The Development of Family Medicine in Lao PDR

The Development of Family Medicine in Lao PDR

Dr Oua Phimmasarn
Deputy Head, Department of Community and Family Medicine, Faculty of Medicine
University of Health Sciences
Vientiane, Lao PDR
President, Lao Family Medicine Specialists Association

Since 1996 The Faculty of Medical Sciences at the National University of Laos (now the University of Health Sciences, or UHS), the Lao Ministries of Health and Education, and the Cumming School of Medicine, University of Calgary (UC), Canada, have worked together (Lao-UC Partnership) for the reform of medical education in Laos; a partnership that was formalized in 2000.1,2 The early years of the partnership focused on the reform of undergraduate medical education: curriculum reform, the introduction of modern teaching and learning techniques, student assessment methods, faculty organization and administration.

From 2002 the focus became the development of postgraduate training programs. Until then there had been little or no postgraduate training opportunities of any kind in Laos2. The Ministry of Health identified that the first postgraduate training priority was for primary health care physicians3, Family Medicine Specialists able to work at rural district hospitals and village health centers where 80% of the Lao population lived. Historically, Lao doctors, having only an undergraduate medical education that had little practical clinical experience, had struggled to gain the confidence of their communities needed to work successfully as primary care physicians in these isolated and underserviced rural settings.

Training objectives for this new Family Medicine Specialist Training Program were developed with the aim to produce family doctors who have the knowledge and skills to practice as generalists, and to work effectively within the communities they serve.4,5,6 The Five Star Doctor concept introduced by the World Health Organization in 19967 was adapted to reflect the diverse skill set that Family Medicine Specialists would require when working at the district hospital and village health center level, namely: clinician, educator, community leader, health care manager, and researcher.

Rural and community-based training sites were needed to support these training objectives, but the country’s only medical school and teaching hospitals were situated in Vientiane, the capital city. The Lao-UC Partnership sought to develop rural-based distributed training sites for the Family Medicine Specialist Training Program. This was achieved through a collaborative mentorship model between Lao PDR and UC physicians based on the “adopt-a-region” concept.8 Lao medical education leaders identified four target regional sites (i.e., a provincial hospital and its associated district hospitals and village health centers) and recruited local physicians to be Family Medicine Specialist Training Program coordinators. UC medical educators active in the Lao-UC Partnership “adopted” one or other of the sites through return visits and the development of collegial relationships with hospital administration and staff. Faculty development workshops were delivered together by UC and Lao physicians. UC physicians role-modeled patient care and medical education methods with a focus on “learning by doing” and acquisition of practical knowledge and skills. Systematic trainee assessment was introduced as a new concept. Lao colleagues provided bridges within the healthcare system and guidance around local and cultural needs.

The Family Medicine Specialist Training Program originally consisted of two years of training, but program review has added a third year beginning in 2022. 16 “batches” (classes) have graduated since 2006 and batch 17 is now in their first year of the program. The program is popular and admission competitive. However, the batches are small in comparison to the county’s need due to limited financial resources in Laos for the support of residents during their postgraduate training. Nevertheless, the program has graduated 230 Family Medicine Specialists.


Dr. Oua Phimmasarn and Dr Noot Sengthavisouk in the Documentary “A Working Adventure in Laos”. Credit: Lightfall Productions

Salary support for some new physicians is provided by the Ministry of Health on a quota basis tied to clinical and geographic need in the country. Because delivery of primary care is a top priority of the Ministry of Health, Family Medicine Specialists are assigned a significant number of quota jobs and Family Medicine Specialists are now working in every province of the country. This has meant that many of the Family Medicine Specialists are working in the provinces, districts or even the villages from which they came. Nevertheless, there are never enough quota jobs for all the Family Medicine Specialist Training Program graduates and approximately 20% of these doctors remain outside of the quota system. About half of this group have attempted to establish private practices, mostly in Vientiane, but this is financially onerous and competitive. Many of the remaining family medicine specialists are involved in healthcare administration for the Lao government or NGO’s.

The Family Medicine Specialists are a new kind of doctor in Laos having all had their undergraduate training in the reformed undergraduate education system and trained in the first postgraduate training program designed by the Lao themselves. The high quality of the clinical care delivered by Family Medicine Specialists and the diverse “five-star” skill set they possess has been recognized within the healthcare system and by the communities they serve. Placement of a Family Medicine Specialist in a community leads to significant increases in utilization of the healthcare system by the local population.1 For the four provinces within which training sites have been established and for which accurate data is available, and despite being relatively young, seventeen Family Medicine Specialists have become directors of district hospitals, three are directors of district public health offices and one is Deputy Director of a provincial hospital. Similar degrees of Family Medicine Specialist career advancements have taken place in other provinces, but accurate numbers are not known by the author. Many anecdotes can be shared of the impacts which family medicine specialists have had in their communities.

