By Madeline Boccuzzi, MSc-GH student
Spending a summer in Laos was a great way to complete my global health thesis research. Southeast Asia has much to offer including amazing food, kind people, glimmering Buddhist temples, and gorgeous landscapes. The work was fascinating and productive, and all in all, it was an incredible experience. I look forward to going back.
I knew very little about Laos before I started my fieldwork preparations, so a bit of a primer before I get into the meat of my work. Laos is a small, landlocked country sandwiched between Thailand (to the west) and Vietnam (to the east). It also shares borders with Myanmar (Burma) and China to the north and Cambodia to the south. The country is roughly shaped like a palm tree, and the capital city Vientiane sits on the western border where the trunk turns into fronds. The total population is just over 6 million people with about 700,000 people living in the capital. Laos is a communist country, but the government has allowed large-scale development projects in huge swaths of the country and is en route to losing its Least Developed Country status by 2020.
My fieldwork project evaluated Laos’ HIV and malaria procurement and supply chain processes. Supply chain and procurement challenges have a direct impact on health outcomes in Laos. Working through the World Health Organization (WHO) country office in Vientiane Capital, I was integrated into the Lao Ministry of Health’s (MoH) national HIV and malaria units in an effort to identify why health commodities do not reach the people who need them most. The WHO works intimately with the MoH, and both entities have identified procurement and supply chain management of health commodities a major public health concern in Laos.
Procurement and supply chain management can mean different things in different contexts, but my research is limited to what happens once commodities arrive in country and the process they go through to get to patients throughout Laos. I focused on HIV test kits, malaria test kits, and Artemisinin-based combination therapy (ACT) tablets to treat malaria in an effort to map the supply chain and procurement processes in Laos. These three commodities are particularly relevant in the Laotian context because of rampant HIV test kit stock outs and a three-fold increase in malaria incidence rates in 2012.
Laos does not have one single factor that would yield a challenging supply chain situation – HIV prevalence rates are low (0.2% in 2011), malaria has been controlled (3,837 cases; 17 deaths in 2011), there is decent infrastructure in place to reach the provinces, the government acknowledges weaknesses in procurement and supply chain management, and the Global Fund for AIDS, Tuberculosis, and Malaria has ensured that there is not a dearth of funding for HIV and malaria programming. This makes the HIV and malaria supply chain failures in Laos perplexing – a small country, with a small population and relatively low rates of infection and disease should be able to test and treat its population accordingly. Unfortunately, this has not been the case in recent years. HIV test kits have been in low supply or stocked out countrywide, resulting in areas with selective testing or none at all. As one of my interviewees said, “Not having [HIV] test kits is the worst possible problem a [HIV] program can have.” The best-laid HIV program plans are useless if you cannot test people for HIV.
Unlike HIV, malaria in Laos is seasonal. Malaria transmission follows the rainy season, which is roughly early May through the end of September. Malaria commodities (insecticide treated bed nets, malaria test kits, and ACTs) must be delivered to at-risk areas prior to the rainy season for effective malaria prevention and treatment. Delays in receiving bed nets and delays in distributing them to the provinces have caused a significant malaria outbreak in the South. There have already been 11,221 malaria cases and 12 deaths from January –May 2012, a shocking three-fold increase from 2011 year end statistics.
My research interests in supply chain management aligned with a great need for clarity on the current health situation in Laos. The MoH and the WHO know all too well that supply chain failures negatively impact Laotian health, but where and why the supply chain fails had not previously been studied. I conducted 35 key informant interviews with health care workers at all levels of the supply chain in an effort to understand the barriers and bottlenecks they face. I spent a week in the southern province Savannakhet and met with people who are actually using health commodities at the point of care and must face patients who are unable to get the products they need. In addition, I sat in on almost all procurement-related meetings during my time in Laos, which allowed me to see firsthand how these issues are being handled. These data collection methods afforded me unprecedented access to what makes the supply chain tick and gave me the opportunity to work with key players to help solve problems.
While the data is still being analyzed, I can report that there is no one reason why commodities are not reaching patients, but rather a complex web of coordination and management issues that you might expect to find in any organization throughout the world. The issues fall on a continuum ranging from systematic challenges (i.e. the human resources available) to implementation/technical challenges (i.e. storage of goods). Although this seems daunting and there is not one magic bullet that can solve all of the supply chain challenges in Laos, there are intermediate steps that can help address specific problems, ultimately improving the system step by step. Seemingly small changes such as making reporting forms for village health workers easier to fill out would make a big difference all the way up the chain.