years Working for Health in the Lao People’s Democratic Republic 5 1962–2012

Fifty Years Working for Health in the Lao People’s Democratic Republic 1962–2012 WHO Library Cataloguing in the Publication Data

Fifty years: working for health in the Lao People’s Democratic Republic, 1962-2012

1. Delivery of healthcare. 2. Health services. 3. Laos. 4. National health programs. 5. Primary health care. I. World Health Organization Regional Office for the Western Pacific.

ISBN 978 92 9061 601 6 (NLM Classification: WA 530)

© World Health Organization 2013

All rights reserved.

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Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: [email protected]). Requests for permission to reproduce WHO publications, in part or in whole, or to translate them – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: [email protected]). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, Fax. No. (632) 521-1036, email: [email protected] Fifty Years Working for Health in the Lao People’s Democratic Republic 1962–2012 Contents

Foreword ii 4. Opening Up: New Directions and New Partners (1986–2000) 19 Who’s Who in WHO iv Health Trends during this period 20 Context 21 Acknowledgements vi The Work of WHO in the Lao People’s Democratic Republic 22 Case Study: Model Healthy Villages in Vientiane Capital 24 Introduction viii Case Study: The Expanded Programme on Immunization in the The Foundation of the World Health Organization ix Lao People’s Democratic Republic 26 The Lao People’s Democratic Republic joins the World Health Organization x Case Study: The Fight Against Schistosomiasis on Khong Island 27 About the Lao People’s Democratic Republic xi 5. Into the New Millennium (2000–2012) 29 1. The Early Days of WHO in Laos (1950–1962) 1 Context 30 Context 2 Global Health Issues and their Impact on the Lao People’s The Work of WHO in Laos 3 Democratic Republic 31 Case Study: Yaws Control in Savannakhet Province, as told Case Study: Strengthening Surveillance and Response 34 by Dr Edmond J. Douvier 6 Case Study: Managing Emerging Infectious Disease Threats through Field Epidemiology Training 35 2. Basic Health Services in Difficult Times (1962–1975) 7 Aid Effectiveness 36 Context 8 The Vientiane Agreement 36 The Work of WHO in Laos 9 Meeting the Challenge of Maternal and Child Health 37 Case Study: Smallpox Vaccination Campaign in Sayabouly Province 10 Case Study: Great Expectations 40 Case Study: Malaria control in Vientiane Province 12 Case Study: Kinoy’s Story 41 Looking to the Future 42 3. Primary Health Care Era of “Health for All” (1975–1986) 13 Context 14 Abbreviations 46 Alma Ata 15 The Work of WHO in the Lao People’s Democratic Republic 17 Bibliography 47 Case Study: Traditional Medicine (Then and Now) 17

i Foreword by the WHO Regional Director for the Western Pacific

It is my great honour in the implementation of its Health Sector to be associated with the Development Plan, in the achievement celebration of the 50th of the health-related Millennium anniversary of the World Development Goals and the attainment of Health Organization’s universal health coverage. presence in the Lao WHO has witnessed impressive People’s Democratic improvements in the health of the Lao Republic. The WHO people over the past five decades. The Country Liaison Office population has grown from 2 million was first established in people to just over 6 million in that Laos in 1962, and it was later expanded time, and the life expectancy at birth has into a WHO Representative Office in 1968. increased from 55 years in 1995 to 64 years Over the last 50 years, WHO has for males and 67 years for females in 2010. worked with Lao authorities, health The number of health centres has increased professionals, communities and from 664 in 2000 to 862 in 2010, making development partners at many levels. We basic health-care services more accessible have built a strong partnership based on to all. mutual trust with the Government of the WHO has worked with the Lao People’s Democratic Republic. WHO Government of the Lao People’s is proud to be a part of the Lao People’s Democratic Republic on the global Democratic Republic’s health development eradication of smallpox, and its through an historically challenging period, certification in 1979 represents a key and the Organization will continue its achievement in the history of WHO. The commitment to support the Government Lao People’s Democratic Republic has

ii remained polio free since the last case of The International Health Regulations WHO looks forward to a brighter the disease was confirmed in 1996, and the (2005) entered into force on 15 June 2007, future with our partners in Government, number of measles cases has decreased and the Lao People’s Democratic Republic other United Nations agencies, from 295 in 2005 to 153 in 2010. is committed to meet the core capacities nongovernmental organizations, civil The International Conference on required under IHR (2005). During the society and the people of the Lao People’s Primary Health Care in Alma Ata in 1978 H1N1 pandemic in 2009, the Lao People’s Democratic Republic. set the framework for WHO’s successful Democratic Republic demonstrated collaboration and facilitation of health its improved public health capacity to sector policies, strategies and plans and respond to public health emergencies of resulted in sector-wide coordination international concern and contributed to and knowledge exchanges in the Lao global information sharing. People’s Democratic Republic. Since Various challenges continue to confront Shin Young-soo, MD, Ph.D. that time, the Expanded Programme on the Lao People’s Democratic Republic, WHO Regional Director for the Immunization has worked to improve including globalization, urbanization, Western Pacific under-5 morbidity and morality rates. migration, mobile populations, ageing, the Safe Motherhood initiatives in the 1990s increasing burden of noncommunicable brought declines in the maternal and diseases, emerging disease outbreaks, infant mortality ratio. And more than 40 epidemics and pandemics, and natural areas of joint development on national disasters. WHO remains committed to policies, strategies and plans, as well as supporting and collaborating with the the recent health-sector reform plan, reflect Government and the health sector in their the close collaboration between WHO, efforts to achieve better health for the the Government and other health-sector people of the Lao People’s Democratic development partners. Republic.

iii Who’s who in WHO

Dr Brock Chisholm Dr Marcelino Candau Dr Halfdan Mahler Canada Brazil Denmark 1948–1953 1953–1973 1973–1988 DIRECTOR-GENERAL DIRECTOR

Dr Fang I-Chi Dr Francisco J. Dy Dr Hiroshi Nakajima China Philippines Japan 1951–1965 1965–1978 1979–1988 REGIONAL OFFICE

COUNTRY

OF Dr Arthur E. Brown Dr Shammas Dr Antonio Brown Dr Wolfgang H. Huehne Dr G. J. A. Ferrand Dr Roger Leclercq Dr Ravi Ramdoyal

United Kingdom Israel Bolivia Germany France Belgium Mauritius 1956–1962 1962–1963 1964–1967 1968–1970 1971–1975 1975–1980 1981–1985 HEAD iv Dr Hiroshi Nakajima Dr Gro H. Bruntland Dr Lee Jong-wook Dr Margaret Chan Japan Norway Republic of Korea China 1988–1998 1998–2003 2003–2006 2006–

Dr A. Nordström* Sweden

Dr Han Sang-Tae Dr Shigeru Omi Dr Shin Young-soo Republic of Korea Japan Republic of Korea 1989–1999 1998–2009 2009–

Dr Ziaul Islam Dr Francois Canonne Dr Imrich Geizer Dr. Yves Renault Dr Giovani Deodato Dr Dean Shuey Dr Dong II Ahn Dr Yunguo Liu India France Czechoslovakia Belgium Italy USA Republic of Korea China 1986–1992 1993–1994 1995–1997 1997–1998 1998–2004 2005–2006 2006–2011 2011–

* From 23 May 2006 until 3 January 2007, Dr Nordström of Sweden was appointed by the Executive Board to serve as acting Director-General, following the untimely death of v Dr LEE Jong-wook on 22 May 2006. Acknowledgements

We would like to acknowledge the Government of the Lao People’s Democratic Republic, particularly the Ministry of Health, for its kind assistance in the sharing and verification of data. The government provided important contacts and advice during the research stage. The staff at the WHO Representative Office in the Lao People’s Democratic Republic have generously shared their experiences in the field of health and have provided valuable input and assistance in reviewing the book for technical accuracy. Finally, we also would like to acknowledge the staff at Khaosan Pathet Lao (Lao News Agency) for retrieving the historical photographs and transcribing labels and captions. Research and writing by Ruth Foster and Irene Tan. Editing by Marc Lerner.

WHO Regional Director for the Western Pacific Dr Shin Young-soo and the staff of WHO Representative Office, Vientiane, 2011.

vi Mongolia

Republic of Korea China Japan

Hong Kong SAR Lao People's Macao SAR Northern Mariana Islands Democratic Republic Philippines Viet Nam Cambodia Guam Marshall Islands Federated States of Palau Micronesia Malaysia Singapore Brunei Nauru Kiribati Darussalam Papua New Guinea Solomon Islands Tuvalu Tokelau Samoa Wallis & Futuna American Samoa Vanuatu Niue French Polynesia Fiji Cook Islands Tonga New Caledonia Australia Pitcairn Islands

New Zealand

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO Regional Office for the Western Pacific 2009. All rights reserved. Introduction 2012 marks the 50th anniversary of the Those who worked with WHO in work of the World Health Organization the country in the 1960s and 1970s might in the Lao People’s Democratic Republic, seem to have lived and worked in an which began in 1962 when a Country entirely different context. In fact, in Liaison Office was established in the December 1975 the country embarked capital city of Vientiane. The anniversary on a new political course and adopted a also celebrates 50 years of partnership new name—the Lao People’s Democratic and collaboration between WHO and Republic. Yet there is continuity and there the Government of the Lao People’s has been an uninterrupted WHO presence Democratic Republic. and involvement through times of great Over the last 50 years, the scale change. of WHO support and the scope of Over five decades, the spirit of partnerships in the health sector have commitment and partnership between increased exponentially. In 1962, there WHO and the Lao People’s Democratic were only a handful of staff members at Republic has flourished and grown. The the new Country Liaison Office. In 2012, huge increase in the number of key health- there were nearly 60 international and sector partners has made it necessary national staff members, both on fixed-term for WHO to frequently assume the role and temporary contracts. of coordinator. Development partners This anniversary also provides an include other United Nations agencies, excellent opportunity to review key events, bilateral organizations, international highlight achievements and successes, and nongovernmental organizations and consider some of the challenges that have civil society. faced WHO in the Lao People’s Democratic Republic over those 50 eventful years.

viii The Foundation of the World Health Organization Globally, WHO has been at the centre of international health cooperation for more than 60 years. As the United Nations specialized agency for health, WHO formally came into existence on 7 April 1948 when its constitution was ratified by its 26th Member States. Since then, 7 April has been celebrated each year as World Health Day. The work of the Organization is governed by the World Health Assembly and the Executive Board and is carried out by the Secretariat. The Constitution of the World Health Organization defines health as its first principle: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The objective of the World Health Organization was stated succinctly:

The attainment of all peoples of the highest WHO possible level of health.

