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

Since1996TheFacultyofMedicalSciencesat 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-UCPartnership)forthereform of medical education in Laos; a partnership that was formalized in 2000.1,2 The early years of the partnership focused on the reformofundergraduatemedicaleducation: curriculum reform, the introduction of modern teaching and learning techniques, student assessment methods, faculty organizationandadministration

From 2002 the focus became the development of postgraduate training programs.Untilthentherehadbeenlittleor no postgraduate training opportunities of anykindinLaos(2).

TheMinistryofHealthidentifiedthatthefirst 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 communitiesneededtoworksuccessfullyas primarycarephysiciansintheseisolatedand underservicedruralsettings

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 serve4,5,6 The Five Star Doctor concept introducedbytheWorldHealthOrganization 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,healthcaremanager,andresearcher

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 mentorshipmodelbetweenLaoPDRandUC physicians based on the “adopt-a-region” concept8 Lao medical education leaders identified four target regional sites (ie, a provincialhospitalanditsassociateddistrict hospitals and village health centers) and recruited local physicians to be Family Medicine Specialist Training Program coordinators UCmedicaleducatorsactivein 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 deliveredtogetherbyUCandLaophysicians. UCphysiciansrole-modeledpatientcareand medical education methods with a focus on “learning by doing” and acquisition of practical knowledge and skills Systematic traineeassessmentwasintroducedasanew concept Lao colleagues provided bridges within the healthcare system and guidance aroundlocalandculturalneeds.

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,thebatchesaresmall 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 programhasgraduated230FamilyMedicine Specialists

Salary support for some new physicians is providedbytheMinistryofHealthonaquota basis tied to clinical and geographic need in thecountry.Becausedeliveryofprimarycare 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, districtsoreventhevillagesfromwhichthey 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 undergraduateeducationsystemandtrained 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 recognizedwithinthehealthcaresystemand bythecommunitiestheyserve Placementof aFamilyMedicineSpecialistinacommunity leadstosignificantincreasesinutilizationof the healthcare system by the local population.1 For the four provinces within which training sites have been established andforwhichaccuratedataisavailable,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.

SimilardegreesofFamilyMedicineSpecialist 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 Asianstandards)livesinvillagecomplexesin mountainous terrain which may be inaccessibleduringtherainyseason.Assuch the Family Medicine Specialists working in district hospitals and village health centres feelasignificantdegreeofisolationandseek opportunities for collegial interaction and continuing medical education (CME) Since 2010, an annual CME conference has been heldatacentrallocation,ledbyLaoandUC faculty. The CME event itself, transportation toandfrom,andaccommodationforFamily Medicine Specialists attending the conference is currently financed by the UC faculty of the Lao-UC Partnership but this sourceoffundingisunstableandalong-term solution is a challenge. The events are attendedbyalargepercentageoftheFamily 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 MinistryofHealthandtoallFamilyMedicine Specialists themselves CME opportunities fortheFamilyMedicineSpecialists,delivered inthecommunitiesinwhichtheypractice,is an increasing priority for the Lao-UC Partnership FMS are well aware of how videoconferencing has become so widely availableandacceptedduringthepandemic in order to overcome geographic and environmentaldistancing

PersonalcellphonesandInternetaccessare used widely by Fms for one-on-one interactions.However,nodistricthospitalor village health centre has Internet access for groupevents.Inaddition,permissiontohold zoom events on a larger scale need to be approvedbeforetheycantakeplaceandthis processisslowandchallenging

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 administrativesupport Membershipduesto the association have been considered but can be a significant financial burden especiallyfortheyoungerFMSinpractice.To be considered for support such associations mustapplytoandbeformallyrecognizedby the Ministry of Health Dr Phimmasarn completedthisprocessin2018withherown labour and time beyond her UHS duties and receivedformalrecognitionfromtheMinistry 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 twoofherBatch1colleagueselectedasvice 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 widelyavailablepublicemailservices,which may seem straightforward, requires too much English language knowledge for many inLaostocompletethesignup Emailisseen 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 thisreason,wehopethatawaycanbefound for us to join WONCA and begin our move ontotheworldstage.