Do Village Revolving Funds Improve Access and Rational Use of Drugs in Laos?

Background 1 VILLAGE REVOLVING FUNDS (VRDF) are small stocks of essential medicines placed at village level and managed by Village Health Volunteers (VHV). The Government of Laos is strongly encouraging VRDF. National coverage by these funds is part of the National Poverty Eradication Plan.

Background 2 Currently 3,629 VRDF have been initiated. The plan is to increase this number to 5,290 by 2005 and achieve full coverage by 2020. The national program has defined - A list of 26 items (essential medicines and medical supplies) to be available at village level. - A training program for VHV including a “medical” module and a management module. - Supervision schedule by district and provincial staff.

Study objective To date, ongoing VRDF have not been evaluated. Financial data are sometimes available but access and rational use have received less scrutiny. OBJECTIVE To assess the effect of three methods of implementing VRDF on access to drugs and Rational Use of Drugs (RUD) for 3 common conditions (diarrhea, malaria and acute respiratory infections [ARI]) in remote areas of Laos.

Study questions What is the status of access and RUD in remote areas in the absence of VRDF? Do VRDF change/improve access and RUD? How can VHV training and supervision influence access and RUD?

Methods 1 Controlled intervention study with pre-test and post-test design without randomization. 60 villages with no existing VRDF were selected in 3 districts of Luang Prabang Province (Chomphet, Viengkham, Pakbeng). A baseline survey was conducted in 10 households in each village (600 households in total): access and RUD for 3 tracer conditions (malaria, diarrhea, ARI) were assessed.

Methods 2 VRDF were implemented in all 60 villages. A post-implementation survey was conducted 1 year later in the same households to assess again access and RUD for the same tracer conditions. Note: data entry and analysis is still underway for the post-test survey. This has been delayed in some areas where villages can only be reached by boat and therefore impossible to visit at the end of dry season

Methods 3 IMPLEMENTATION OF VRDF National program TRAINING SUPERVISION District 1 National program District 2 Nat’l program + add sessions on the 3 tracer conditions by provincial staff District 3 Intensified

Results 1 Baseline household survey VILLAGE N= 60 Average size: 346 inhabitants 44% could not be accessed in difficult wheather conditions (rainy season or end of dry season) Average transport time to private pharmacy or health center: 4h Main transport method: boat, walk or combination of both. The villages are remote and difficult to access.

Results 2 Baseline household survey TRACER CONDITIONS (N = 602) Condition n(%) Malaria 452 (75.1%) Diarrhea 253 (42.0%) ARI 233 (38.7%)

Treatment providers for the 3 tracer conditions. Malaria (n=449) Diarrhea (n=252) ARI (n=230) Public 91 (20.2%) 37 (14.7%) 35 (15.2%) Private 358 (79.8%) 215 (85.3%) 195 (84.5%)

Results 3 Baseline household survey TREATMENT PROVIDER People use more private services In remote areas, Itinerant Drug Sellers become the main providers of drugs. WHO ARE THEY? Itinerant sellers traveling to Laos from China or Vietnam, or retired health workers (eg. from army). This result is consistent with the Lao National Health survey 2000.

Results 4 Baseline household survey COST OF DRUGS The cost of malaria and diarrhea treatments is significantly higher in the public system than in the private system. This is also true for ARI treatment although the result is not statistically significant. The quality of privately sold drugs is questionable. Median cost (Range) Wilcoxon P value Public Private Malaria 6.5 (0.5-84.0) 2.6 (0.2-65.0) <0.0001 Diarrhea 3.6 (1.0-35.0) 2.0 (0.1-80.0) 0.0002 ARI 2.8 (0.7-50.0) 2.5 (0.2-35.0) 0.12

Rational Drug Use by Public and Private Providers This is where a large graphic or chart can go.

Results 5 Baseline household survey RATIONAL USE Public facilities are more likely to prescribe rational treatments. The difference between public and private provider for rational prescription is statistically significant for all 3 conditions (p< 0.0001, MH Chi2 test on proportion of rational treatment from public and private provider). However, irrational drug prescription is still high in public facilities (23%)

Conclusion Private drug sellers are likely to compete with VHV and VRDF They have a long time experience. They sell a range of drugs villagers are used to purchase. They sell cheaper though irrational drugs where uninformed clients are driven by economic considerations rather than quality.

Recommendations 1 VRDF is not a substitute to primary health care services, it is a tool VHV are minimally trained volunteers and should be closely supervised and supported by the rest of the health care system. A contradiction exists in that the need for VHV is greatest in remote areas where support/supervision is difficult to provide.

Recommendations 2 Private providers should be regulated. The relationships between public and private health sectors should be examined at all levels of care. Consumers should be educated on the quality they can expect from the health care system.

Post-implementation survey has been conducted, data is available and now being analyzed. We expect more conclusions and recommendations when this work is done. Thank you