Lao Human Resources for Community Health
A collaborative program of the Faculty of Medicine, University of Calgary, the Lao University of Health Sciences, and the Ministries of Education and Health, in Lao PDR
Clarence A Guenter MD, University of Calgary Lao Project Director (email: cguenter@telus.net) Go to the People, live with them, learn from them, love them. Start with what they know, build with what they have. But with the best leaders, when the work is done, the task accomplished,
the people will say, “We have done this Ourselves.” Attributed to Lao Tzu 604 - 531 BC Lao Proverb: If you want to help someone, don’t do it unless it dignifies them.
Map of Laos with Vientiane and Provincial training sites
Purpose of the project: to strengthen the Lao University of Health Sciences capacity to contribute to improving the economic and health status of the people of Laos, especially beyond the Vientiane capital, through reform of health human resource training. Health human resource development is the top priority in the Lao Health Master Plan, and Lao PDR has invited the UofC to be a partner.
Background to the Lao situation: Lao PDR is tropical, landlocked and mountainous; one of the least developed, low income countries. Eighty percent of its 5.9 million people (47 ethnic groups) reside in rural areas with difficult transportation; most live at a subsistence level with little access to government services including health care. Lao PDR ranks 135 out of 177 countries on the Health Development Index. Health indicators are the poorest in the SE Asia Region, and much worse in the remote rural areas than in the larger urban centres.
Family farms along Mountain river beds The mighty Mekong River traverses the country
The country has gone through major transitions in recent history. For nearly 300 years they were overrun by wars with Myanmar, China, Japan, and Thailand. In the twentieth century the government ranged from Monarchy to French Protectorate to Socialist as the People’s Party came to power in 1975. The Geneva Accords for Indochina (1954) attempted to ensure a democratic and neutral transition to Independence from France through the
International Commission (India, Poland, and Canada). Lao leaders still greatly respect the position Canada took at that time. However the USA reversed their commitment to neutrality with the Vietnam War and their ‘secret war’ in Laos (1964 – 73).
Health initiatives depended largely on government resources (supported by other socialist countries) until the late 1980’s. After 20 years of near isolation, the country has been emerging since the early 1990’s, with an increase in support by foreign agencies. At present the health system is a mix of government facilities with a program of cost recovery, private services, and foreign agency projects that are often sectoral, geographically limited, fragmented, or of short duration.
The Lao government is working toward poverty alleviation and improved health in the inaccessible communities: promoting roads, education, electrification and economic development. Health initiatives are very limited. Meeting basic human needs and providing access to effective primary care remain long term goals. Most health personnel do not have the training or skills to address health problems of communities, or respond to individual needs. The Medical School: The University of Health Sciences (UHS) is the only Lao medical school, with about 200 students per year (more female than male) in a 5 year program following one year of University. There are also about 100 Dentistry and 100 Pharmacy students each year in 4 year programs. Lao faculty members had most or all of their training in Laos; a few benefitted from advanced training in other countries. Most teaching is in Lao language, which does not have professional or scientific literature. While Lao students and teachers can read Thai language books, the range of Thai materials is limited and decreasing as Thai scholarship is moving to
Moreover clinical experience in the Vientiane teaching hospitals was under supervisors who had little training for teaching. The curriculum did not effectively address the population health needs and graduates were not
prepared or confident to work in rural communities.
Less than half of the annual graduates practice medicine because they lack training and confidence for rural health work. Furthermore as in most countries they prefer to live in the capital where there are not enough government salaried positions for all graduates. There is no system for licensing health professionals, continuing medical education or professional societies, although these are under discussion.
Background to the UofC in Lao PDR: The UofC Faculty of Medicine has been involved in manpower training and medical education reform in Nepal, Thailand, Philippines, Malaysia, Korea or China for more than 25 years. We have been working in Lao PDR with Mahosot Hospital, since 1994 and UHS, since 1996.
Since 1994, more than 80 UofC faculty and community experts have visited Laos for 1 week to 4 month periods, with many repeat visits. UofC has sponsored more than 55 visits by Lao leaders to Canada, Philippines, Viet Nam or Thailand for short term training and planning. The Minister of Health, Minister of Education, President and Vice President of the National University of Laos, Dean and Vice Deans of UHS and the Director of the Medical School are among those who visited Calgary.
In 2002 a formal comprehensive plan was presented to us by the Ministries of Education and Health (MOE, MOH), who jointly requested long-term support from UofC for six areas of health human resource reform listed below. A new MOU was signed in 2004 till 2010. The planned initiatives represent the priorities established through discussions and workshops with rural health centres, medical students, university faculty, hospital and academic leaders, and the Lao Government.
UofC team leaders with Lao UHS Dean and Minister of Hhealth
Partnership Strategy:
Six health human resource training initiatives are now in progress:
1. Faculty development program on teaching, learning and management.
2. Comprehensive reform of the medical school curriculum, to be community relevant and Lao health-needs based, with emphasis on problem solving, evaluation of student competence, and on-going curriculum evaluation and improvement. The new curriculum began with the class entering in 2004, and the final year of the revised curriculum is being implemented in 2008-09. High school and
one year of university foundation studies is followed by 2 years of preclinical sciences structured as an organ system curriculum, then 2 years of clinical sciences structured as a clinical presentation
From learning resource centre to health needs in the villages, and back
3. Improved use and access to learning resources as part of the new curriculum: books, CD ROMs, internet, translated publications, equipment and models for the teaching of clinical skills. Modest improvements began in 2005 in a renovated Learning Resources Centre, which is being further improved in 2008 by a World Bank grant.