General view of the plenary meeting at the First World Health Assembly, Geneva, 1948.

ix The Lao People’s Democratic Republic joins the World Health Organization

Laos joined WHO on 17 May 1950. The Dr Arthur E. Brown, a British doctor first session of the Regional Committee for with a background in public health, assumed the Western Pacific, the WHO governing the post of WHO Area Representative from body in Western Pacific, took place at 1956 to 1962, a title that later changed to the fourth World Health Assembly in WHO Representative, with responsibility for Geneva, Switzerland, on 18 May 1951, with Cambodia, Laos and Viet Nam. attendance by eight countries from the Region and four countries responsible for areas in the Region. The three office bearers at that first session of the Regional Committee represented Laos, the Philippines and Viet Nam. Dr Oudom Souvannavong, the first Western-trained doctor in Laos, was the rapporteur, a clear indication of the active participation of Laos from those early days. Initially, WHO interventions in Laos were directed from the Regional Office for the Western Pacific in Manila. WHO did not have an official representative based in Indochina, although the senior adviser in Viet Nam was increasingly taking on that role. On 1 March 1956, the WHO

Representative Office opened in Saigon, WHO now known as Ho Chi Minh City. For the next few years, the office also covered Cambodia and Laos. Dr Arthur E. Brown, Area Representative, 1956–1962 x About the Lao People’s Democratic Republic

In the early 1950s, Laos was comprised Democratic Republic’s opening up and of 11 provinces, with a population of embracing a more market-driven economic less than 2 million people. While the model in recent years, new challenges soon population continues to be predominantly emerged in international health. rural, there has been a significant rise in Accelerated development in recent urban migration since the mid-1990s. The years is leading to rapid change that proportion of the population in rural areas impacts the health status of the population decreased from 83% in 1995 to about 68% in both positive and negative ways. in 2011. In 2012, there are 17 provinces, The story of health in the Lao People’s including Vientiane Capital, and a Democratic Republic and the involvement population of more than 6 million people. of WHO run parallel to the many The country has a population density challenges the country has faced and will of just 26 people per square kilometre, continue to face. with large interprovincial variations, creating challenges in the delivery of health-care services. The Government has strengthened its policy on resettlement of villagers from the highlands to the lowlands so they can be closer to roads and essential public amenities. The people of the highlands have traditionally practised slash- and-burn agriculture and in the past were often migratory. All of the provinces have international borders, and the geographical proximity WHO generates significant movement of people that can sometimes result in cross-border disease transmission. As globalization becomes inevitable with Lao People’s The Nam Song River winds around the bottom of the Karstic Mountains in Vang Vieng, Vientiane Province. xi Chapter 11

The Early Days of WHO in Laos 1950–1962 KPL The SchoolofMedicineinVientiane intheearly1960s Context Setthathirath Hospital. July 1960.Inlateryears,thisbecamethe from 49in1962to9451990. People’s DemocraticRepublicincreased period. ThenumberofdoctorsintheLao ratio increasedsignificantlyduringthat the Region,andphysician–population heavily inpromotingmedicaleducation medical trainingathome.WHOinvested possible forLaodoctorstoreceivefull achievement—for thefirsttimeitwas to 1980. Democratic Republic,servingfrom1975 WHO RepresentativeintheLaoPeople’s education. DrLeclercqwaslaterappointed to overseeitscontributionmedical Rural HealthDevelopmentProgramme Leclercq wastransferredfromtheWHO school trainingdoctors.DrRoger in Laos.In1970,itbecameafullmedical Assistant MedicalDoctorswasfounded The firsthospitalinLaoswasbuilt The SchoolofMedicinewasakey In 1958,theSchoolofMedicinefor 2 3

Dr Keo Phimphachanh The Work ofWHOinLaos CHAPTER 1:THEEARLY DAYS OFWHOINLAOS long-range nationalhealthplans. health surveyswasundertakentoprepare beginning in1958.InApril1961,aseriesof Saigon, withtwodoctorsworkinginLaos programmes weredirectedfromManilaor public healthfromtheearly1950s.WHO Health staff fromXiengKhuangProvince outsidethehealthfacilities,1960s WHO collaboratedwithLaoson development agenciestowardscommon service andalsoworkedcloselywithother assistance insettinguptheruralhealth close toVientianein1961.WHOprovided component, wasinitiatedinapilotarea rural development,includingitshealth A concertedapproachtoaccelerated that requestedthiskind of assistance. and VietNam,wasamong thecountries and services.Laos,along withCambodia preparation ofnursingand midwiferystaff project activitiesfocusedmainlyonthe or moreWHOnurseswereassignedand general publichealthprogrammes,two development. control, andruralhealthservices training programmes,treponematoses control, publichealthdemonstrationand projects, suchasMCH,tuberculosis were assignedasteammembersonspecial programmes weresetup. in Laoswereascertained,training maternal andchildhealth(MCH)needs health partners.Oncetheprincipal Children’s Fund(UNICEF),andother in partnershipwiththeUnitedNations developed withsupportfromWHOand Laos. Anambitious10-yearplanwas maternal andchildhealthservicesin development partners. development planningwithother goals—an earlyexampleofintegrated In severalMCHprogrammesand In thisRegion,internationalnurses Until 1959,therewerevirtuallyno 4

KPL malaria remained the most significant malaria remained the most significant Other health problem in most of Laos. colds, major health problems included measles, pneumonia, tuberculosis, and dysentery, worms, skin diseases malnutrition. The work of WHO in Laos was Health workers checking a tuberculosis patient, 1962. Health workers checking a tuberculosis patient, for and to determine the training needs popular physicians. Malaria was the most fellowships field of study, taking up 16% of awarded, followed by public health 9%. administration at 15% and nursing predominantly needs based. In 1959, Over the years, WHO has cooperated years, WHO has Over the and training activities WHO education A regional adviser in education in many activities that have helped activities that have in many and strengthen the organization nursing services in Laos. management of have been awarded Potential nurse leaders to study nursing overseas fellowship and leadership training administration, to strengthen activities were conducted skills. leadership and management a substantial in the Region included fellowships to assist focus on providing countries in the production of well- to the trained health personnel—essential However, development of health services. the fellowship programme was intended local to supplement rather than supplant educational facilities. and training was appointed by WHO of in 1953 and a significant number intercountry meetings were organized. were The most common topics considered malaria, public health administration, communicable diseases, environmental and sanitation, vital and health statistics out dental health. Surveys were carried to assess the status of medical education CHAPTER 1: THE EARLY DAYS OF WHO IN LAOS

In addition, enlarged or infected Yaws (endemic treponematosis) is thyroids, cholera, smallpox, yaws, eye a chronic infection that affects mainly infections (trachoma), typhoid, typhus, skin, bone and cartilage. It is caused rabies, leprosy, venereal diseases, by a bacterium related to the one that traumatic wounds (from hunting and causes venereal syphilis. However, yaws warfare), opium addiction and dental is a non-venereal infection transmitted caries were some of the other problems mainly through skin contact with an identified during that period. infected person. Although rarely fatal, the There were occasional cholera disease could and does lead to chronic epidemics, and typhoid was endemic. disfigurement and disability. There was a relatively high incidence of The global campaign against yaws was leprosy. Thyroid problems were common one of the early successes of WHO. The among mountain people and opium main approach of yaws control projects addiction was significant among Hmong focused on training national personnel in and Mien ethnic groups. Rabies was an clinical and laboratory diagnosis and in increasing problem in towns. modern treatment methods. A single dose The yaws control project was of penicillin could treat yaws effectively. established in Laos in 1953, the second The treatment of yaws is often carried out such programme in the Western Pacific with Bacillus Calmette-Guerin (BCG) and Region. When WHO was established, smallpox vaccinations and other rural some 50 million people globally were health-care activities. inflicted by the disease, which is spread by Dr Edmond J. Douvier, a WHO WHO poor hygiene. Yaws is prevalent in rural, medical officer, was based in Laos from Dr Edmond J. Douvier and the field team leader warm, humid tropical areas in the Region, 1953–1954. When he made his final report examining a child at Bulaene, 1956. characterized by poor sanitation, poverty on the WHO-and UNICEF-assisted-Yaws and inadequate health facilities. Control Campaign of Laos in November 1954, he also included an account of his experiences in the Savannakhet Province.

5 Yaws control in Savannakhet, as told by Dr Edmond J. Douvier

In point of fact, no one knew the In April 1953, a WHO expert together Operations organized in this way prevalence of yaws in Laos, nor its with one medical officer and six young men continued, and in June 1953 we reached geographical distribution. Indeed, it was left for the Kengkok district during the rainy the district of Phalane and in July, Dong not common in Laos for a medical worker season. In theory the work was exceedingly Hen. In August and September, work was to leave the main towns or the dispensaries simple: assemble the population, and carried out in the Savannakhet district to visit the villages to provide medical examine and treat yaws patients and and towards the end of the year in the consultation or to establish statistics. contacts in their families. Arriving early Lahanam-Songkhone district. Moreover, the state of war did not in the morning in the village, we settled Despite the critical situation, 691 encourage workers to go into the villages. down in the pagoda until evening when the villages were visited between April 1953 population came along to be examined. and November 1954. We examined Everybody, however, wanted to be 132 000 people, including 64 000 children given a shot—the people suffering from and 7607 yaws patients and 1348 contacts yaws, from rheumatism, those who had were treated. The total rate of contagious scabies and even those who were well. It yaws was 0.36%, and the rate of non- was very difficult to explain that only yaws contagious yaws was 5.3%. Thus, the patients and family contacts could be treatment of patients and their contacts given treatment. was deemed adequate. After two months, we found that despite Carried out with limited resources administrative help and the eagerness of in a country at war, this campaign people to be treated, we had only covered nevertheless enabled us to estimate about 70% of the population. We were precisely the rate of yaws endemicity in forced to change our methods. I decided Savannakhet Province, to treat patients that going forward we would stay in every even in the most remote villages, and to village and remain there until we had educate and train health workers who examined practically the whole population. were able to continue the work. The approach worked if we started examining our first “customers” at first light WHO in the morning and the last with the light Dr Edmond J. Douvier explaining diagnosis and of a kerosene lamp, obtaining results we treatment to field workers while examining the children, 1956. wanted and reaching 90% of the people.

6 Chapter 2

Basic Health Services In Difficult Times

1962–1975 and tuberculosis. by malaria,diarrhoea,parasiticdiseases urban populationcontinuedtoberavaged significant publichealthissue.Thesmall Communicable diseasesremaineda little changedfromthatofthe1950s. 1970s, theburdenofdiseasewas Context In the1960sandupuntilmid-

Physical therapy andrehabilitationprogrammes intheMahosothospitalVientiane,1968. WHO 35 deaths. epidemic in1969,with484casesand Laos sufferedanotherseriouscholera reported casesanddeathsfrom1961–1965. Viet Nam,but13countriesintheRegion it wascentredinthePhilippinesandthen major epidemicofElTorcholera.Initially Western PacificRegionexperienceda During theearly1960s,WHO Region sawsteadyimprovements. were launchedandthehealth statusofthe many seedsweresown, new programmes condition, malnutrition. Inthisperiod, of sufferingfromanother preventable little ifchildrenfacedahighprobability infant mortalityrate–wouldcountfor that successinonearea–reducingthe Region, therewasagrowingrealization vaccination programmeforchildren. with thedevelopmentofanational vaccines formajorchildhooddiseases, were usedinthedevelopmentofother Lessons learntfromthesmallpoxactivities eradication, wereinitiatedintheRegion. smallpox, whichleadtoitsglobal countries wererampantinLaos. immunization inricher,moredeveloped that couldsoeasilybecontrolledby in thecountry.Thechildhooddiseases 1964, therewasaseriouspolioepidemic (pertussis) anddiphtheria.In1963 died ofmeasles,polio,whoopingcough diarrhoea andmalnutrition,children addition tothescourgesofmalaria, 180–500 deathsper1000livebirths.In different areasandcircumstancesfrom InsurveyingtheworkofWHOin Vaccination campaignsagainst The infantmortalityratevariedin 8 WHO One example of a WHO intervention of a WHO One example outside the area was a smallpox the area was a smallpox outside conducted in vaccination campaign northwest of Sayabouly Province, the west of Luang Vientiane and to This was the first time Prabang Province. had been to remote that such a team from the towns and settlements away the Mekong River. villages close to During this period, the work of WHO period, the work During this was often conducted in a fairly restricted fairly restricted conducted in a was often war, some WHO area. Despite ongoing manage to visit an staff members did of provinces: Luang impressive number Prabang, Sayaboury and Namtha, Luang to the north, and Vientiane provinces and Pakse to Khammouane, Savannakhet the south. Home visiting for a sick baby near Vientiane, 1970. Home visiting for a sick baby near Vientiane,

