Damian Sendler: Health policies, initiatives, decrees, and regulations have been created and enacted by Lao People’s Democratic Republic (LPDR) throughout the last 20 years. It is still a long and tough process to put in place. With a historical perspective and an emphasis on the National Drug Policy (NDP) and Health Care Reform (HCR), this essay tries to explore the difficulties of crafting sound health policy and putting it into practice. Special emphasis is placed on research’s function in policymaking. There are several factors that go into implementing a health policy effectively; these include the structure and agency of individuals who are engaged, as well as the environment in which they are operating and the policy substance itself. Short on resources, the National Drug Policy was put together and implemented with the help of devoted policymakers and concerned foreign partners in a short period of time. To support the policy’s implementation and future revisions, operational health systems research was crucially important. It took many years for the Health Care Law to be developed, and implementation was delayed by institutional legacies and questions over the choice of institutional architecture and finance, despite significant support from lawmakers. The timing of the implementation, in conjunction with excellent leadership, seems to be the most important aspect. More research and better communication between researchers and policymakers are needed in order to better understand and execute successful policy initiatives, as shown by these two instances A path ahead might be to increase local research capability and foreign research cooperation both regionally and worldwide..
Damian Jacob Sendler: There have been 30 health policies, plans, decrees, and regulations passed by the Lao People’s Democratic Republic since 1993. (MoH 2012). In spite of the effectiveness of policy design, implementation remains a problem. Health-policy formulation and implementation in Lao PDR face a number of issues, which this essay aims to address. The National Drug Policy (NDP) and the Health Care Law have been selected as the subject of our investigation. For the first time in 1993 (Paphassarang et al. 1995), an NDP was enacted, and the Health Care Legislation of 2005 is a relatively new health law. Moreover, both have been well-documented in published publications and translated policy documents, and international cooperation has played a role in both policy formation (Jönsson 2002; Boupha et al. 2005) and research to enhance implementation (Tomson et al. 2005; Jönsson et al 2007. Due to recent advances in evidence-based policymaking, we have opted to concentrate our efforts on research in this area (Buse et al. 2012). But even if research is still a very small part of Lao PDR’s health planning it may be learned from the experiences collected thus far.
Policy analysis studies from low and middle-income countries are uncommon (Gilson and Raphaely, 2008), but this is especially true in Lao PDR. A theoretically informed examination of Lao health policies is our goal in addressing this gap. In the following parts, the analytical framework is offered, followed by a brief summary of Lao PDR’s current health status. A historical framework is provided in the third section of the essay, while the fourth section focuses on more current policy processes and players in order to better understand how problems arise and fare on the policy agenda. Conclusions and prospects for health policy analysis in Lao PDR are discussed in the concluding portion of the paper.
This is a case study of Lao PDR’s health policy evolution in hindsight.. Two policy processes are included in the technique so that cross-case comparisons can be made, resulting in a more comprehensive case study (cf. Walt et al. 2008). When the Lao Ministry of Health, Sweden’s International Development Cooperation Agency (Sida), and Stockholm’s Karolinska Institutet first started working together on the NDP, the consequence was a long-term, bilateral relationship. Health systems research (HSR) was introduced in 1998 as part of the creation and strengthening of institutions, in which all the authors have participated in different capacities. As part of a European Commission-funded research project from 2005 to 2009, all of the authors participated in sub-projects in Lao PDR, Cambodia, and China that aimed to feed health policy in these countries with research evidence drawn from sub-projects in the three countries (Bloom et al. 2008; Meessen et al. 2008; Ir et al. 2010; Bloom 2011; Syhakhang et al. 2011). The Health Care Law was selected as a current case study of policy implementation in one of the sub-projects after input from Ministry of Health policymakers at the highest levels.
Damian Sendler
As a whole, our goal is to shed light on both the “what” and the “why” of what transpired. As a result, putting the situation into perspective is critical (cf. Gilson and Raphaely 2008). Research in policy studies and institutionalism is used in this article to examine the Lao health sector as a whole, as well as particular health policy procedures in Laos. When it comes to the politics of health, health policy refers to all aspects of it. Health sector changes, initiatives, and practices are outlined here. The term “health policy” is used here to refer to a particular endeavor stated in written policy papers that comprise goals, priorities, and tactics. The study is organized on Walt and Gilson’s (1994) health policy triangle. It is the fourth component in the triangle (context, process, and content) that has an impact on the other three components. As analytical notions, the four parts make it difficult to problematize the difficulties of successful policy implementation.
