Before and After in Laos: The challenge of providing health services to the poor

By Lukas Messmer
January 19, 2013

Mr Virasak shows the pink card which qualifies poor families for free health care.

Behind the Xekong Provincial Hospital Mrs Kavi is resting on a bamboo bed inside a wooden maternity home. The air is hot and smoky. A fire is burning beneath her bed. This is the traditional way after giving birth to a child.

At 44 years of age and already having given birth to nine other children, Mrs Kavi is a high-risk patient. It’s her first birth in a hospital. One time she gave birth in a rice paddy – the child died.

“It’s very nice here and I don’t have pay anything,” she says. Feeling comfortable, she starts to breastfeed her newborn son, who is just two days old. “He doesn’t have a name yet,” she says, appearing quite contented.

Mrs Kavi is one of many villagers to benefit from a national policy of the Ministry of Health (MOH) called “Free Mother and Neonatal Child Health” (MNCH). It offers free health care for pregnant women and children under five.

Another official MOH policy is the “Health Equity Funds” (HEF), which provide the whole range of health services in public facilities to poor people free of charge. Both work in the same way – the equity funds cover the costs of medical treatment, transport and provide a food allowance for patients who could not afford it otherwise.

Overall, Health Equity Funds for the poor are now set up in 98 districts throughout the country. Nowadays, over 700,000 poor people can benefit from this valuable social protection scheme, while the Free MNCH policy is being progressively rolled out around the country. Both will be part of the National Health Insurance Agency, through which the government aims to harmonise different insurance policies in the near future.

“The goal is to improve access to health services and to prevent catastrophic health expenditure,” says Jean-Marc Thomé, country delegate from the Swiss Red Cross in Laos and a technical advisor to the Ministry of Health. While in western countries a lot of people see a doctor too often, here in Laos most poor people delay seeking proper treatment because of their dire financial situation.

When they get seriously ill, the cost of treatment is often far too high for them to afford on their meagre cash incomes. It is well-known that health problems are often a major factor driving many families further into impoverishment (the so-called “medical poverty trap”).

To see how the HEFs and Free MNCH schemes work in practice, the two southern provinces of Xekong and Saravan are a good place to visit. In Xekong, 42 percent of the 100,000 or so population are poor. Over 95 percent belong to ethnic groups that speak their own languages, often living in remote, mountainous areas with no road access during the rainy season – like the districts of Kaleum and Dakcheung. Here, the MOH entered into a partnership with the Lao and Swiss Red Cross to implement these social health protection schemes.

The person managing the HEF and MNCH schemes down south is Virasak Phetpasak, who is the regional coordinator for Xekong and Saravan provinces. Originally from Savannakhet, he occasionally moans about the pleasures one can enjoy in his hometown which he misses out on in the quiet town of Meuang Lamam, the capital of Xekong province.

But he works with conviction though. “I can contribute to assisting the poor,” he states emphatically. Mr Virasak has the aura of a businessman. He’s tall, constantly talking on his two mobile phones, advising his staff back in Xekong and arranging various appointments. “Management”, he says again and again, if asked about the complications of his job.

Indeed, the HEF and MNCH focus heavily on administration, reporting, monitoring and auditing. In the office in Meuang Lamam, his staff are meticulously checking every payment, every bill and all reports from provincial and district hospitals and health centres.

The lists stack up on the desks: 10,000 kip here, 20,000 kip there. To ensure effective service provision and to avoid ghost patients appearing, several promotion and monitoring officers randomly select and visit treated patients in their home and interview them about their hospitalisation. Here, in the office, the system looks simple and efficient. The work in the field, however, is another story altogether.

One obstacle is to get the information and understanding about free treatment out there in the communities. If villagers don’t know that they will be treated for free, they won’t come to the hospital. The fact that there is free access to health services has been promoted through radio broadcasts and information leaflets in Lao and other ethnic languages.

M r Virasak also has some ideas for the future. He plans to equip his promotion officers with battery-driven loudspeakers. “We’ll record an advertisement about the Health Equity Funds and Free MNCH in every ethnic language in the target areas and put music to it,” he says, “so that our staff can simply play the files from their mobile phones.”

Another issue is the eligibility. “Poor” is a simple word. It basically means not having enough of something. But from here on it gets difficult: Not having what? Money? Food? A metal roof? Cattle?

Here, in very remote areas where poverty is widespread, everyone is eligible for the benefits of the HEF. In other areas though, district and HEF officers ride their motorbikes from village to village, and interview the people at length about their daily life with village committees.

Results are validated by district committees and HEF cards are delivered to the households determined as poor. With these HEF cards, their holders have the right to be treated for free in all public health facilities.

Since 2009, in the nine districts of the four southern provinces, the free of charge services included 200,000 consultations, 18,000 admissions, 5,000 deliveries and 700 main surgeries. The value of benefits going directly to poor people, mothers and young children reached over 11 billion kip (US$1.4 million).

The funds were provided by the Health Services Improvement Project of the Ministry of Health and the Swiss Red Cross. Not only the patients, but also the health facilities benefit from this policy.

With more people seeing a doctor, they notice a significant increase in revenue that enables them to improve both the quality of services and the working conditions of the staff.

The story of Mr Chouysamone and his family is a fine example of the HEF’s purpose. The 57-year-old is sitting on the edge of a white plank bed in Taoy district hospital in Saravan province, wearing a camouflage jacket and a baseball hat.

Behind his back, his wife, Mrs Yasamone, 45, lies in pain with a drip attached to her arm. At her feet, their daughter Pau, 13, silently waits in a pink dress. The girl is the second youngest of 11 children. They are Katang people.

Cheerfully her father explains that he does not plan to foster any more children: “I can’t,” he says and smiles broadly, revealing his black teeth. Despite her serious stomach pains, his wife looks somehow relieved.

While waiting for a diagnosis, the family does not have to worry about the ensuing costs. It was the chief of the village who told Mr Chouysamone that and a truck brought them here on the just recently finished road.

Five years ago, there were no Health Equity Funds in Taoy district, Saravan province. Being from Ban Soytam, where there was no road, Mr Chouysamone had to walk some 50 kilometres over mountainous terrain. Luckily, the treatment was cheap. His family only earns a few thousand kip per day if they are lucky. After treatment, he walked another 50 kilometres back home again.

Thanks to the Health Equity Funds, these kinds of financial barriers have been taken away. He will be reimbursed for the treatment and transport costs and instead, of worrying about money, he can take care of his family now.

Lukas Messmer is a Swiss journalist doing an internship at the Vientiane Times.

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Categories: Health | 1 Comment

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One thought on “Before and After in Laos: The challenge of providing health services to the poor

  1. like the idea… but better if there are barefoot doctors and some village-based sustainability programs with the support of these equity funds.

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