Transcript Oral Presentation 1

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
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?
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
TRAINING
SUPERVISION
District 1
National program
National program
District 2
Nat’l program + add
National program
sessions on the 3 tracer
conditions by provincial
staff
District 3
National program
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
Malaria
n(%)
452 (75.1%)
Diarrhea
ARI
253 (42.0%)
233 (38.7%)
Treatment providers for the 3 tracer conditions.
70%
66%
63%
62%
Health center
Hospital
60%
Itinerant drug seller
% patient
50%
Private pharmacy
40%
Other
30%
20%
15%
12%
10%
14%
12%
8%
4%
13%
9%
3%
9%
7%
6%
0%
Malaria
Diarrhea
ARI
Malaria (n=449) Diarrhea (n=252)
Public
91 (20.2%)
37 (14.7%)
Private 358 (79.8%)
215 (85.3%)
Condition
ARI (n=230)
35 (15.2%)
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
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
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.
Rational Drug Use by Public and Private Providers
120%
100%
23%
80%
60%
40%
This is where a large graphic or
chart can go.
67%
77%
20%
33%
0%
Public
Private
Irrational
Rational
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