Dr. Sendler: In contrast to many other health policy essays, this one pays particular attention to context. When analyzing the context, Leichter (in Buse et al. 2012, pp. 11–2) recommends four systematic factors: situational factors or focusing events like wars; structural factors such as political system, type of economy; demographic features; technological advancement or national wealth; and cultural factors, such as formal hierarchies or inequalities in society, for example based on gender or ethnic origin (cf. Lavis et al. 2012). However, the first part of the paper will focus on situational and structural issues, while international factors will be explored in the second half. In the background section, cultural elements are mentioned to some degree.
The article’s second section examines policymaking and the people who have a role in it. The policymaking process and its substance are shaped by the interests, power, and ideas of many players and stakeholders (cf. Gilson and Raphaely 2008). Policy dissemination and international research cooperation have played a significant role in Lao PDR’s policy development and will be highlighted in connection to the NDP and the Health Care Law in the coming months and years. According to Jönsson (2002), a diffusion approach helps to understand why policies appear on the policy agenda and how they are implemented. This viewpoint is important because it shows the legacy of prior choices and changes and the friction between various institutions. As a rule of the game, an institution may be characterized as either a formal or informal arrangement, such as formal finance methods and informal health care seeking behavior (Pierre et al. 2008). We can better appreciate why new policies and concepts are difficult to adopt and require time, when we take an institutional viewpoint, and why excellent policies in principle don’t always work in reality. In spite of the fact that we concentrate on policy processes, we do so in the context of the Lao PDR health care system as a whole, which helps us better understand Lao PDR health policy development and implementation (cf. Bigdeli et al. 2013). The ultimate goal of our study is a contribution to literature on the research–policymaking relationship by contextualizing and problematizing how and when research might influence policymaking (cf. Lavis et al. 2009, 2012; Gilson 2012).
Damian Jacob Markiewicz Sendler: Cambodia, China, Myanmar, Thailand, and Vietnam share borders with the Lao People’s Democratic Republic (Lao PDR), a nation with a limited population located on the Indochina Peninsula. The Lao People’s Revolutionary Party is in charge of running the country. As a result of a policy change in the 1980s, the nation has evolved toward a more open economy. Economic development in Lao PDR has been strong for many years, and the World Bank said in 2011 that the nation had become a lower-middle-income country owing to greater exploitation of natural resources (World Bank 2012). Some rural and distant locations are difficult to access because of the country’s hilly terrain. There has been an increase in the number of people living in urban or semi-urban regions, but a large percentage of the population still lives in rural areas that are not accessible by road. As a result of their lack of interaction with government, the general public has low demand-side expectations (Annear et al. 2008).
Even though Lao PDR’s health indices have steadily improved over the previous two decades, the country’s health care system remains underdeveloped at all levels, especially in basic health care. Historically, this has been explained by a high illness burden (Coker et al., 2011), inequitably allocated resources, a lack of financial incentives for healthcare providers, and insufficient training. Geographical maldistribution has resulted in a concentration of highly-trained health personnel in metropolitan regions, and over-use of central hospitals that are under-utilized (Dodd et al. 2009; Kanchanachitra et al. 2011).
Damian Jacob Sendler
The National Assembly determined in 2011 that the government’s expenditure should rise from 4% to 9%, which is likely to lead to a significant increase in government spending on health. Capital expenditures like wages and administration have been primarily financed by these costs (Tangcharoensathien et al. 2011). Patients’ out-of-pocket expenses for pharmaceuticals and medical services have been among the highest in the world (over 60 percent ). Disease control, investment, training and management and administrative expenditures have been supported mostly by donors and grants or loans, whereas hospitals and curative operations at health centers rely on user fees (48–83 percent of the budgets). Many tax dollars have only covered a small percentage of the costs (Thomé and Pholsena 2009). Lao women’s union and youth union have a role in delivering health services, typically in partnership with foreign non-governmental organizations. As a result of conflicting and overlapping donor requests, more coordination has been urged and partially implemented during the past several years in accordance with the Paris Declaration and the Vientiane Declaration on Aid Effectiveness (Thomé and Pholsena, 2009). (WHO 2008, p. 175).
