Influencing Use of Medicines in Lao PDR through NDP

2. Influencing use of medicines in Lao PDR through NDP: A decade of policies and choices Dr. Bounkuang PHICHIT Vice-Minister of Health, Lao PDR

3. Lao PDR – Background data In 2000: • Area: 236,800km2 • Population: 5.1 million - Female 51% • Growth rate 2.6% • Income per capita 322 USD • Illiteracy rate 30% -Female 41%; Male 18% Health Facilities: • Total health facilities: 749 (Central hospitals 8, provincial 18, district 127, Health centres 596) • Private pharmacies: 2000

4. Health Indicators 1993 2001 • Maternal mortality rate 656 530 • Infant mortality rate 125 82 • Under 5 mortality rate 182 107 • Average life expectancy 51years 59 years Male 50 57 Female 52 61

5. Challenges in the drug sector • Shortage of ED in public health facilities • Limited government budget • Rapid increase of private pharmacies • High self- medication • 60% of antibiotic use without prescription • Government control was inadequate and ineffective • Lack of necessary regulations, the existing ones had some loopholes • Smuggling of illegal, counterfeit and substandard drugs • Poor IEC on drug use to health personnel and general public

6. NDPformulation-approach • Involving relevant stakeholders: ministries, provinces, health practitioners, consumers, private sector • Seminars to encourage mutual understanding • Forming inter-sectoral working groups • Finding and disseminating evidence: household and pharmacy survey; review of prescribing; case management of fictitious patients; cost comparisons.

7. The 13 elements of NDP 1. Drug Legislation and Regulations 2. Drug Selection 3. Drug Nomenclature 4. Drug Registration and Licensing for sale 5. Drug Procurement 6. Financial Resources 7. Drug Distribution and Storage 8. Quality of Drug Substances and pharmaceutical specialities 9. Rational Drug Use 10. Drug Advertising and Promotion 11. International Technical Cooperation 12. Traditional Medicines 13. Drug Monitoring and Evaluation

8. Objective of NDPP To contribute to good health, with focus on the poor and vulnerable population in remote areas, through the availability of sufficient, good quality essential drugs at low cost, through RUD and through effective institutional capacity building and system development in accordance with the overall objectives of the Health Strategy of Lao PDR.

9. NDP products! • Law, Laboratory, Inspectorate, Drug Therapeutic Committees, Treatment Guidelines, Health Education etc.

10. Effects? • Monitoring indicators (GPP, GWP, RUD, DTC etc) • relevant • easily measurable • valid • action oriented

11. HealthSystemsResearch • Several Health System Research projects for supporting the NDP implementation and improving use of medicines in Lao PDR (1996-2000): • Drug information • Self medication of antibiotics • STG use and DTC performance improvement • Private pharmacies,quality of drugs, perceptions and knowledge • Effects of regulations • Use of traditional Medicines • Availability/Access to Essential Drugs

12. RUD • 32 % of females self medicated with antibiotics for RTI/STD • More ED prescribed and less injections in NDPP pilot province (Luangprabang) • Low quality of private pharmacy service improved with NDPP inspections • DTC improved case management at public hospitals of: -diarrhoea (less irrational antidiarrhoeals, antibiotics) -pneumonia(less antihistamins and cough medicines) -malaria (including diagnostics and history taking)

13. Quality • 46 % substandard drugs (ampi, tetra, CQ, ASA) from 100 private pharmacies Savannakhet • Improvements with NDPP 1997-1999 -Ampicillin from 67 % to 9 % substandard -Tetracycline from 38 % to 12 % • Only 1/59 sellers knew good quality criteria • Layman:”I don´t know anything about fake or substandard drugs – it´s like playing flute for a buffalo”

14. Access Public Sector: • Only 36.5 % ED availability (Khammouane & Champasak) • Of these as many as 40 % expired Private pharmacies: • More ED in NDPP pilot province Drug information: • Improvement from 48% in Savannakhet to 93% in VTE province

15. “Translate” evidence research results to action • More information on antibiotic use to lay people through different media • Training of drug sellers to improve drug information • DTC expanded to district level in the whole country • Strengthen inspections of private pharmacies through law enforcement • Increase pre-post marketing surveillance of drugs in the market • Increase coverage of Revolving Drug Funds at village level

16. 1. Law and regulations 2. Drug selection 3. Drug nomenclature 4. Quality assurance (registration, licensing, quality surveillance) 5. Drug advertising 6. Drug supply (procurement, distribution, storage) 7. Rational use of drugs 8. Strategy on drug economy 9. Traditional medicine 10. Operational research 11. Organization, mana- gement, monitoring of NDP 12. Human resources development 13. Technical cooperation The13 elements of the revised NDP

17. Lessons learnedThe success of NDP implementation is due to:- Government support and appropriate policy, in which the development of law, quality assurance and rational use of drugs are priority activities.- Active participation of different stakeholders in NDP implementation.- Health staffs gained more experiences and knowledge(> 40 people trained on HSR, one Ph D from Sweden, two Master Degree-from Thailand).

18. Ongoing challenges in NDP • Sustainability of drug QA • Enforcement of law and regulations • Strengthening the drug QA system • Improve RUD through IEC and training • Use of HSR and evidence-based approach to NDP • Effective management and financial systems