In 1969, WHO staff in Vientiane In 1969, WHO staff in Vientiane The next Country Liaison Officer, Dr The next Country A WHO Country Liaison Office was Country Liaison A WHO

numbered about 20. Each WHO team numbered about 20. Each WHO Manila reported to a different adviser in for the and there was little opportunity country. different teams to collaborate in by Dr Dr Huehne was succeeded in 1971 G. J. A. Ferrand of France who continued in the post until 1975. Antonio Brown, served from 1964 to 1967, Antonio Brown, period. In 1968, a particularly challenging with a full WHO presence was established first WR WHO Representative (WR). The German was Dr Wolfgang H. Huehne, a malariologist who had been actively involved with high-level interventions had in the Region since 1959. Dr Huehne for the been WHO Permanent Secretary Anti-Malarial Coordination Board. established in Laos in April 1962. Dr in Laos in April established first Country Liaison Shammas was the during his tenure Officer (CLO) and Laos expanded and WHO presence in were established. administrative systems the Mahosot The office was located close to the Mekong Hospital complex, River. Work of WHO in Laos in WHO of Work The Basic Health Services In Difficult Difficult In Services Health 2: Basic CHAPTER Times 9 A Smallpox Vaccination Campaign in Sayaboury Province

A resolution proposing a global Initially, progress was slow as the American psychiatrist and anthropologist, campaign against smallpox was approved programme had to compete with the far was involved in the WHO smallpox by the World Health Assembly (WHA) more costly Malaria Eradication Programme, vaccination campaigns in Laos, as was Dr in 1956, three years after it had been which begun in 1955 and enjoyed a Victor Guetzel, a WHO paediatrician from first put forward. By then, a successful greater level of support. However, in 1966, Moldavia. national smallpox eradication campaign the WHA voted to undertake a special, Dr Westermeyer trained health workers in the Union of Soviet Socialist Republics intensified smallpox eradication campaign. in the routine of smallpox inoculations. (USSR) had demonstrated that eradication When the campaign was launched in Local nurses and other team members did was feasible. Once the political will was 1967, the disease still threatened 60% of the much of the work. The doctors were there established, resources had to be mobilized. world’s population, killed every fourth primarily to screen cases that should not be victim and scarred most survivors. While vaccinated and to run a general “sick call” only 131 000 cases were reported in 1967, it for people coming for vaccinations and be was estimated there were actually 10 million available in the event of adverse effects to 15 million cases in 44 countries at that following immunization. Dr Westermeyer time. recalls that the turnout was overwhelming. Smallpox vaccination became The last transmission of smallpox feasible worldwide—and in remote and was recorded in Laos in 1953. However, hot climates—due to the development eradication necessitated continuing efforts of vaccines that would remain stable to inoculate and to conduct surveillance. and potent for a limited time, even at The certification process began in 1973. high temperatures. As the programme Countries in the Western Pacific Region accelerated, two other innovations took had to provide to WHO information from place: the invention of the bifurcated reports of visits by independent experts and vaccination needle and the development of a other country reports, supported by data

WHO strong search and containment strategy. from the Regional Office. Smallpox was the Smallpox endemicity in South-East Asia first disease in history to be eradicated. The Members of the Global Commission for the Certification of Smallpox Eradication, Geneva, 9 December 1979 was never particularly high; the greatest complete global eradication of smallpox number of cases occurred in Africa and was achieved in 1979 and remains one India. In 1966, Dr Joseph Westermeyer, an WHO’s greatest achievements.

10 CHAPTER 2: Basic Health Services In Difficult Times

Malaria control was an important Although malaria remains a public area of activity for WHO in Laos from the health problem in the Lao People’s earliest days. All accounts of the health Democratic Republic, mortality has been situation mentioned the gravity of the greatly reduced due to intensified control problem. Between 1969 and 1975, limited measures applied to countries with a high DDT spraying took place in Vientiane incidence. Drug supply and treatment Province, together with mass drug methods are usually adequate, but many administrations of chloroquine, supported people with severe malaria die because by WHO. they arrive at the hospital too late. Spraying was carried out in part The construction of the first major of the northern Vientiane Prefecture dam in the country in the late 1960s and Saithany and Phon Hong districts prompted real concerns that a significant from 1969 to 1972, and in Naisaithong new malarial zone might have been district from 1973 to 1975. In 1975, there established relatively close to the capital were malaria outbreaks in Vang Vieng, city. The following account provides Vientiane and Xieng Khouang provinces, the background of the global malaria according to WHO malaria adviser eradication programme and the early Dr C.T Ch’en. Massive influxes of people interventions in Laos and deals with the from non-malarious highland areas made important work conducted in Vientiane them very vulnerable to the disease. Province from 1969.

11 Malaria Control in Vientiane Province

The Eighth World Health Assembly The project began in 1969 with the DDT household spraying resumed, in 1955 launched the Global Malaria arrival of Dr M. Di Iorio as WHO malaria mostly around the Nam Ngum site and Eradication Programme. The following adviser for Laos. The work centred on the surrounding villages. Mass drug year, Laos set up the National Malaria the construction site for the Nam Ngum administrations with chloroquine were Service (NMS). Initially based in hydroelectric dam to the north also carried out in the sprayed villages. Savannakhet, the NMS moved to Vientiane of Vientiane. By 1970, the malaria situation at the in 1958, with additional stations in Luang Due for completion in 1970, this major Nam Ngum dam was well under control, Prabang and Pakse. engineering project had been undertaken but the completion of the project had been By 1960, the NMS claimed to have with Japanese funding and technical very significantly delayed and there were protected 900 000 people through DDT advice. The dam site had two labour camps fears that the area would become highly residual spraying in households, and surrounded by 16 villages. Blood slides were malarious following the completion of there was a curative programme using collected from people attending the Japanese the dam and the increase in size of the chloroquine. However, by this time, the clinic and dispensary at Thalat between 30 enclosed lake. increasingly insecure political situation May and 17 June. Of 144 patients, 104 tested One of the most serious concerns— and the intensification of the war made positive for malaria (72%). that Nam Ngum lake would become the it impossible to continue the malaria Workers at the site also had been epicentre of a highly endemic area—was programme. Spraying ceased in 1961. severely affected by malaria. There were never realized. As the lake filled, the In 1969, Laos and WHO agreed to 11 cases of malaria among the workers from breeding places for the major vector collaborate on a malaria control project in March to July. Some of the Plasmodium Anopheles maculates disappeared and the Vientiane Province. falciparum parasites were found to be lake perimeter became virtually malaria chloroquine-resistant. free through this ecological change.

12 Chapter 3

Primary Health Care Era of “Health for All”

1975–1986 Context

On 2 December 1975, Laos embarked upon a new political path and was renamed the Lao People’s Democratic Republic. It was also a time of great change within WHO. The big “vertical” programmes that had enabled the eradication of smallpox and had attempted to eradicate malaria had also helped develop urgently needed public health infrastructure. The Organization’s thrust began to move towards “horizontal” programming and primary health care (PHC). In 1975, the World Health Assembly defined and expounded a radical new approach that contrasted dramatically with the conventional health-care delivery systems of the past. The Thirtieth World Health Assembly in 1977 adopted the concept of “Health for All by the Year 2000”, a goal to be attained on the basis of primary health care. Health for All was defined as: The main social target of governments and WHO is the attainment of all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Soon after, WHO and UNICEF organized the International Conference on Primary Health Care in Alma Ata, where the PHC approach was resoundingly endorsed. 14 CHAPTER 3: Primary Health Care Era of “Health for All” Alma Ata

The period from the mid-1950s up until families and communities. These include The Alma Ata Declaration reaffirmed the Alma Ata Conference in 1978 is now preventative, promotive, curative and the original definition of health, which considered an era of basic health services. rehabilitative health measures and was the first principle of the WHO The International Conference on community development activities. Constitution and went on to say that Primary Health Care at Alma Ata in Dr Keo Phimphachanh, head of health was: Kazakhstan in 1978 was a defining Cabinet for the Ministry of Health of A fundamental human right and that moment in the history of WHO. the Lao People’s Democratic Republic, the attainment of the highest possible level In the words of Dr Halfdan Mahler, attended the International Conference of health is a most important worldwide the WHO Director-General at that time: with Dr Khamlieng Pholsena, Vice- social goal whose realization requires the Primary health care is taken to mean Minister of Health. In fact, Dr Pholsena action of many other social and economic a health approach which integrates at the had an important role at Alma Ata as sectors in addition to the health sector. community level all the elements necessary he was one of the five vice-presidents to make an impact upon the health status of elected by acclamation. Looking back on The following year at the Thirty- the people. Such an approach should be an this historic occasion, Dr Phimphachanh second World Health Assembly in 1979 integral part of the national health stressed that both the philosophy and the Global Strategy for Health for All was care system. practice of primary health care were launched. The goal was commonly known already well established in the Lao as “Health for All by the Year 2000”. This It is an expression or response to the People’s Democratic Republic. was explained in the 10th and final clause fundamental human needs of how can a After the establishment of the Lao of the Alma Ata Declaration: person know of, and be assisted in, the People’s Democratic Republic, primary Health for all does not mean that in the actions required to live a healthy life and health care was enshrined in the policy year 2000 doctors and nurses will provide where can a person go if he/she needs of the new Government. While this was medical care for everyone in the world for relief from pain or suffering. definitely in line with the international all their existing ailments and that nobody A response to such needs must be a move towards primary health care, it was will be sick or disabled. It does mean that series of simple and effective measures in particularly relevant and necessary in the health begins and is fostered at home, in terms of cost, technique and organization, Lao People’s Democratic Republic given school and in factories, where people live which are easily accessible to the people the extreme penury of funding for health and work. People will use better approaches in need and which assist in improving and all other areas of development at this than they do now for preventing disease the living conditions of individuals, time. and alleviating unavoidable illness and disability, and have better ways of growing up, growing old and dying in dignity. 15 Essential health care will be accessible • to launch self-help campaigns so that to all individuals and families, in an the villages could participate in the acceptable and affordable way, and with building and financing of their own their full involvement. There will be an community health delivery systems. even distribution among the population of whatever resources for health are available and people will realize that they themselves have the power to shape their lives and the lives of their families, free from the avoidable burden of disease and aware that ill health is not inevitable. Following the Alma Ata Declaration, the Government of the Lao People’s Democratic Republic took on the following commitments in order to implement primary health care on a wider scale:

• to increase the training of additional medical personnel to be assigned to rural areas with a mission to enrol and train voluntary village health workers; • to give priority to preventative and promotional activities which would meet the basic health needs of the rural communities. This would be achieved

by concentrating on a few vertical WHO programmes with a view to eradicating endemic diseases such as malaria, diarrhoea and tuberculosis; and Convened by WHO and UNICEF, the International Conference on Primary Health Care met in 1978 in Alma-Ata, which is now Almaty in the Republic of Kazakhstan.