Laos is considered a “least developed nation” and as such the transportation and communication infrastructure leaves much to be desired. Compounding this, much of the small population base (by Southeast Asian standards) lives in village complexes in mountainous terrain which may be inaccessible during the rainy season. As such the Family Medicine Specialists working in district hospitals and village health centres feel a significant degree of isolation and seek opportunities for collegial interaction and continuing medical education (CME). Since 2010, an annual CME conference has been held at a central location, led by Lao and UC faculty. The CME event itself, transportation to and from, and accommodation for Family Medicine Specialists attending the conference is currently financed by the UC faculty of the Lao-UC Partnership but this source of funding is unstable and a long-term solution is a challenge. The events are attended by a large percentage of the Family Medicine Specialists who benefit not only from the educational agenda but also from the collegial, academic and social interactions the event allows. For instance, the Lao Family Medicine Specialists Association was initially organized at one such CME event. At another CME event a family medicine specialist textbook of medicine was envisioned, a working committee established, chapter authors identified and within three years the textbook had been completed and printed. This was the first textbook of medicine written in the Lao language by Lao authors. The textbook was distributed to all District Hospitals and Village Health Centres by the Ministry of Health and to all Family Medicine Specialists themselves. CME opportunities for the Family Medicine Specialists, delivered in the communities in which they practice, is an increasing priority for the Lao-UC Partnership. FMS are well aware of how videoconferencing has become so widely available and accepted during the pandemic in order to overcome geographic and environmental distancing. Personal cell phones and Internet access are used widely by Fms for one-on-one interactions. However, no district hospital or village health centre has Internet access for group events. In addition, permission to hold zoom events on a larger scale need to be approved before they can take place and this process is slow and challenging.

The Lao Family Medicine Specialists Association was created informally at the 2013 CME event. Dr. Oua Phimmasarn was elected as its’ President. The association does not have any source of financial nor administrative support. Membership dues to the association have been considered but can be a significant financial burden especially for the younger FMS in practice. To be considered for support such associations must apply to and be formally recognized by the Ministry of Health. Dr. Phimmasarn completed this process in 2018 with her own labour and time beyond her UHS duties and received formal recognition from the Ministry of Health. This has not so far been accompanied by any financial or administrative resources. In that year Dr. Phimmasarn was reelected as president and two of her Batch 1 colleagues elected as vice presidents. Under these circumstances and without knowledgable advice and guidance, the association leadership has not created Terms of Reference or the other parts of a regulatory framework for the FMS Association. Communication with the membership as a single entity, considered a minor group e-mail administrative task in developed countries, is far from minor in Laos. Signing up for any of the free and widely available public email services, which may seem straightforward, requires too much English language knowledge for many in Laos to complete the sign up. Email is seen only as a formal and narrow means of communicating. Many do not have any form of email account. Communications between FMS take place on common social media platforms. This is clearly not a successful strategy for mass communication to its constituents by the leadership of the FMS Association.

We are very proud of how we FMS are changing our communities in a very positive way. At the same time, we know we are young and inexperienced in many ways, but we seek to learn how to move forward. For this reason, we hope that a way can be found for us to join WONCA and begin our move onto the world stage.


Prof Mohammad Husni Jamal, WONCA APR President, Dr Oua Phimmasarn, President of Lao Family Medicine Specialists Association and Prof Christopher Brown of the University of Calgary

References:

1. A Working Adventure In Laos. Brown, CB, Kay, D, Hollaar, G, Lee, R, https://vimeopro.com/lightfallvideos/a-working-adventure-in-laos-1. 2013.
2. Guenter C. Association of Universities and Colleges of Canada, Tier 2. University partnerships in cooperation and development program. Lao human resources for community health. University of Calgary final report. 2002.
3. Ministry of Health, State Planning Committee. Report of the National Health Survey: Health Status of the People in Lao PDR. Ministry of Health, Lao PDR; 2001.
4. Family Medicine Specialist Program: A collaborative program of the University of Health Sciences, Ministry of Health, Lao PDR, and the University of Calgary, Canada. Program overview and objectives. Ministry of Health, Lao PDR; 2004.
5. Nammavongmixay K. Draft Curriculum of Family Medicine Program, A Joint Collaboration between Faculty of Medical Sciences, National University of Laos, Ministry of Education and Ministry of Health. Ministry of Health, Lao PDR; 2004.
6. Kanashiro J, Hollaar G, Wright B, Nammavongmixay K, Roff S. Setting priorities for teaching and learning: an innovative needs assessment for a new family medicine program in Lao PDR. Acad Med. 2007 Mar 1;82(3):231-7.
7. Boelen C. The five-star doctor: An asset to health care reform? [monograph on the Internet]. Geneva: World Health Organization Available: https://www. google. co. za. 1996.
8. Lemaire JB, Hollaar G, Wright B, Bouphavanh K, Guenter C. The “adopt-a-region” initiative: a collaborative mentorship approach to developing community based academic medical education training centers in Lao PDR. Abstracts. Canadian Conference on Global Health. http://www.csih.org/wp-content/uploads/2015/10/poster-abstracts_Nov2.pdf pg 103. 2015.