4. Rural needs assessment and training programs for physicians, with links to other health human resource development initiatives. This began in 2004 and is increasing.
5. An ongoing two year primary care (family medicine) training with a major rural, community focus began in 2005. 53 (23F) completed training, and most are working in provincial or district hospitals.
6. Develop a system for quality assurance in medical education. This is an ongoing integrated program of continuous improvement.
These are enormous initiatives for Lao institutions, their staff and teachers. The UofC serves a collaborative, mentoring and coaching role; building capacity in Lao personnel. All activities must effectively address Lao needs; responding step by step to the Lao agenda. We hope to model participatory management in all initiatives, therefore implementation steps are determined by readiness and commitment of our Lao partners. Other agencies involved in health training: Many foreign agencies conduct health activities in Laos. Some agencies are providing targeted specialty training assistance, short term courses or focused on single hospitals but UofC is the only institution involved with systemic reform of medical training. The following list is not
complete:
WHO (policy, multi-agency coordination)
Grand Duchy of Luxembourg and the Maria Thereza (Lao-Luxembourg) Hospital, UofC training partner Institute de la Francophonie pour la Médicine Tropicale: Master Degree and Diploma in Tropical Medicine, for Francophone students
Japan International Cooperation Organization (facilities, medical and nurse training)
Health Frontiers and Case Western Reserve University: long standing activities in Laos, sponsor Postgraduate education in Internal Medicine and Pediatrics
The China Medical Board provides financial assistance for faculty training and learning resources Asia Development Bank and World Bank (some facilities and living allowances for FMSP trainees) Germany - sponsors an Obstetrics and Gynecology Residency
Belgian Technical Cooperation active in many areas including primary care Australia Aid - major rural health initiatives
European Commission active in several rural health initiatives
Wellcome - Oxford Tropical Medicine Research Program with Mahosot Hospital
Thailand - Khon Kaen, Cheng Mai, Chulalongkorn, Mahidol, Thammasat University – technical Cooperation, training in Thailand
South East Asian Ministries of Education Organization training through Mahidol University in Bangkok Ateneo de Zamboanga University School of Medicine, community health training for Lao teachers and
International and Swiss Red Cross working in decentralized areas
University of Strasbourg, Bordeaux collaborating for Surgery and Anesthesiology Residency Medicine Sans Frontiers (Doctors Without Borders) working in southern Laos
Agencé Universitaire de la Francophone active in broadly based technical consultation and training US AID, Rockefeller Foundation, support for a Master of Public Health Program
Universities of Zurich, Basel: developing web based and CD learning for tropical countries
Regular communication with Ministry of Health leaders ensures that government is a major project participant, and that the project is aware of potential collaborators. The Lao UHS and MOH try to bring all potential partners together annually, to enhance resources and minimize fragmentation.
Results:
These initiatives are expected to build capacity of the Lao University of Health Sciences to offer medical education relevant to country priorities; to produce community-oriented physicians prepared for rural or urban service and skilled in primary care and health team management. Outcomes already developing include:
Increased ability among teaching faculty: improved management, improved teaching methods, more self directed learning, better student evaluations, and better clinical skills.
A reformed curriculum: learning objectives related to Lao health and development needs, student study guides for all courses, improved learning resources, emphasis on problem solving, evaluation of student competence, and methods for ongoing curriculum evaluation and improvement.
Understanding of and responsiveness to rural health problems: methods for community needs assessment, capacity to train students and interns in and for effective rural placements. (4 rural training nodes consisting of Provincial and District hospitals, health offices and village health centres)
Calgary – Lao Scholarship awards for students from remote poor families
A family medicine style, primary care training program with major rural training components focused on teamwork, community assessment and development, and socioeconomic determinants of health. Of 53 graduates,
50% are working at district hospitals or health centres and 23% are working at provincial
hospitals – involving 10 provinces,
First group of Family Medicine Specialist trainees, Minister of Health, and University leaders Methods for continuous improvement of quality of medical education (adapted from WHO Guidelines
for Western Pacific Region).
Improved institutional management and more inter-institutional and interagency cooperation. Funding: The activities are conducted by volunteers from the faculty and community attached to the UofC (always working with Lao colleagues). The project has received financial support from: the Government of Canada through the Canadian International Development Agency (Association of Universities and Colleges; $1M CAD for 2004 – 2010); the Government of Luxembourg ($.5M USD for 2003 – 2008); WHO; the University of Calgary, the Calgary Health Region, the Calgary Health Trust and many private donors.
Anyone wishing to contribute to this project may contact: Ms Ruth Malus
Administrative Coordinator, UME Room G 701, Health Sciences Centre 3330 Hospital Drive NW
Calgary AB Canada T2N 4N1
Phone: 403 220 3843 Email: rmalus@ucalgary.ca