16 CHAPTER 3: Primary Health Care Era of “Health for All” The Work of WHO Traditional Medicine in the Lao People’s Democratic Republic (Then and Now)

During these years, WHO provided WHO initiated a major series Over the centuries, an herbal medicine important continuity in the Lao People’s of programmes in the Lao People’s tradition based both on local knowledge Democratic Republic. The WHO Democratic Republic during this period. and Ayurvedic principles derived from Representative in the Lao People’s One of the area was traditional medicine India was practised in the Lao People’s Democratic Republic was Dr Roger Leclercq which can be incorporated into primary Democratic Republic. People gathered from Belgium who served from 1975–1980. health care. plant material from the abundant forests, He had been in the country for a number Scientific research projects on but also cultivated both native and exotic of years, was well connected and knew the traditional medicine funded by WHO plants for this purpose. Herbalist healers country well. included a survey on medicinal plants in included Buddhist monks and nuns who In 1976, the Government of the Lao the Lao People’s Democratic Republic. learnt the healing arts at the wat (temple) People’s Democratic Republic submitted a WHO fellowships have been awarded and villagers who grew medicinal plants request for US$ 2 046 000 broken into basic to researchers from the Lao People’s or gathered them from the forest. Animal health-care services (US$ 416 317), hospital Democratic Republic to learn research parts were also be used in small quantities. services (US$ 344 451), health laboratory methods and new techniques from abroad. Different ethnic groups had their own services (US$ 36 264), health education In many developing countries, indigenous herbal pharmacopeia. (US$ 12 821), human resources for health traditional healers are essential human Between 1954 and 1975, in the development (US$ 16 161), immunization resources for health care in rural provinces of Sam Neua and Phongsaly, (US$ 21 768) and drug production communities, but most have had no the herbal aspects of traditional medicine (US$ 1 198 218). Some of these obligations formal training in primary health care. were widely used and encouraged. The were met by the 1976 regular budget and WHO provided training to the traditional Lao People’s Democratic Republic over others from bilateral donations. healers with the objective of using the years had been influenced by China Dr Leclercq was succeeded by trained traditional healers as public and Viet Nam, which were close both Dr Ravi Ramdoyal from Mauritius who was health educators or primary health-care geographically and ideologically and Programme Coordinator from 1982–1983 providers. had very strong cultures of traditional and then WHO Representative from In addition, technical support has been medicine. 1983–1985. The next WHO Representative, provided for the development of national In 1976, one of the first health who also served as Programme Coordinator, policies and programmes, the regulation of initiatives for the new Government of the was Dr Ziaul Islam from India who took up the practice of traditional medicine and the Lao People’s Democratic Republic was his post in 1986. registration of herbal medicines. to organize extensive training in the use of traditional medicine. Some 520 people 17 from all provinces received training on it was reorganized as the Research Institute on traditional medicine held in December the promotion of the use of traditional of Medicinal Plants. In time, it became 1995 and submitted to the Ministry of medicine. The training sessions lasted three the Institute of Research on Traditional Health. or five days. Trainers were senior healers, Medicine, before reverting to the title of A community-based traditional pharmacists and doctors, and the course Institute of Traditional Medicine. medicine programme was developed participants were young healers, herbalists, There was renewed focus on traditional and expanded in several provinces of the village heath volunteers and the heads of medicine between 1995 and 1999. A draft Lao People’s Democratic Republic. This provincial traditional medicine stations. national policy on traditional medicine focused on providing locally available, That same year, the Institute of in the Lao People’s Democratic Republic affordable and simple remedies by setting Traditional Medicine was created. In 1989, was discussed at the national workshop up herbal gardens in districts and villages and on training village health workers on the safe use of plants. An inventory and survey of medicinal plants was initiated in collaboration with the Research Institute of Medicinal Plants, Ministry of Health. Thirty commonly used plants were selected and a booklet entitled The Medicines in Your Garden was published in the Lao language. This provided information on the identification, collection, use and scientific basis of these plants. In 1997, a six-acre model medicinal plant garden was set up in Vientiane, and since 2000 more than 700 acres of medicinal plant preserves for in situ conservation have been established throughout the country. Research projects funded by WHO included research on dihydro-artemisinin, an antimalarial drug

KPL used for multidrug-resistant cases. Traditional healer working alongside health staff at Hoon District, Oudomxay Province, 1970s. 18 Chapter 4

Opening Up: New Directions and New Partners

1986–2000 Health Trends during this Period

HIV/AIDS was perhaps the greatest In 1993, another disease that was diphtheria. Up until 1995, WHO had coped new global challenge during this period. seen disappearing in some countries was with public health problems associated The first cases of HIV in the Western recording significant numbers of new with emerging and re-emerging diseases Pacific Region were recorded in 1983. By cases in other countries. Tuberculosis was through disease-specific programmes. 1986, the seriousness of the epidemic was declared a global emergency as a result of A cholera outbreak in the Lao becoming apparent. WHO established a the high number of deaths each year— People’s Democratic Republic in 1995 Special Programme on AIDS in 1987, and 3 million worldwide—and also because reported 1261 cases, with 161 deaths. The the following year it was renamed the it affects so many people of working age. regional Outbreak Response Task Force WHO Global Programme on AIDS (GPA). The number of tuberculosis cases of all responded with stockpiles of cholera kits The programme had three main objectives: types in Lao People’s Democratic Republic from Cambodia. In the following year, a to prevent HIV infections, to reduce increased from 2083 in 1990 to 2234 in diphtheria outbreak saw 73 cases, with five the personal and social impact of HIV, 2000, where overall the number of newly deaths. and to mobilize and unify national and notified cases in the Western Pacific Region international efforts. The GPA continued almost doubled from 186 522 to 353 138 until December 1995. over the same period. The Joint United Nations Programme The National Tuberculosis Programme on HIV/AIDS (UNAIDS) was launched (NTP) started directly observed treatment, in January 1996. The new programme short course (DOTS) in 1995 with the was co-sponsored by United Nations support of WHO and the Damien Development Programme (UNDP), the Foundation Belgium. NTP implemented United Nations Educational, Scientific DOTS in all 140 districts of the country and and Cultural Organization (UNESCO), in 2005 reached the targets of identifying the United Nations Population Fund 70% of smear-positive cases and (UNFPA), the United Nations Children’s successfully treating 85% of those cases. Fund (UNICEF), the World Bank and Tuberculosis was an example of a WHO, with the purpose of expanding and disease that was thought to have been strengthening the response of the United declining, but that now was seen to be re- Nations system to HIV/AIDS through emerging. Other examples of enhanced collaboration and joint action on re-emerging diseases were cholera, dengue policies and programmes. fever and dengue haemorrhagic fever, and

20 CHAPTER 4: Opening Up: New Directions and New Partners

Context

From 1986, as part of the New constraints that followed the New Economic Mechanism, the Government Economic Mechanism had resulted in of the Lao People’s Democratic Republic a reduction in available funds, and by decided to reduce public spending for 1993 the number of health centres had the health sector, which since 1975 had, decreased to 723. together with education, accounted for a large part of the budget. In 1987, health budget responsibilities were decentralized to provincial authorities. However in 1992, it was decided that this decision should be reversed, with the health budget and public expenditures again falling under the central Government. The combination of recentralization and limited resources for primary health care and health promotion, plus the poor economic situation in rural areas, led to a reorientation towards the economically stronger urban areas. Higher-level medical and paramedical health workers in particular were not keen to take up postings in rural and remote areas. Between 1979 and 1989, the number of health centres in the Lao People’s Democratic Republic had increased from WHO 294 to 1190. From 1986, the budgetary

A girl being examined at a paediatrics ward, 1999.

21 The Work of WHO in the Lao People’s Democratic Republic

Before the 1990s, when very few donors Other areas that were accorded a epidemiologic surveillance, essential drugs were present in the country, WHO’s significant level of attention included: and vaccines, health systems development, strategy was twofold: capacity-building community water and sanitation, AIDS and communicable diseases. through international training and support prevention and control, leprosy, maternal In addition, there was also focus on for the development of all key institutions and child health, nutrition, blindness financial management planning, oral in the Ministry of Health. Collaborative and deafness, disease vector control, health, primary health care, clinical activities were expanded to cover a large number of projects, many of them receiving donor funding through WHO. These collaborative activities were demand oriented and responsive to the country’s changing needs based on jointly agreed plans. This is a period when the Lao People’s Democratic Republic gradually opened up and actively sought the engagement of more development partners. In addition to bilateral aid, multilateral aid became a major factor. The most substantial areas for WHO involvement in this period were development of human resources for health, malaria, acute respiratory illness, diarrhoeal diseases, immunization and environmental health. In addition to whatever support WHO that was being provided in country, each of these health areas had over 20 separate missions from WHO experts who visited the Lao People’s Democratic Republic Young mothers attending a maternal and child health consultation, 1999. between 1986 and 2000. 22 CHAPTER 4: Opening Up: New Directions and New Partners

laboratory techniques, management for The national malaria control in the Mekong countries in March 1999. national health development, tuberculosis, programme was supported by several This brought the six Mekong countries— parasitic diseases, drug and vaccine safety, partners and in particular, the European Cambodia, China (Yunnan Province), health sector reform, public information, Commission (EC), which made good the Lao People’s Democratic Republic, and health education. progress in protecting the population Myanmar, Thailand and Viet Nam— Traditional medicine, cancer, health of at risk with insecticide-treated bednets. together with various partners. the elderly, hospital services development, Pregnant women and children were The number of malaria cases has mental health, emerging and re-emerging identified as most vulnerable. All types of decreased from 40 666 in 2000 to 22 800 in diseases, food safety, health statistics, malaria can lead to severe problems during 2010. Community participation has helped laboratory development, cardiovascular pregnancy and have severe ill effects on address the malaria problem from the diseases, other noncommunicable diseases, mothers and infants. grassroots level. The Ministry of Health, health situation trend assessments, The Centre of Malariology, Vientiane Capital Health Department, research promotion and development, Parasitology and Entomology (CMPE) and WHO work with district and village alcohol and drug abuse, external relations, instituted public health programmes community representatives on the Model health biomedical information and and measures to evaluate and modify Healthy Villages programme, which informatics complete the list of health procedures on net impregnation, treatment mobilizes community participation priorities. protocols and adequate supplies of to maintain a clean environment and Malaria remained the most serious chemicals at reasonable prices, along with integrate basic health services, which health problem during the 1980s, with some operational, diagnostic and positively impact the health of the prevention techniques focusing mainly treatment capacities. population by adopting better hygiene on community engagement and bednet Towards the end of this period, the Lao practices. usage. By 1995, the gravity of the problem People’s Democratic Republic remained resulted in the Government seeking one of the nine countries in the Western additional resources by taking a World Pacific Region where malaria was still an Bank loan of US$ 5.9 million to implement important health problem. The Roll-Back a malaria control programme covering Malaria (RBM) Initiative was launched 24 districts in eight provinces.

