Covid-19: What went wrong after initial success in Laos?

Initial success scuppered

In an intra-agency review on covid-19 response in October 2020,5 Mark Jacobs, World Health Organization representative to Laos at the time, compared the country to New Zealand, a high income country where a survey of antibody prevalence in 16 of 20 district health board regions in December 2020 and January 2021 had also detected little transmission.6 Jacobs said both responses shared strengths, including early lockdowns and a focus on border restrictions—in July 2021, Radio Free Asia reported that six citizens who had allegedly contributed to the coronavirus’s spread by helping people enter from Thailand were sentenced to years in prison.7

A presentation WHO provided to The BMJ said 56% of 1000 Laotian respondents to a WHO ordered survey on vaccine confidence between 17 June and 11 July 2021 agreed that the threat of covid-19 was real. Yet the survey also indicated that only half of respondents wore a face mask, washed their hands, or covered their nose and mouth more regularly than in the three months previously (this was lower compliance with protective and preventative guidelines than in other countries surveyed such as Cambodia, Malaysia, Mongolia, the Philippines, and Vietnam).

At the same time, only 54% of the population has access to handwashing facilities.8 And according to WHO, inadequate logistics management means hospitals don’t always have personal protective equipment available.

Add to that the coronavirus’s continuing mutation, and the efficiency of public health measures has dropped. “The single best explanation for why a new wave has occurred in any region has been the emergence of a new variant,” says Amy Hurford, a mathematical biologist at Memorial University of Newfoundland in Canada. “I used to say that a criticism of travel restrictions is that they ‘delay the inevitable’; however, frequently when we think of what is ‘inevitable,’ we overlook evolution.”

Low training investment bites

In 2019, Laos spent about 3% of its gross domestic product on health, compared with the Organisation for Economic Co-operation and Development average of 9.7%.

Spending more on health doesn’t necessarily relate to better health outcomes. One analysis, published in BMJ Global Health in October 2020, suggested some low income and middle income countries outperformed high income countries at efficiency towards achieving universal health coverage.9 That study found the main drivers were income, education, and governance—and the last is a major challenge for Laos, according to Ying-Ru Lo, the current WHO representative to Laos in Vientiane.

Lo says that the levels of investment in health and poor public health administration in the years before the pandemic meant there were insufficient numbers of healthcare workers and also infrastructure for isolating infectious patients safely. Also, there aren’t enough intensive care unit doctors nationwide to provide intensive care in cases of severe disease. “There is still a certain level of strain due to a shortage of needed specialists,” she says.

A survey of local stakeholders in 2016 identified several barriers to strengthening Laos’s healthcare workforce,10 including the size of the national budget for recruitment, poor quality education, and a lack of continuing education programmes. Between April and May 2020, WHO conducted customised two day training exercises in simulated clinical management and infection prevention and control at central and provincial hospitals in Laos; these were followed by intensive care training at central and provincial hospitals in August 2020. Laos had time for training in hospitals before covid-19 patients arrived, but Lo and some doctors The BMJ spoke to don’t think it was sufficient.

Intensive care training in general is expensive and can take months or years. In 2018, there was less than one healthcare professional per 1000 people in Laos,11 and a 2019 Asian Development Bank Institute report on healthcare quality identified knowledge gaps on a variety of clinical issues, including diarrhoea and heart failure.12

Truls Østbye, professor at the Duke University School of Medicine’s Department of Community and Family Medicine, who worked on the 2016 survey, says that a “promising” approach for Laos might be learner led continuing education. One study found that a year of coaching on hospital care for children with reinforced feedback at two district hospitals in 2017 saw case management scores jump from 50% to 80% at one hospital and 52% to 97% at another.13

Outreach

As of 1 March 2022, Laos has reported about 620 confirmed deaths from covid-19, though some people are sceptical of official figures. Researchers estimated that in 2018 less than half of all deaths annually in Laos were registered, and a report published in August 2020 citing government statistics also said that 93% of deaths in the country occur outside a health facility.14

The pandemic has, however, provided some optimism that healthcare access can improve in Laos. For instance, engaging with provincial governors instead of the central government has helped improve investment in health service delivery and quality of services, such as training, says Lo.

Laos has fully vaccinated 60% of the population, and because of the spread of the omicron variant, the government has approved a second booster shot for priority vaccination groups and people over the age of 18.

Door-to-door vaccinations started in late 2021, and in February 2022 a new outreach and mobile vaccination campaign began focusing on mass vaccination sites, schools, villages, and homes. This was prompted by donated doses nearing expiry—the country has relied heavily on donations of vaccines and equipment from the Covax alliance and countries including China, Russia, and the US.

Outreach remains a problem for some areas. As of 14 March, three of 18 provinces had vaccination coverage for recommended doses of less than 50%, according to WHO. Lo said there are shortages of vehicles for mobile vaccination, which particularly affects healthcare workers in remote communities. They often ride their own motorcycles along bumpy roads or sometimes rent longboats to reach villages. The non-governmental organisation World Vision has also pointed to how outreach services are “key to many of our remote communities accessing these essential health services, including accessing covid-19 vaccine.”15

Funding from outside the country has poured in during the pandemic. But donations won’t continue for ever. For instance, a spokesperson for Gavi, the Vaccine Alliance, told The BMJ that vaccine support—and not just for covid-19—finishes at the end of this year and cash support at the end of 2023.

As one healthcare professional at the World Bank in Laos, who asked not to be named, told The BMJ: “Covid funding is not something that the government can continue to count on for the next 10 years.”