Transcript Do Village Revolving Funds Improve Access and Rational Use of

Do Village
Revolving
Funds Improve
Access and
Rational Use of
Drugs in Laos?
Bigdeli M1
Ketsouvannasane B2
Shuey DA1
1.
2.
WHO, Laos
Ministry of Health, Laos
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 MantelHaenszel 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.
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.
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?
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.
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
TRAINING
SUPERVISION
District 1
National program
Nat’l program
District 2
Nat’l program + add sessions
Nat’l program
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
Health center (HC)
4 h (±4h)
Hospital (HO)
4 h (±4h)
Private pharmacy (PP)
5h20 (±5h)
– Main transport methods
1. Boat (28% HC- 54% HO- 34% PP)
2. Walk (21% HC- 28% PP)
3. Combination of both (23% HC- 23% HO)
The villages are remote and difficult to access
•
TRACER CONDITIONS (N=602)
Condition
n(%)
Malaria
452 (75.1%)
Diarrhea
253 (42.0%)
ARI
233 (38.7%)
Results 2
baseline household survey
•TREATMENT PROVIDER
70%
66%
63%
62%
Health center
Hospital
60%
% patient
Itinerant drug seller
50%
Private pharmacy
40%
Other
30%
20%
10%
15%
12%
14%
12%
8%
4%
9%
9%
3%
13%
7%
6%
0%
Malaria
Diarrhea
ARI
Condition
Malaria
Diarrhea
ARI
(n=449)
(n=252)
(n=230)
Public
91 (20.2%)
37 (14.7%)
35 (15.2%)
Private
358 (79.8%)
215 (85.3%)
195 (84.5%)
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.
Results 3
baseline household survey
•COST OF DRUGS (in USD)
Median cost (Range)
Wilcoxon
P value
Public
Private
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
2.5 (0.2-35.0)
0.12
Malaria
ARI
2.8 (0.7-50.0)
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
Malaria
(n=452)
Diarrhea
(n=253)
ARI
(n=233)
Injection
34 (7.5%)
3 (1.2%)
32 (13.7%)
IV Drips
89 (19.7%)
38 (15%)
1 (0.4%)
Smaller number of injection and IV Drips
than expected
Results 4
baseline household survey
• RATIONAL USE
Malaria
Treatment
Rational
Irrational
Total
Public
75 (82%)
16 (18%)
91
Private
157 (44%)
210 (56%)
358
232
217
449
Rational
Irrational
Total
Public
26 (70%)
11 (30%)
37
Private
66 (31%)
149 (69%)
215
92
160
252
Rational
Irrational
Total
Public
24 (69%)
11 (31%)
35
Private
37 (19%)
158 (81%)
195
61
169
230
Total
MH Chi2
P<0.0001
Diarrhea
Treatment
Total
MH Chi2
P<0.0001
ARI
Treatment
Total
MH Chi2
P<0.0001
Results 5
baseline household survey
• RATIONAL USE
120%
100%
23%
80%
67%
60%
40%
Irrational
Rational
77%
20%
33%
0%
Public
Private
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%)
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.