23 Model Healthy Villages in Vientiane Capital

Many years ago, health workers in the environmental health and sanitation, The criteria that had to be met Lao People’s Democratic Republic came vaccination, mother and child health, included the “three cleans”, namely clean up with a catchy slogan they refer to as control of communicable diseases, essential food, clean water and a clean household the “three cleans”: Gin Sa’at, Deum Sa’at, drugs, and an improved health network. environment, as well as access to a latrine, Yu Sa’at. These can be loosely translated as It focused on a clean environment, the destruction of mosquito larvae, “clean or safe food, clean drinking-water, enough clean water and latrines, and a necessary vaccinations for pregnant clean or hygienic home”. very low rate of communicable diseases. women and children, the absence of One setting where the “three cleans” If a village was particularly successful in epidemic diseases such as dengue fever in have been central is in the designation of improving sanitation and standards of the village, a good drainage system, animal “Healthy Villages” and “Model Healthy cleanliness and health, then it could be cages kept away from homes, and clean Villages” (MHV). The Lao People’s designated as a Model Healthy Village. and tidy areas around homes. Democratic Republic has few big cities In Vientiane Capital, the Model Village health committees continue and even the main centres of population Healthy Village programme started in to organize and hold meetings for such as Vientiane Capital, Luang Prabang, Sisattanack District in 1991. By 1995, villagers about MHV activities. Villages Savannakhet and Pakse are not truly urban six villages had been declared Model are inspected and scores are awarded to settlements. The basic administration unit Healthy Villages and the scheme was households. Coloured flags are handed out in the Lao People’s Democratic Republic is later extended to all nine districts in the to the households after the evaluation (red the ban or village. Several villages are Vientiane Capital. for best, yellow for moderate households clustered together into a village group and Households were scored on a scale of and blue for households in need of the next unit is the district. The average 1 to 10 according to a checklist. The best improvement). Award ceremonies are held province in the Lao People’s Democratic households scored 8–10, a moderate score to recognize the Model Healthy Villages. Republic has about nine districts. was 5–7 and a poor household scored less The idea behind Healthy Villages was than 5. For a village to be declared a Model to establish a local community where Healthy Village, 80% of households had to primary health care was implemented be ranked in the top category. in terms of health education, nutrition,

24 CHAPTER 4: Opening Up: New Directions and New Partners

Like the Model Healthy Village Another project that achieved success In 1996, the Report of the Regional programme, Healthy Cities and Healthy by working closely through schools is the Director on the Work of WHO in the Islands initiatives recognized the key Expanded Programme for Immunization, Western Pacific Region noted that one of role of education in enhancing the health which targets six diseases: diphtheria, the contributing factors to the remarkable status of entire populations. The WHO pertussis, tetanus, polio, measles and improvements in the health status in Western Pacific Region recognizes schools tuberculosis. The five-year acceleration plans children in the Region was the expanded as a priority setting in the regional health resulted in rapid geographic expansion, even coverage for immunizations, including promotion programme. In addition, the to remote areas. This was achieved through tetanus toxoid given to mothers during New Horizons in Health programme the mobilization of a cross-section of society: pregnancy. suggests concrete actions for developing political and religious leaders, women’s and Comprehensive reviews enabled healthy lifestyles and healthy physical and youth groups, schools, and governmental national plans to be revised and targets social structures in school settings. and nongovernmental organizations, and were met. However, work was still needed the media. to extend cold-chain management so that vaccines could retain their potency even after being transported to remote districts. WHO’s collaboration with UNICEF resulted in the development of a new generation of cold-chain equipment. Neglected tropical diseases, namely soil-transmitted helminthiasis (STH), foodborne trematode infection due to Opisthorchis viverrini, schistosomiasis and lymphatic filariasis are important public health problems in the Lao People’s Democratic Republic. The schistosomiasis control project on Khong Island was a major WHO-supported initiative. Schistosomiasis control began in October 1989, with active participation from the Institute of Malariology, Parasitology and KPL Entomology in Vientiane. Health workers carrying out health checks at a primary school in Champassak Province, 1986. 25 A vaccinationcampaign inChampassakProvince, 1980s KPL tetanus vaccine(DPT),oralpoliovaccine, EPI werefordiphteria,pertussisand underserved regionsoftheworld. for majorchildhoodillnessestochildrenin smallpox activities toprovideothervaccines use theexpertiseandlessonslearntfrom Eradication Programme,itwasdecidedto for children.AttheendofSmallpox create nationalvaccinationprogrammes 1977 byWHOtohelpdevelopingcountries Immunization (EPI)wasestablishedin in theLaoPeople’s Democratic Republic The ExpandedProgramme onImmunization Initially, theantigensprovidedthrough The ExpandedProgrammeon Outreach tovillagescamelater.Since1991, in provincialandsomedistricttowns. to selectedpartsofthecountry,mainly 1991, immunizationserviceswerelimited established intheearly1980s.Priorto Republic, theNationalEPIwas vaccine). encephalitis andpneumonia(pneumococcal influenza typeB,rubella,Japanese protection againsthepatitisB,Haemophilus vaccines havebecomeavailableproviding measles andBCG.Inrecentyears,new In theLaoPeople’sDemocratic surveillance, whichhelped able toestablish good Programme (NIP)was National Immunization Democratic Republic’s the 1990s,LaoPeople’s polio eradicationeffortin diseases. Withitssuccessful reliable surveillanceforthe disease incidencerequires of vaccinationsontarget all antigensatabout70%. occurred, withcoveragefor country. Steadyincreases expanded tocovertheentire programme activitieswere Monitoring theimpact result inincreased immunitylevels. previously hard-to-reach areasshould regular programmethrough accessto continue sogradualextension ofthe system infrastructure.This trendwill improvement inbothroads andhealth in thecountryhaveresulted inan outreach. Recenteconomicdevelopments the year,assumingthereareresourcesfor reached foronlyfourtofivemonthsof must becoveredbymobileteams. that areverydifficulttoaccesssothey of thenationalpopulationlivesinareas been bothfinancialandhuman.Some30% populations. Resourceconstraintshave has beenresourcesandaccesstotarget disease interventionssupportedbyWHO, indeed formostofthecommunicable Lao People’sDemocraticRepublic,and free inOctober2000. Region wereofficiallycertifiedaspolio- and othercountriesoftheWesternPacific October 1996. Lao People’sDemocraticRepublicwasin the country.Thelastpoliocasein the eliminationofwildpoliovirusfrom guide programmeeffortsanddocument Some ofthesedifficultareascanbe The mainchallengeforEPIinthe The LaoPeople’sDemocraticRepublic

26 CHAPTER 4: Opening Up: New Directions and New Partners The Fight Against Schistosomiasis on Khong Island

Schistosomiasis, also known as The symptoms of schistosomiasis Schistosomiasis haematobium, S. mansoni and bilharziasis or snail fever, is a significant are caused by the body’s reaction to the S. japonicum, none of these occur in the Lao zoonotic disease. It is a waterborne worms’ eggs, not by the worms themselves. People’s Democratic Republic. infectious disease that affects both humans Intestinal schistosomiasis can result in In 1950, a specific schistosomiasis, similar and a variety of animals. It is caused by abdominal pain, diarrhoea and blood in to S. japonicum, was discovered when a Lao blood flukes or trematode flatworms of the the stool. Liver enlargement is common in student studying in Paris was admitted to a genus Schistosoma. The intermediate host advanced cases and is frequently associated hospital there. The student originally came for the parasite is a freshwater snail that with an accumulation of fluid in the from Khong Island to the south of Pakse in releases the larvae form of the parasites peritoneal cavity and hypertension of the Champassack province. Khong district has a into the water. They then penetrate the abdominal blood vessels. In such cases there population of approximately 65 000 distributed skin of people while they are swimming, may also be enlargement of the spleen. among 13 communes and 131 villages that wading or fishing. The economic and health effects depend on rice cultivation, fishing and tourism. of schistosomiasis are considerable. In The Mekong flows through the district, children, schistosomiasis can cause anaemia, which contains a large number of islands stunting and a reduced ability to learn, of which Khong Island is the largest. For although the effects are usually reversible generations, every island community had with treatment. Chronic schistosomiasis its “fat-bellied people”, but the inhabitants

WHO may affect people’s ability to work and in were unaware of the parasites that caused the some cases can result in death. condition. Between 1963 and 1967, a number of In 2010, schistosomiasis was endemic other Lao students in France were found to have in 74 countries affecting more than 207 the same parasite. WHO recruited a number of Children on Khong Island, 1989 million people worldwide, mostly living parasitologists and epidemiologists and sent In the body, the larvae develop into in poor communities without access them to the Khong Island on two occasions. adult schistosome, which live in the blood to safe drinking-water and adequate It was not until a third mission in vessels. The females release eggs, some of sanitation. An estimated 700 million 1966–1967 by Toshihico Iijima and Rolando G. which are passed out of the body in the people worldwide may be at risk of Garcia that a survey among school children urine or faeces to continue the parasitic infection as their agricultural, domestic on Khong Island found a high prevalence of life-cycle. Others are trapped in body and recreational activities expose them to the disease. At this point the parasite was also tissues, causing an immune reaction and infested water. There are three major strains recognized as a new species, given name S. progressive damage to organs. of schistosomiasis that affect humans: mekongi. 27 Many years went by before a major found that 100% of the people interviewed took the form of workshops, training programme was undertaken to control the bathed in the Mekong River: 97% of them sessions and the distribution of illustrated disease in the Lao People’s Democratic bathed exclusively in the river, while posters and calendars. The programme to Republic. The intervention supported by 3% occasionally used well-water. All the control schistosomiasis due to S. mekongi in WHO began in November 1988, 30 years families used the river water for domestic Khong district lasted from 1989 to 1999. after the discovery. The intervention included purposes; about 2% used well- water. Despite limited resources, the a mass drug administration (MDA) of All of the families fished in the Mekong programme was successful. The coverage praziquantel and health education in Khong and this inevitably involved wading in of the population by MDAs was excellent district, which continued until December 1990. the Mekong, whatever fishing method and the campaign was considered a major The MDA of praziquantel, with a single was used. Some 40% of the families said achievement. Prevalence in 21 sentinel dose administered at the rate of 40 mg/kg they had never used latrines, and of those villages declined dramatically: in 1989, body weight, was conducted in April 1989 and who had 8% said that they also defecated in 21 villages surveyed, prevalence was continued until the end of the programme. outdoors occasionally. In addition, 38% estimated to be more than 50%; in 1993, The MDA excluded children under 2 years of the families said that their children in 17 villages surveyed, prevalence old, pregnant and breastfeeding women, defecated in the Mekong. had decreased to 1.5%; and by 1999, in people with neural diseases, and those living None of the families had any idea 21 villages surveyed, prevalence was inland, more than 6 kilometres from the of a link between the disease and water estimated to be 0.8% Mekong River. snails, hence their lack of concern about After the end of the intervention, From August 1991, the MDA targeted the health risk of contact with the Mekong. limited monitoring was carried out. In everyone above 4 years of age, and the Clearly, health education would be of May 2003, the Lao government and WHO programme was conducted at least four times paramount importance. Therefore, the conducted a survey in 65 villages in Khong in more than 100 villages in all the communes. Lao government and WHO created a new district and 24 villages in Mounlapamok In 1994, an evaluation supported by WHO name, Phayadhoy Muang Khong (snail district and found that the prevalence was showed the prevalence had fallen to below transmitting the disease in Khong), to 1%–47%, with an average of 11% in Khong 0.4%. assist in health education by explaining district. The re-emergence of S. mekongi A survey conducted of 100 families how the disease was transmitted through was confirmed and WHO immediately living in Chomthong in Khong Island found the river. provided drugs for the treatment of the that almost everyone was aware of the This strategy was very effective in disease. Follow-up surveys conducted in disease, but they knew very little about the raising awareness, but the campaign was 2004 and 2011 showed that the prevalence intermittent host, S. mekongi. The survey limited to Khong Island. Health education is low and well under control.

