health are characterized by a rich and complex network of interactions and influences – both across government and the donor community. This complexity provides a good prism through which to assess the potential of the aid effectiveness agenda to support health development and, conversely, possibilities to extend the impact of aid-effectiveness approaches to sector level.