Damien Sendler: Health care system improvement is a national priority, and the objective is to attain universal health coverage by 2020 (Boupha et al. 2005). (Annear and Ahmed 2012). Because of this, the Ministry of Health underwent a recent organizational restructure to keep pace with the sector’s current developments.
The development of policy is contextualized.
Health care in Laos has been shaped by a variety of factors over the last century, including French colonialism (1893–1953), American involvement in the American-Vietnam War (1963–73), Marxism–Leninism and the one-party system (as well as donor countries and the free market), and UN agencies and donor countries. Health care for the French expatriates in metropolitan areas and the governing class was a French heritage, although it was a restricted one (Stuart-Fox 1997, p. 44). Even though the civil war in Liberia continued until 1973, the United States offered some health-related training and instruction, but much of its assistance was military in nature (Stuart-Fox 1997, p. 154; Phraxayavong 2009, p. xii). Due to extensive US bombardment of Lao PDR’s east and northeast during the American-Vietnam war, the Lao people became even more divided, with one side supporting the royal government and the other supporting Pathet Lao, which was commanded by communists. A network of military clinics and health centers were established in caves or concealed in the woods to evade severe bombardment under the Pathet Lao’s rule of Lao PDR before to the fall of the Royal Lao Government in 1975. (Boupha 1997).
Once Pathet Lao took power in 1975, the country’s new government was forced to depend almost exclusively on bilateral assistance, primarily from the Soviet Union (via the USSR) and Vietnam (via Vietnam), as well as assistance from international organizations such as the International Monetary Fund (IMF), the World Bank (WB), and the United Nations (UN) (Phraxayavong 2009, p. xvi). Because of this, a considerable number of young Laotians have studied for long periods of time in other communist nations. As a consequence, medical professionals now possess a broad range of skills and knowledge. In the years 1975-1985, a co-operative health care system was established, but it eventually failed, resulting in a significant reduction in the availability of essential health care services (A Noel, unpublished data).
In the mid-1980s, health became a top priority (Boupha et al. 2005). Prior to 1995, Lao PDR’s public health care system was severely constrained by a lack of cooperation from other communist nations (Boupha 1997). Lack of medical equipment and pharmaceuticals, as well as the poor quality of health treatment, discouraged people from going to hospitals. The number of private pharmacies grew from 32 in 1986 to around 1850 in 1995, and many people decided to forego physician consultations in favor of purchasing medications directly from pharmacies during this period. Fake or inferior pharmaceuticals, frequently smuggled into the country, were on the market in alarming quantities. Many drug merchants had little or minimal pharmacological knowledge (Stenson et al. 1997, 2001; Syhakhang et al. 2001). To address this, Lao PDR’s first comprehensive national health strategy, the National Development Plan (NDP), was approved in 1993. (Paphassarang et al. 1995).
Since the adoption of the present constitution in 1991, new laws have been permitted to be enacted. To ensure equal access to health care for all Lao citizens and to improve the quality of services, the Prime Minister’s Decree 52 was issued in 1995. This decree was based on the Bamako Initiative of 1987, which was designed to implement cost-recovery systems and drug revolving funds to improve the quality of health care (Ebrahim 1993). There has been a dependency on central level supplies and contributions that might include both outdated and improper sorts of pharmaceuticals in the drug stores before (Thomé and Pholsena 2009). Due to a lack of funding from the government, persons who sought the services were forced to pay out-of-pocket for inspection and treatment. Non-payers included children, monks; crippled people; students; military members; and the impoverished. They were covered by a social assistance program but would apply for an exemption at the hospitals to avoid having to fill out paperwork for payment (Paphasarang et al. 2002b, page 80; Boupha and Phipps 2005, page 21–2). The village leaders were meant to supply disadvantaged homes with a reference letter, but this did not work out effectively in actuality (Patcharanarumpol et al. 2009). Many public health facilities have introduced medication revolving funds and now they are the primary source of income for curative health institutions.