28 Chapter 5

Into the New Millennium

2000–2012 Context

For much of the 20th century, people leaders present at the summit committed and poverty is clear. The Lao People’s looked towards the year 2000 as a hugely to combat poverty, hunger, disease, Democratic Republic has been the most significant threshold. The turn of the illiteracy, environmental degradation and heavily bombed country, per capita, in century also marked nearly 25 years since discrimination against women. history. Today, cluster sub-munitions the proclamation by the World Health The eight Millennium Development and other UXO continue to kill and Assembly of “Health for All by the Year Goals (MDGs) are derived from the injure 300 people a year. The presence of 2000”. But as the new century dawned, the declaration and all have specific targets UXO negatively impacts socioeconomic majority of the world’s population was and indicators. development, preventing access to still a long way off in terms of enjoying the development land. good health that was now considered as a Millennium Development Goals (MDGs) While some of the MDGs are clearly fundamental human right. health-specific, they are all interdependent. In his Millennium Report, Kofi Annan, MDG 1: Eradicate poverty and hunger All of the MDGs influence health, and the United Nations Secretary-General, MDG 2: Achieve universal primary health will indirectly affect all of the signalled the progress made since the education MDGs. For example, better health founding of the organization, but also MDG 3: Promote gender equality and enables children to learn and adults to highlighted many intolerable inequalities: empower women earn. Gender equality is essential to the “There is much to be grateful for. There are MDG 4: Reduce child mortality achievement of better health. Reducing also many things to deplore and correct.” MDG 5: Improve maternal health poverty, hunger and environmental Most people could expect to live MDG 6: Combat HIV/AIDS, malaria and degradation positively influences—but longer; they were better nourished and other diseases also depends on—better health. enjoyed better health. At the same time, MDG 7: Ensure environmental The nine MDGs are made up of 21 grinding poverty and striking inequalities sustainability quantifiable targets. Sixty indicators persisted within and among countries, MDG 8: Develop a global partnership for measure progress towards those targets. even amid unprecedented wealth. Diseases development The Millennium Summit was followed old and new still threatened to undo by another summit and report in 2008, progress. In 2010, the Lao People’s Democratic and another in 2010. In addition, regular On 8 September 2000, following a Republic introduced a localized goal— reviews have measured the overall three-day Millennium Summit of world MDG 9—to reduce the impact of progress of individual countries and their leaders at the United Nations, the General unexploded ordnance (UXO). With likelihood of achieving each MDG by 2015. Assembly adopted the United Nations 41 out of 46 of the poorest districts facing Millennium Declaration. All 189 world the threat, the correlation between UXO 30 CHAPTER 5: Into the New Millennium

Global Health Issues and their Impact on the Lao People’s Democratic Republic Globalization had become an increasingly important issue in the 1990s. The interconnectedness of nations and communities was evident in the way disease outbreaks spread alarmingly across borders. While the attention of the development community was focused to a large extent on working towards the achievement of the MDGs, new challenges were soon to emerge in international health. The process of opening up and embracing a more market-driven economic model continued and accelerated after 2000. Over the last 10 years, the economy of the Lao People’s Democratic Republic has been growing steadily with annual growth of gross domestic product (GDP) at around 8%. The changes have had a positive impact on the health status of the population and on health developments. In 2003, there was an outbreak of a new and highly virulent virus, known as the severe acute respiratory syndrome, or SARS. The outbreak originated in China and came to international attention in February 2003. Over the next few months, the SARS epidemic caused an enormous WHO amount of fear and social disruption,

SARS preparation at Mittaphab Hospital, 2003 crippling international trade and travel and massively impacting economies. 31 This health emergency loomed large During the critical period of April However, it did give rise to much- and extraordinary measures were taken to July 2003, integrated training was enhanced surveillance and improvements both in countries where cases were delivered to front-line staff in hospitals in infection control. recorded and internationally. WHO and to border and checkpoint staff at The SARS epidemic was halted within coordinated the international response the central and provincial level. The a few months and the crisis led to a and was able to help countries to contain training included epidemiology, clinical 2005 revision of the International Health transmission, seal off opportunities for management, infection control and Regulations (IHR). This marked the first the spread of SARS and prevent this new laboratories. Health workers in the Lao time IHR had been fully revised since 1969, disease from becoming endemic. People’s Democratic Republic were highly when it added six quarantine diseases. The One feature of SARS was that it had motivated to improve their skills and 2005 revision embodied a major paradigm a very high level of transmission within knowledge, as they were aware of the shift: from control at borders to achieving health facilities. A large proportion of enormity of the risk. containment at the source, from a list of the people contracting the disease were At that time, the only isolation unit diseases to all public health threats, and health workers who came into contact with was at the Mittaphab (Friendship) Hospital from preset measures to adapted response. people already infected. Of over 8000 cases in Vientiane Capital. Personal protective The legal requirements became far globally, 95% occurred in the Western equipment was distributed to the main more wide ranging and had implications Pacific Region and 12 countries were hospitals and border checkpoints. A for building capacity to “detect, assess, affected. About 10% of the cases proved manual for preparedness and response notify and report events in accordance fatal. Two of the most seriously affected was drafted and it served as the basis for with the regulations” and to “respond countries were China and Viet Nam, both training of trainers for other provincial promptly to what was discovered”. Instead sharing borders with the Lao People’s hospitals later in the year. In 2004, a of covering a list of specific diseases, it Democratic Republic. variety of training materials for infection broadened the range and definition of Three WHO consultants were hastily control and for information, education and health threats. posted to the Lao People’s Democratic communication was developed for the Lao Epidemic-prone diseases are still at the Republic to provide support to the People’s Democratic Republic. forefront in the battle against emerging Ministry of Health for SARS preparedness Fortunately, the SARS outbreak did and re-emerging diseases. But IHR (2005) and response. not spread to the Lao People’s Democratic covers foodborne diseases, accidental Republic. The prevailing hospital facilities and deliberate outbreaks, toxic chemical and limited human resources would accidents, radiological and nuclear have made it very difficult to contain. 32 CHAPTER 5: Into the New Millennium

accidents, and environmental disasters. The Lao People’s Democratic Republic losses to basic infrastructure. A joint Control at borders is important but so is is generally not affected as severely by damage, losses and needs assessment was containment at the source. natural disasters as some of the other undertaken by the Government of the Lao Soon after SARS, another serious countries in the Western Pacific Region. People’s Democratic Republic, United threat emerged in the Western Pacific However in 2009, several of the provinces Nations agencies and nongovernmental Region when eight Asian nations reported in the south of the country were seriously organizations. outbreaks in poultry of a highly pathogenic affected by Typhoon Ketsana, which The Office of the WHO Representative avian influenza A (H5N1). Huge numbers caused extensive flooding and damage to in the Lao People’s Democratic Republic of domestic birds were culled in order to infrastructure. Five district hospitals were led the “health cluster” in the assessment. halt the disease, with serious economic affected or destroyed, and hundreds of Health facilities in three out of four Haima- and social consequences, especially in the houses were destroyed. Nine people died. affected provinces were damaged by poorer communities. The pathogen could In the following months, there was a flooding. Flood damage affected buildings, and did transmit to humans and proved need to support relief and reconstruction equipment, furniture, medicine and fatal. efforts and health interventions. A medical supplies among other resources. In March 2009, another significant new subsequent nutritional survey conducted Substantial funding was required to cover strain of influenza originated in Mexico, by the National Institute of Public Health the cost of conducting disease-prevention known by the popular name “swine flu” (NIPH) found critical or serious rates of activities, including health education, because it was initially thought to have malnutrition in 13 districts of Attapeu, distribution of insecticide-treated bednets, links with pigs. As it started to spread Salavan and Savannakhet provinces. As the use of abates to control mosquitoes, internationally, WHO progressively raised a result, there was a joint United Nations and better treatment and enhanced disease the level of alert until it reached level 6 and response in support of the Government surveillance activities. was declared a pandemic. The first case in in these districts. WHO, along with the Lao People’s Democratic Republic was other United Nations agencies, provided detected in 16 June 2009, raising the level emergency relief. of surveillance. On 24–25 June 2011, Typhoon Haima A quick multisectoral approach was hit the northern and central parts of initiated with stakeholders from the the Lao People’s Democratic Republic various ministries and the Department causing heavy rain, widespread flooding of Immigration. Risk communications and serious erosion in the provinces of training was organized and was attended Bolikhamxay, Vientiane, Xayaboury WHO by high-level officials, demonstrating its and Xieng Khouang provinces. The priority for the Government. typhoon caused severe damage and

Field epidemiology work in community mobilization, 2011 33 Strengthening Surveillance and Response

An effective surveillance, risk electronic transmission of data that can be and a hotline at the NCLE for health-care assessment and response system is an implemented easily at the provincial level workers. The lines are staffed day and important part of any country’s defence once staff had received basic training. It night, answering calls, recording reports against emerging infectious diseases. includes clear indicators and automatically and passing on information to NCLE or the The first steps towards establishing a generates trend graphs that are easy to National Animal Health Centre if action is surveillance system in the Lao People’s interpret and alerts that signal when action required. Democratic Republic were taken in 1989 needs to be taken. Another initiative piloted in 2010 when an indicator-based surveillance (IBS) Another recent surveillance involved issuing guidelines and training on system was introduced called the National development involves the allocation of the prevention and control of communicable Surveillance System for Notifiable Selected provincial sentinel hospitals for sending diseases to school teachers in Vientiane Diseases (NSSNSD). of samples from patients with suspected Capital, including reporting of outbreaks The system involves cases and influenza-like illness and severe acute or high absenteeism to the nearest health deaths associated with priority diseases respiratory infections to the NCLE on a facility or office. The successful programme and conditions seen at health facilities weekly basis for influenza testing. The is now being extended to other provinces. nationwide, with the data collected by results are fed back on a weekly basis to As the main objective of emerging health offices in a systematic way and help public health decision-making at the disease surveillance in the Lao People’s routinely reported to the next level within local and national levels. Also, samples are Democratic Republic is to enable timely the public health system. Data are then sent to international reference laboratories recognition of and response to outbreaks, analysed, interpreted and fed back to for typing. In the future, routine testing of these early warning surveillance systems users in a timely way to allow for a rapid samples from other priority diseases, such have had a significant impact on the ability local response and to inform timely policy as dengue, could be referred in this way. of national and provincial health office staff decisions. While indicator-based surveillance to identify and respond to outbreaks. At the In 2008, a computerized system was (IBS) ensures that patterns of diseases same time, multidisciplinary rapid response developed by WHO and introduced as and syndromes in health facilities are teams have been set up in all provinces, part of the NSSNSD Lao Early Warning monitored on a weekly basis, a different including staff members who have been and Response Network (Lao EWARN). approach needs to be taken for immediate trained in the one-year, in-country field It was implemented using the existing reporting of unusual events, especially in epidemiology training programme. In fact, surveillance structure at provincial health the community. This is where event-based the Lao People’s Democratic Republic was offices and centrally at the National surveillance (EBS) is important. recognized throughout the Western Pacific Centre for Laboratory and Epidemiology Hotlines are the main mechanism Region for the progress made in surveillance (NCLE). The benefit of this system is a for encouraging reporting by the general and response over the last few years. computerized data entry form and timely public, with a “166” hotline for the public 34 CHAPTER 5: Into the New Millennium

Managing Emerging Infectious Disease Threats through Field Epidemiology Training

Against the backdrop of pandemic public health needs. Applied activities are FET has played a major role in influenza threats, including highly linked to supporting essential surveillance developing core surveillance and response pathogenic avian influenza, the Lao and response activities at the National capacity in the Lao People’s Democratic People’s Democratic Republic recognized Centre for Laboratory and Epidemiology Republic. The applied nature of the the need to strengthen and decentralize (NCLE). training has equipped graduates with national epidemiological capabilities. In February 2009, the first eight Lao the ability to readily and effectively This was accomplished by establishing FET trainees gathered at NCLE in Vientiane employ their newly gained knowledge. an adapted Field Epidemiology Training Capital to start the training course. In addition, the impact of the trainees’ (FET) programme with support from They came from six strategically located field work findings and recommendations Influenza Division of the United States provinces (Champassack, Luang Namtha, has translated into Ministry of Health Centers for Disease Control and Prevention Luang Prabang, Oudomxay, Savannakhet policies for the control of communicable and WHO. and Vientiane Capital), as well as from diseases. These include, for example, the With critical pressure on human NCLE and the National Animal Health starting of new vaccine initiatives for resources for health, the Lao Ministry of Centre (NAHC). rubella and Japanese encephalitis. In the Health developed an innovative one-year After three years, the Lao FET alumni near future, the Lao FET is to be further FET tailored to the Lao context. Eight network boasts 23 graduates, covering strengthened through development of the trainees from the national and provincial 16 of 17 provinces, who have since returned alumni network and a focus on training for levels are selected annually from both to work after completing the training. trainers, supervisors and mentors. the human (six) and animal (two) health FET has proven to be a critical resource in sectors, thereby facilitating the “One the rapid identification and response to Health” concept. outbreaks and in providing more accurate Each of three modules consists of one- and timely surveillance data. Furthermore, month practical classroom instruction and the network of graduates, armed with three months of applied field experience. new skills, now comprises the core human Each FET trainee is assigned an operational training resources for undertaking training research project tailored to meet national at the local level.

