1. BUILDING THE NATIONAL DRUG POLICY ON EVIDENCE: ASSESSING IMPLEMENTATION IN LAO PDR Paphassarang C1, Wahlström R2, Phoummalaysith B3, Boupha B1, Tomson G2 1 NIOPH, National Institute of Public Health, Ministry of Health, Vientiane, Lao PDR; 2 IHCAR, Division of International Health, Dept of Public Health Sciences, Karolinska Institutet, Stockholm,Sweden; Cabinet, Ministry of Health, Vientiane, LaoPDR
Problem Statement: The National Drug Policy (NDP) of Laos, endorsed in 1993, has since 1995 been implemented through an intervention program in 5 pilot provinces (out of 18 provinces), including training of health personnel. Has the implementation contributed to policy awareness, accessibility of essential drugs, and rational use of drugs?
Objective: To assess the impact of the NDP through comparisons between a pilot province and a non pilot province, and thereby obtain evidence for revising the NDP.
Design: Cross-sectional.
Setting and Population: In each province (pilot and non pilot), 3 districts were purposively chosen. Four pharmacies at the public hospitals were included, and 20 private pharmacies were randomly selected.
Intervention: Implementation of the NDP, including training, supervision, and material support.
Outcome Measures: A set of 29 combined indicators were utilized. One hundred ten prescriptions for children under 5 with simple diarrhea and 240 adult outpatient prescriptions were sampled. Twelve health care managers were interviewed on knowledge and attitudes.
Results: Health managers in the pilot province had better knowledge of NDP concepts. Significantly more essential drugs were available in the private pharmacies in the pilot province. The proportion of prescriptions of essential drugs in hospitals was also higher in the pilot province (95% vs 86%; p<0.001). Fewer drugs were prescribed per patient in the pilot province (2.7 vs 3.3; p<0.001), and the management of simple diarrhea in children was significantly more in accordance with Standard Treatment Guidelines in the pilot province.
Conclusions: The pilot province performed significantly better in several aspects of quality and rational use of drugs, probably related to the imple- mentation program. National as well as regional and global diffusion of research findings is recommended to promote evidence-based national drug policies.

2. Background Lao PDR, a poor country with: GNP: USD 383/capita in 2003,
Public health expenditure: < USD 12 for each of its 5.3 million citizen in 2000
Adult illiteracy: 60%.
Aver. Life expectancy: 59 years
IMR: /1000 live births,
MMR: 530/ live births
(Health survey 2000)
Has its NDP endorsed in 1993 for achieving availability, affordability and the rational use of safe and effective essential drugs (ED) for all people in its18 provinces
Special program of implementa- tion supported by Sida from 1993 in 3 and from 1996 in 5 pilot provinces including both private and public sector in the form of :
training of private drug sellers,

3. development standard treatment guidelines (STGs)
training of inspectors and
development of monitoring indicators for good pharmacy practice (GPP) and rational use of drugs (RUD),
establishment of drug therapeutic committees (DTC)
IEC for and with the general public on RUD
Central and pilot provincial key persons were main focus for human resource development
This study is one of six operational research projects conducted and their results presented during the Vth National Drug Conference for revising the NDP.

4. BUILDING THE NATIONAL DRUG POLICY ON EVIDENCE-
A CROSS SECTIONAL STUDY ON ASSESSING IMPLEMENTATION IN LAO PDR Paphassarang C, Wahlström R, Phoummalaysith B, Boupha B, Tomson G Southeast Asian J Trop Med Public Health, Vol 33 No.3 Sept. 2002
Objectives:
This study aims at using monitoring indicators to assess the effectiveness of the NDP program implementation in one pilot province compared to a non-pilot

5. Method Luangphrabang (LPB) = Pilot province
Sayabury (SBR) = Control province.
Three districts of each province selected as urban, rural and remote areas
Data collection in each province:
12 health care managers interviewed with structured questionnaires on NDP and ED concept, STG and inspection principles.
24 pharmacies surveyed with structured questionnaires, including a check-list of top ten ED and essential materials
45 customers per province at the private pharmacies interviewed regarding their knowledge about the drug and the information received

6. 50-60 prescriptions for children under five with simple diarrhea and 120 prescriptions for adult OPD patients
29 indicators were used:
-15 WHO monitoring indicators for NDP.
- 10 GPP indicators of the Food and Drug Department (FDD) .
- 4 Indicators to measure the knowledge of the objectives of the NDP; ED concept; the use of STGs; and inspection principles).
Descriptive data analysis, with statistical analysis, through EPI6 and SPSS10 with 95% CI.

7. n=24 pharmacies(20privates+4 publics) (Pilot via Control)
Results
Ten of the twelve health care managers in the pilot province, had at least half of the maximum score on each of the four indicators, versus five in the control province.
GPP Indicators
n=24 pharmacies(20privates+4 publics) (Pilot via Control)
No inspection/year: via 0.5
No pharmacies with ED list available via 3
No pharmacies with banned drug list via 18 ns

8. n=24 pharmacies (20 privates+4publics)
GPP Indicators
n=24 pharmacies (20 privates+4publics)
(Pilot via Control)
No pharmacies with no advertising posters via 18 ns
No pharmacies dispensing from original package
4 via 0 ns
No of ED available in public sector out of ten EDs
9.0 via ns
No of ED available in private sector out of ten EDs : 8.5 via 7.3, p=0.03

9. GPP indicators: Observed quality n=24pharmacies (20privates+4publics) (Pilot via Control)
% ED being registered
70 via 54 p<0.001
% EDs with bill of purchase
42 via 18 p<0.001
% informed customers
(n= 45 / province)
18 via 7 ns

10. Prescriptions Indicators (Pilot via Control)
Under five children with simple diarrhea n=110
ORS (oral rehydration solution)
100 via p=0.001
Anti-diarrheals
0 via ns
Antibiotics
22 via p=0.002
Adults at OPD n=120
No of drug per patient
2.68 via P<0.001
% ED of all prescribed drugs
96.5 via P<0.001
% injections of all prescribed drugs
1.3 via P<0.001
% antibiotics : 13.1 via ns

11. Conclusion
In the pilot province compared with the control province, there was a better knowledge on NDP concepts, and essential drugs (ED) were more often available and regularly distributed in the private health facilities. The proportion of prescriptions of ED in public hospital of better quality was higher in the pilot province, and these drugs are assumedly of better quality as the stricter regulations to ensure good quality drugs were followed. Prescribing practice were also of a higher standard with more correct treatment of childhood diarrhea, and better overall prescribing for adult patients.

12. Policy implications .
The majority of participants at the Vth National Drug Conference found operational research useful and has included it as a new element in the revised NDP.
The MoH of Lao PDR has thus ensured that the future the NDP will build on evidence from the Lao context.
This experience may contribute to a better understanding of the process of implementing a National Drug Policy and serve as an inspiration for other countries, rich and poor.
Research can be performed for policy as well as on policy to ensure evidence-based decision making.