A new Health Care Law, passed in 2005, amended and enhanced Decree 52, which was in place before that year. Health care management, national health funding, and social health insurance are all covered by the new legislation. All four of Lao PDR’s social health protection programs were launched in the early 2000s: the Social Security Office, the State Authority for Social Security, the Community-Based Health Insurance (CBHI), and Health Equity Funds (HEFs) programs (Annear and Ahmed 2012). To utilize HEF, you must be identified as impoverished and have a third party pay your fees on your behalf. The government has agreed to merge the existing four social health protection programs into one National Health Insurance Authority in order to attain universal health coverage by 2020. (Ahmed et al. 2013; Alkenbrack et al. 2013). At this point, the National Committee of Health Insurance (NCHI) has authorized the design of health finance institutional arrangements, which are expected to be implemented in the next several months. Decree 349, which took the place of Decree 52, was ratified in 2013 and is now in effect.
Activists and procedures
In the context of health care changes and policy creation, it is clear that context is important. Inherent in the growth of health policy are global, national and local political-administrative and socio-economic structures, processes, and concerns. This is true at all levels. It is important to understand the environment in which policymaking takes place, as well as the legacy of earlier choices and institutions. The history and setting of the Lao health care system and policy development in many respects have been remarkable, as shown in the narrative above.
Although the health sector is more open than other sectors, Lao PDR’s real decision-making authority is concentrated in a small number of individuals and policy procedures are highly opaque to an outsider, even though the health industry is more open than other sectors (Tomson et al. 2005). Government, the Ministry of Health, and other governmental agencies are the primary providers in the health sector, which is why the Party is accountable for the entire policy framework. It is more complicated in reality because of the dependence on external cooperation and finance, as well as a largely privatized health sector (Thomé and Polsena 2009), with several players exerting influence at various stages of the policy process. There are many international specialists who have assisted in the development of Lao PDR’s new policies and legislation (Paphassarang et al. 1995; Boupha et al. 2005). This has helped to ensure the development of well-designed policies in accordance with global knowledge. Some foreign specialists, however, may not be familiar with the cultural background, political processes, inter-ministerial and administrative structure, and situation for people who are impacted by the execution of agreed policies and reforms (Owen 2010, p. 5). It’s difficult to strike a balance between the long-term character of policy formation and its successful implementation, as well as the short-term nature of research financing and project-based international cooperation. There have been numerous standards and unequal coverage in certain situations due to funders prioritizing projects based on their own interests (Boupha et al. 2005).
Government cooperation is vital in the execution of public programs in Laos, which are heavily administrative (Annear et al. 2008). Laws and regulations are poorly understood by the public, and there is a lack of ability to enforce them (Sengdara 2011). As far back as 2006, there were no official channels for coordinating health policy or legislation. Legislation adoption has been governed under the Law on Legislation Adoption since 2012. This law mandates that new laws must go through a public consultation process that includes workshops and meetings, as well as chances for the public to comment on the legislation before it is adopted and made public. Despite recent organizational changes within the Ministry of Health, the underlying administrative structure has remained unchanged since the NDP was first introduced in 2010.
Policy dispersion in the NDP: a case study
In many aspects, the NDP’s development and adoption occurred in a unique situation. Situation in the area of pharmaceuticals was becoming more problematic when the Lao government requested assistance from Sida, which led to a series of fact-finding and problem-identification missions in 1990–91. A new policy was developed and implemented in a remarkable one-year span, largely due to the efforts of a small group of committed persons on both the Laotian and Swedish sides who served as policy entrepreneurs beginning in 1992 (Jönsson 2002). This review expedition (which comprised the author and experts from both Laos or Thailand) convinced Lao authorities to broaden their focus to include a more thorough approach to medication quality monitoring. Among these things are a National Drug Policy, new laws, a procurement system, better distribution, quality control, monitoring, and sensible use of medications; all of these things are essential. At the time, the administrative resources were insufficient to implement such a wide-ranging strategy. Regular meetings and seminars with foreign participants, both to collect comments on the draft National Drug Plan (NDP) as well as to disseminate information about the NDP, were held to facilitate these talks. Prior to the sessions, the Lao teams wrote background papers, drawing on their own experiences as well as those of other NDPs and WHO guidelines. Ten ministries, officials from 18 provincial health offices and members of different professional groups in the sector were participating in the process, as well as several non-governmental organizations (NGOs). The Lao Women’s Union and other NGOs also participated (Paphassarang et al. 1995). The policy approval process was still a top-down one and the draft NDP got less comment than expected. As a result, there were few ways for the general public to influence lawmakers at the national level, and there was no history of social pressure.