35 Aid Effectiveness The Vientiane Since the late 1990s, there has Harmonization: Donor countries Agreement been increasing concern about aid coordinate activities, simplify effectiveness— the extent to which procedures and share information to The number of United Nations agencies aid achieved demonstrable results in avoid duplication. and international nongovernmental overcoming poverty and increasing the Results: Developing countries and organizations partnering with the Lao quality of people’s lives. Critics have said donors shift their focus to development People’s Democratic Republic has been aid was too often donor led, reflecting the results and measure those results. increasing steadily over the years. To better priorities of the richer nations rather than Mutual accountability: Donors coordinate the efforts of the Government and empowering the developing countries and partners are accountable for development partners, a new coordination they intended to help. Too often, aid was development results. mechanism was established in 2006. The first uncoordinated, unpredictable and lacking round-table meeting was held in 1998. At its heart was the commitment to in transparency. Eight sector working groups addressing help governments in developing countries In 2005, the international community different areas of social and economic formulate and implement their own gathered in Paris for a High-Level Forum activity began meeting regularly. The health- national development plans, according on Aid Effectiveness, hosted by the French sector working group soon became one of to their own national priorities, using Government and the Organisation of the most active, with a reputation for best wherever possible, their own planning and Economic Co-operation and Development practices and attention to aid effectiveness. implementation systems. (OECD). Representatives from donor- A national census was conducted in 2005. At In February 2007, the Government of and developing-country governments, the same time, a nationwide reproductive theLao People’s Democratic Republic and multilateral donor agencies, regional health survey was carried out. its partners in development adopted the development banks and international In 2009, the Government of the Lao Vientiane Declaration of Aid Effectiveness. nongovernmental organizations endorsed People’s Democratic Republic enacted a This localized version of the Paris the Paris Declaration on Aid Effectiveness. decree for the regulation and operation Declaration and added specific details to The declaration highlighted five of Lao non-profit associations. This fit the circumstances of the Lao People’s fundamental principles for making aid marked a significant step towards a more Democratic Republic. In addition to the more effective: enabling environment for civil society in MDGs, it also looked to the long-term Ownership: Developing countries the country. There is now a mechanism development goal of exiting from the least- set their own strategies for poverty for civil society organizations to become developed country status by the year 2020. reduction, improve their institutions registered and recognized as legal entities, and tackle corruption. with the possibility of accessing funds and Alignment: Donor countries align contributing to the development process behind these objectives and use local within the country. systems. 36 CHAPTER 5: Into the New Millennium Meeting the Challenge of Maternal and Child Health

Maternal and child health, in particular 79 per 1000 live births and the infant A wide range of traditional practices that of infant and children up to 5 years, mortality rate at 68 per 1000 live births. and beliefs, such as food taboos or has always been a huge challenge in the Thus, target for MDG 4, which calls for a restrictions for women during pregnancy Lao People’s Democratic Republic. In 2005, reduction in child mortality, is relatively or in the days or weeks following the maternal mortality rate (MMR) was on track. childbirth, need to be addressed. A balance 405 per 100 000 live births, the under-5 Many factors continue to contribute needs to be struck between respecting mortality rate was 97 per 1000 live births, to these high mortality rate including the traditional practices, such as how the and the infant mortality rate was 70 per remoteness of communities and transport umbilical cord is cut and that of a new 1000 live births according to 2005 census difficulties, the tendency of many ethnic mother lying over a hot bed of coals. data. groups to marry and start child-bearing According to the Lao Reproductive There was progress noted in the recent at a young age, a relatively high birth rate Health Survey of 2005, almost 85% of Lao Social Indicator Survey (LSIS) 2011 and lack of birth spacing, a paucity of births took place at home, and trained data, with MMR at 357 per 100 000 live services, and difficulty in accessing those health personnel assisted with only births, the under-5 mortality ratio was services when needed due to financial or about 18% of births. This means that personal reasons. complications in pregnancy or during Maternal mortality suffers from childbirth may not be recognized in considerable under-reporting, as time and potentially life-saving actions maternal deaths are difficult to measure to address minor complications may be owing to many factors, including their delayed, resulting in the high maternal relative comparative rarity and context- mortality ratio. specific factors such as reluctance to The 2011 LSIS data show 37.5% of report abortion-related deaths, problems childbirths taking place in health facilities with memory recall or lack of medical and 42% were assisted by trained health attribution. personnel, marking progress since 2005. Social and cultural barriers often However, most maternal deaths occur in prevent women from exercising their rural, hard-to-reach areas where access to a WHO freedom of reproductive choices. health centre may be difficult. The outreach team making a regular visit to Limited choice or poor availability of Houaysatanh Village up from the Nam Kanh River in Luang Prabang Province, 2003. contraceptives makes the adoption of fertility-regulating methods difficult.

37 Improved data collection and analysis governance and management capacity for In May 2010, with financial and human also show that the low status of women programme implementation; to strengthen resource support from the Korea Foundation and a lack of education may directly or the efficiency and quality of health-service for International Healthcare, US$ 1 million indirectly influence a woman’s choice in provision; and to mobilize individuals, was mobilized and one staff member was terms of the number of pregnancies, access families and communities for maternal, provided on secondment for WHO to to health care and better nutrition, among neonatal and child health. scale up the initiative in 10 districts of two other issues. The current challenge is to implement provinces, Xieng Khouang and Huaphan. Maternal education can enhance the this package of services at the district, This in turn led to further scale up of chance of a child’s survival as measured health-centre and community levels. the initiative to support five additional by nutritional status, infant mortality and While WHO supports the nationwide districts in Huaphan in May 2011, thereby child mortality. A child whose mother has implementation of the MNCH strategy, it supporting all districts in the two provinces not been to school is 2.5 times more likely has simultaneously supported and MNCH with this coverage. to die than one whose mother has had initiative in two districts, one in the north seven years or more of education. and the other in the south to gain practical A technical working group bringing experience of MNCH service-package together groups involved in maternal and delivery. child health and EPI covering government The MNCH initiative is an integral sectors, United Nations agencies, part of the Government’s efforts in the bilateral donors and nongovernmental nationwide implementation of the MNCH organizations was established in 2007, strategy. The role of WHO is to support the and assisted in the development of the Government to obtain practical experience Strategy and Planning Framework of through the initiative in delivering the Implementation of Maternal, Neonatal and integrated MNCH package, through timely Child Health Services in the Lao People’s updates on the implementation process Democratic Republic (2009–2015), which elsewhere, and to speed up the progress in

was launched in September 2009. achieving MDGs 4 and 5. WHO The national Maternal, Newborn and Many data collection tools, forms and Child Health Strategy defined an MNCH guidelines were formulated as a result of integrated package of care and a service- the initiative, such as health-centre micro- delivery mechanism. It outlined three plans, village data collection forms, and Expanded Programme on Immunization outreach strategic objectives: to improve leadership, operational guidelines and reporting forms activities in Ban Samphanna in Sangthong District of Vientiane Province, 2003. for district planning. 38 CHAPTER 5: Into the New Millennium

The original initiative and the scaled- All of these activities were conducted MNCH is improving in the Lao up programme focus on three strategic in close cooperation with the Ministry of People’s Democratic Republic given the objectives: to build the capacity of Health through joint visits, training and priority set in recent years. The coverage Government staff at the provincial, district supervision and resulted in strengthening of antenatal care with at least one visit and health-centre levels to make their own capacity at the central level and a spirit of has increased from 35.1% in 2006 to annual plans; to organize simultaneous ownership and mutual respect between 71% in 2009. For the same period, the training and collection of data at the village collaborating partners. proportion of births assisted by skilled level; and to make regular supervision In early 2011, a joint United Nations birth attendants has increased from 20.3% visits. project involving four United Nations to 37%. Clinical skill capacity-building was agencies (WHO, UNFPA, UNICEF and The Lao People’s Democratic Republic made possible through support to short the World Food Programme) successfully remains a relatively low-prevalence training courses for health centre staff and signed a Memorandum of Understanding country for HIV/AIDS. There have the provision of basic medical equipment, securing a US$ 10 million fund from the been concerted efforts to ensure that such as delivery beds and delivery kits to Luxembourg Government to support information and prevention measures health facilities in district hospitals and the Ministry of Health in implementing reach at-risk populations. Half of all new health centres. the Integrated MNCH service package HIV infections are among people aged Mobilizing community human to reduce maternal, newborn and child 15–24. As the Lao People’s Democratic resources, especially village health mortality and morbidity, as well as the Republic is surrounded by countries with volunteers, involves setting up terms of high levels of malnutrition in women and high prevalence rates and mobility is reference for the focal MNCH person in children under 5 years of age. increasing rapidly both within the country the village to collect data, to provide health Through this joint programme, the and across borders, there is still a real education to villagers, and to encourage United Nations agencies supported the threat of an expanding HIV epidemic. pregnant women to visit a health facility Government in its implementation of the for delivery. It also includes a scale-up Integrated MNCH Services Package in four phase with a voucher system in support of provinces (Luang Namtha, Oudomxay, free delivery service for pregnant women. Phonsaly and Savannakhet). WHO also supports the nationwide school de- worming programme and weekly iron/ folate supplementation programme for women of reproductive age.

39 Great Expectations

A 27-year-old mother from the Lao The feature, Great Expectations, People’s Democratic Republic was among continued in the months leading up to six women highlighted in a one-of-a-kind the World Health Day on 7 April 2005, WHO web site feature on pregnancy and which highlighted issues of maternal and childbirth. The feature followed the daily child health, with the slogan “Make every life of Bounlid from Vientiane Province, mother count”. from the time she was five months The other mothers came from Bolivia, pregnant until her child was 1 year old. Egypt, Ethiopia, India and the United Bounlid’s story was part of a global Kingdom (each country representing a effort to ensure that women give birth different WHO region). It showed both safely to healthy children and to publicize the universal aspects of the experience the fact that over half a million women die of pregnancy, childbirth and caring for in pregnancy and childbirth annually and a young baby, but also the differences nearly 11 million children do not reach in the lives of the six women. While the their fifth birthday. initial project ran for a shorter time span, the team in the Lao People’s Democratic Republic continued to record the lives of WHO Bounlid and Lang until the little girl was 5 years old. At the time, the choice of a woman Bounlid and Lang at 5 years of age, 2010 from a rural village in the Lao People’s Democratic Republic was a bold one as The Lao mother and child did not the country had one of the worst records have access to the recommended postnatal in the Western Pacific Region regarding care and Lang did not have the childhood maternal, neonatal and child health. The immunizations that should have been series of photographs taken of Bounlid and completed before turning 1. Their family WHO her new baby girl, Lang, were intimate, did not have access to clean drinking-water Lang at one week, 2005 poignant and representative of many and sanitation, though that has improved families in the country. over time.

