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

1. Do Village Revolving Funds Improve Access and Rational Use of Drugs in Laos? Bigdeli M1 Ketsouvannasane B2 Shuey DA1 WHO, Laos Ministry of Health, Laos

2. Abstract Problem Statement: The Government of Laos is encouraging revolving drug funds at the village level (VRDFs) in remote areas. Currently, 3,629 VRDFs have been initiated and are administered by village health volunteers (VHVs). The plan is to increase the number of VRDFs to 5,290 by 2005. To date, the ongoing VRDFs have been evaluated in terms of financial sustainability, but accessibility and rational drug use have received less scrutiny. Objective: To assess the effect of three methods of implementing VRDFs on access to drugs and the rational use of drugs (RUD) for three common conditions (diarrhea, malaria, and acute respiratory infection [ARI]) in remote areas of Laos. Design: Controlled intervention study with pre-test and post-test design without randomization. Setting and Study Population: Sixty villages with no existing VRDFs were selected in three districts of Luang Prabang province. A baseline household survey was conducted in 10 households in each village (600 households in total) to assess access and RUD for the three tracer conditions. A postimplementation household survey is scheduled for January 2004, after 6 months–1 year of VRDF activity. Access and RUD will be reassessed and compared to baseline. The impact of training and supervision will be assessed by comparing intervention and control districts. Intervention: Implementation of VRDFs in 60 villages in Luang Prabang province, Laos, including selection and training of VHVs, provision of drug boards and drug stock, and supervision by district health staff. In one district, an intensive training course was conducted focusing on the three tracer conditions. In another district, intensive supervision was implemented. The third district strictly followed the national program and served as a control location. Results: Preliminary analysis shows poor access to quality drugs. The main first-line providers are itinerant drug sellers (malaria 62%, diarrhea 63%, ARI 66%), followed by private pharmacies (malaria 15%, diarrhea 14%, ARI 13%), with fewer residents having access to public facilities (9-12% to hospitals, 3-8% to health centers). Costs are highly variable (ranging from 0.2 –84 US$ for malaria, 0.1-80 US$ for diarrhea, 0.5-50 US$ for ARI).They are significantly lower in the private sector for malaria and diarrhea treatments (Wilcoxon Test on median cost p <0.001). The private providers are also cheaper for ARI treament but the results are not statistically significant. Medications (prescribed or sold) are often irrational in terms of number and type of drugs as well as in terms of injection use (48.2 % irrational drugs for malaria, 63.2% for diarrhea and 72.5% for ARI). Private providers give out significantly more irrational drugs than public providers for the 3 tracer conditions (all 3 Mantel-Haenszel Chi2 p<0.0001). Conclusions:Postimplementation survey is currently being conducted in the study villages and comparative results will be available at the time of the conference: they will clarify whether rational use of drugs is improved with VRDFs. However, we expect itinerant drug sellers and private pharmacies to remain important providers of irrational, though cheaper, drugs and that they will remain competitors with VRDFs at village level. We need solutions to address the specific problems of the private health care sector and its relationship with public services.

3. Background • 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. • 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.

4. Study Question • 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. • QUESTIONS 1. What is the status of access and RUD in remote areas in the absence of VRDF? 2. Do VRDF change/improve access and RUD? 3. How can VHV training and supervision influence access and RUD?

5. 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. • 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.

6. Methods 2 • BASELINE HOUSEHOLD SURVEY Data • Village data (size, accessibility) • Household data (socio-demographic) • Occurrence of tracer conditions • Prescribed drugs (recall help used: sample of drugs available for the tracer conditions in LP province) • Affordability (financial access) • Provision of preventive messages Analysis • EPI Info 2000 • Panel rating for rational use (WHO + MOH) • IMPLEMENTATION OF VRDF

7. 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 • Main transport methods • Boat (28% HC- 54% HO- 34% PP) • Walk (21% HC- 28% PP) • Combination of both (23% HC- 23% HO) The villages are remote and difficult to access • TRACER CONDITIONS (N=602)

8. Results 2 baseline household survey • TREATMENT PROVIDER People use more private services. In remote areas, Itinerant Drug Sellers become the main providers of drugs. They are itinerant sellers traveling to Laos from neighbouring countries (China, Vietnam) or retired Lao health workers (e.g. from the army) This result is consistent with the Lao National Health Survey 2000.

9. Results 3baseline household survey • COST OF DRUGS(in USD) 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. • INJECTION & IV DRIPS Smaller number of injection and IV Drips than expected

10. Results 4baseline household survey • RATIONAL USE Malaria Diarrhea ARI MH Chi2 P<0.0001 MH Chi2 P<0.0001 MH Chi2 P<0.0001

11. Results 5baseline 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. However, irrational drug prescription is still high in public facilities (23%)

12. Conclusion and recommendations • CONCLUSIONS Private drug sellers are likely to compete with VHV and VRDF – They have a long time experience, a range of drugs villagers are used to purchasing, they sell cheaper though irrational drugs where uninformed clients are driven by economic considerations rather than quality. • RECOMMENDATIONS 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. 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.