40 CHAPTER 5: Into the New Millennium

Kinoy’s story

Kinoy, who lives in Savannakhet In 2001, he joined a study visit to When he returned from the study visit, Province, has known his HIV positive Thailand where he met other people living he joined others in advocating for ARV status since 2000. At that time, there was with HIV and heard about antiretroviral drugs to be brought to the Lao People’s no antiretroviral therapy (ART) in the Lao (ARV) drugs for the first time. They Democratic Republic. In September People’s Democratic Republic. In 2001, explained how the drugs worked and 2003, ARV drugs became available at he joined a group of HIV- infected people how important it was to be committed to Savannakhet Hospital. He was the second in Savannakhet and began to volunteer taking them properly: to get into a routine HIV-infected patient to have access to this helping provide counselling to HIV- and to keep taking them regularly. It was treatment in the country. infected people who came to the provincial important to take the correct dose at the Since then, the number of people hospital. Many HIV patients had the right time. They explained the advantages with access to these drugs has increased wrong information about HIV/AIDS, and of these drugs and also the possible dramatically. People who need ART do not they needed some kind of psychological side effects. have to pay for it. There are several centres support as well as medical care. in the country where treatment is free. The therapy allows HIV-infected people to lead a normal life. Kinoy became the head of self- help group for people living with HIV and a full member of the national HIV group involved in the development and review of HIV national strategies and laws. People living with HIV should have a say in how policy and services are developed. But it is a long road because many people who may be at risk still do not know their HIV status and do not have access to HIV information. A lot has been accomplished, but there is still a way to go before the entire country is properly WHO covered. Kinoy would like to continue working to help others to have a better quality of life and fair access to prevention Kinoy as an advocate for people living with HIV, 2011. and treatment. 41 Looking to the Future

WHO works with other development As a member of the United Nations, The first Country Cooperation partners in a continuing commitment WHO operates within the United Nations Strategy (CCS) signed between WHO and to support the Government of the Development Assistance Framework the Lao People’s Democratic Republic Lao People’s Democratic Republic to (UNDAF) for 2012–2015 and works with covered the period of 2009–2011. It was implement its 7th National Socio-Economic other international agencies to support followed by a second CCS covering Development Plan (2011–2015). the Government to achieve the country’s 2012–2015. The CCS is aligned with the development goals. other major development frameworks for the Lao People’s Democratic Republic, as set out by the Government and other development partners. This framework aligns the work of all cooperation partners and is crucial to the overall development of health policy development and capacity- building over the long term. The health system relies heavily on donor support. The very low level of Government health expenditures poses an enormous challenge for the country in its goal to achieve the MDGs by 2015 or universal coverage by 2020. Global partnership for development, stronger policies, good governance and a real sense of shared responsibilities are crucial, and development partners need to recognize the changing development priorities of the country in order to address them effectively. WHO

Signing of the first Country Cooperation Strategy between the Minister of Health, Dr Ponmek Dalaloy, and WHO Regional Director for the Western Pacific, Dr Shin Young-soo, 2010. 42 CHAPTER 5: Into the New Millennium

implementation of the Health Personnel Development Strategy by 2020, and promoting evidence-based decision- making, planning and policy-making by strengthening the implementation of the Health Information System Strategy (2009–2015). The shortage of qualified health staff, especially in rural areas, needs to be addressed so that the gap in access to health care for people in those areas can be bridged. Strategic Priority 2 focuses on WHO’s contribution to the achievement of the health-related MDGs. An integrated MNCH and nutrition services package has been developed to achieve MDGs 1, 4 and 5. Continual efforts to control HIV/AIDS, tuberculosis and malaria as part of MDG 6 are under way and are contributing to

WHO efforts to reduce environmental risks to Dr Liu Yunguo, WHO Representative (first on right), with Lao ethnic minorities, 2012 health as part of safe water and sanitation initiatives for MDG 7. The WHO Country Cooperation improving national health policy, strategy Since 2003, the National Tuberculosis Strategy has four strategic priorities, each and planning processes and supporting Program (NTP), which had implemented with its own main focus areas. Strategic implementation of the National Socio- DOTS in 140 districts, has decentralized Priority 1 calls for an increase in the access Economic Development Plan (2011–2015). and moved responsibility for TB control to primary health care and a reduction Other areas include providing support and DOTS to 808 out of 869 (93%) health in health inequities by strengthening for implementation of the National Health centres and it will be further extended to the health system and improving aid Financing Strategy (2011–2015), advocating cover the entire network of health centres. effectiveness. Focus areas include and providing technical support for the The programme increased its capacity to

43 examine patients by microscopy from Strategic Priority 4 addresses health The Millennium Development Goals 15 617 in 2004 to 35 980 in 2011 and almost risk factors to reduce noncommunicable have provided clear directives for the doubled the notification of new and diseases, mental health and disabilities. United Nations agencies to work towards relapse tuberculosis cases from 2227 in There is a need to advocate for and common goals. Better integration of 2000 to 4306 in 2011. The treatment success support noncommunicable disease control, efforts from Government sectors, United rate of new smear-positive tuberculosis especially in the areas of promotive and Nations agencies, bilateral and multilateral cases increased from 77% in 2000 to 91.9% preventive services by recognizing the donors, civil society and nongovernmental in 2011. modifiable causative factors. organizations must be achieved to Environmental risks to health can be This final strategic priority also maximize the efforts of those working to reduced with a focus on safe water and involves the scale up of care for mental, contribute to the development process proper sanitation. Achievements have neurological and substance use disorders within the country. been made in this area with regards to the and support for disabilities prevention and More cooperation with non-health enforcement of the Water Law, revision of rehabilitation, with focus on the effects of sector development partners must be National Drinking-Water Standards and UXO, road safety, violence, blindness and forged to provide analysis of the health the establishment of the Environmental visual impairment. Most countries in the impacts of Government policies and large- Health Impact Assessment Unit within the Western Pacific Region report a shortage scale development programmes (mining, Ministry of Health. of mental health staff and underdeveloped hydropower, agricultural land use Strategic Priority 3 targets the mental health facilities. changes, and rail and road construction) prevention and control of emerging Stigmatization and marginalization and the impact of climate change on infectious diseases and public health of the mentally ill continues around the health- service provision. events. There is a need to strengthen world, and mental health care is given To achieve these strategic priorities, the capacity of key players, such as low priority in general health care in most WHO will continue to provide technical Government agencies, to prevent and countries. support for the implementation of various control health security risks of emerging Lack or insufficient mental health health programmes. WHO will continue to and re-emerging diseases, neglected legislation, inadequate services and the work with its main partner, the Ministry tropical diseases, food safety events and lack of specialist services result in people of Health, and other key development other health hazards. Preparedness and with serious mental illness or disorders organizations and partners, including response to health security risks following and those with other mental health other United Nations agencies and natural and man-made disasters have to be problems not receiving proper care. nongovernmental organizations, and civil strengthened through capacity-building. society to achieve the MDGs by 2015.

44 CHAPTER 5: Into the New Millennium

The work of WHO has moved from a needs-based approach to one in which it supports the Government of the Lao People’s Democratic Republic to develop better primary health care and implement health reforms. More planning and implementation are possible with data collected that address areas where health services can be improved. For WHO in the Lao People’s Democratic Republic, strengthening the country health system, building national health capacities, developing and implementing more pro-poor health policies and providing equitable access to good quality health services for all are important priorities. There is a lot that needs to be done and can be done to improve the provision of health services. Universal health coverage is a goal that we are working towards, a step at a time. Throughout the world, the mission of WHO is to attain the highest possible level of health for all people. Until the day “health for all” becomes a reality and everyone enjoys good health as a fundamental human right, the work of WHO WHO in the Lao People’s Democratic WHO Regional Director for the Western Pacific Dr Shin Young-soo (centre) and the Minister of Public Health, Republic will go on. Dr Eksavang Vongvichith

45 Abbreviations

MNCH Maternal, Neonatal and Child Health BCG Bacillus Calmette-Guerin MSF Medecins Sans Frontieres CCS Country Cooperation Strategy NAHC National Animal Health Centre CHAS Centre for HIV/AIDS and STIs NCLE National Centre for Laboratory and Epidemiology CMPE Centre of Malariology, Parasitology and Entomology NIPH National Institute of Public Health DOTS Directly Observed Treatment, Short Course NMS National Malaria Service DDT Dichlorodiphenyltrichloroethane NSSNSD National Surveillance System for Notifiable (Organochlorine insecticide) Selected Diseases DPT Diphtheria NTP National Tuberculosis Program EBS Event-based Surveillance OB Operation Brotherhood EC European Commission ODA Overseas Development Agency EPI Expanded Programme on Immunization OECD Organisation of Economic Co-operation and Development EWARN Early Warning and Response Network PHC Primary Health Care FET Field Epidemiology Training RBM Roll-Back Malaria GDP Gross Domestic Product SARS Severe Acute Respiratory Syndrome GMEP Global Malaria Eradication Programme UN United Nations GPA Global Programme on AIDS UNAIDS Joint United Nations Programme on HIV/AIDS IBS Indicator-based Surveillance UNDAF United Nations Development Assistance Framework IHR International Health Regulations UNDP United Nations Development Programme LSIS Lao Social Indicator Survey UNFPA United Nations Population Fund MCH Maternal and Child Health UNESCO United Nations Educational, Scientific and Cultural MDA Mass Drug Administration Organization MDG Millennium Development Goal UNICEF United Nations Children’s Fund MHV Model Healthy Village USAID United States Agency for International Development MMR Maternal Mortality Ratio USCDC United States Centers for Disease Control and Prevention USSR Union of Soviet Socialist Republics UXO Unexploded Ordnance WHA World Health Assembly WHO World Health Organization

46 Bibliography

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Dalaloy P, Boupha B, Heuangvongsy K. Analysis on Health manpower Watson L. Lao malaria review, 2.9 Traditional medicines, 1999. management in Lao PDR, December 1998. 1998. “We the Peoples” - the role of the United Nations in the 21st century: the The Declaration of Alma-Ata. Copenhagen, WHO Regional Office for millenium report. New York, United Nations, 2001. Europe, 1978. Weldon C. Tragedy in paradise: a country doctor at war in Laos. Asia Fifty years of the World Health Organization in the Western Pacific Region: Books Company Ltd., 1999. report of the Regional Director to the Regional Committee for the Western Pacific, Part 2, forty-ninth session. Manila, WHO Regional Office for the Weekly Epidemiological Record, 1939, 14:17-24. Western Pacific, 1998. The work of WHO in the Western Pacific Region: report of the Regional Halpern J. Laotian health problems. 1961. Director to the Regional Committee for the Western Pacific, 1 July 1985-30 June 1987. Manila, WHO Regional Office for the Western Pacific, 1987. Holloway AP. Basic data for planning a public health program in the King- dom of Laos. Vientiane, USOM, 1957. The work of WHO in the Western Pacific Region : report of the Regional Director to the Regional Committee for the Western Pacific, 1 July 1995-30 Khamkeo T, Pholsena K. Control of schistosomiasis due to Schistoso- June 1996. Manila, WHO Regional Office for the Western Pacific, 1996. ma mekongi in Khong District, 1989-1999. In: Crompton D.W.T. et al, eds. Controlling disease due to helminth infections. Geneva, World Health Yaws: a forgotten disease. Available at: http://www.who.int/neglected_ Organization, 2003. diseases/diseases/yaws/en

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WHO Western Pacific Region PUBLICATION

ISBN-13 978 92 9061 601 6