Laos - Laos builds specialty training system through partnerships

Over the past decade, Laos has been developing its postgraduate medical training system through a series of international partnerships. Katherine Nightingale reports on their successes.

In 1996, there were seven paediatricians in Laos. There were no internists—the concept of internal medicine did not even exist—and there were few doctors in the rural areas where they were needed most.

Some medical students and graduates were trained in countries such as Australia, Japan, and the USA, says Chu Vang, head of the cardiology department of Mahosot Hospital in the capital Vientiane. But postgraduate training in specialties such as paediatrics was not available in the country itself, and subspecialties such as cardiology were a distant dream.

Now Laos' University of Health Sciences—the country's only medical school and institution for medical training of any kind—has a cardiology fellowship which is run with the support of French and Luxembourgian non-governmental organisations (NGOs) Santé France-Laos and Aide au Dévelopment de la Santé. The fellowship began in 2008 and graduated its first class of ten this year.

This kind of partnership with international NGOs and universities has seeded Laos' postgraduate medical education system in the past 15 years, introducing residency programmes in many major specialties, and allowing physicians to complete their medical training almost entirely in their home country.

Laos has just 23 doctors per 100 000 people but, unlike many other low-income countries, it does not have a huge problem with medical brain drain. Vang says that Laos experienced most of its medical brain drain in the years after 1975, when about 10% of the population—largely the educated middle class—left in objection to the new communist government and the formation of Laos. “It did affect the health-care delivery in Laos”, he says. Since that time of emigration, doctors going abroad for training have tended to come home, says Vang.

After 1975, all postgraduate training for Lao doctors occurred in socialist countries, including Russia, Vietnam, China, and Cuba, says Sing Menorath, vice president of the University of Health Sciences in charge of academic affairs. But after the collapse of the Soviet Union in 1990, Laos was left with fewer places to further train its newly graduated doctors, and without the resources to train them in the country.

This situation meant that normal practice in Laos was—and in some cases still is—for a medical student to graduate straight into practice, “without enough knowledge to deal with the health-care issues they are going to face”, says Vang.

The Ministry of Health (MoH) assigns graduates a position, often catering to the estimated 70% of the Lao population that lives in rural areas, where, because of the prohibitive costs of travelling to medical care, patients often present with advanced and complex disease.

Seeking to plug this training gap, the University of Health Sciences (UHS), then the Faculty of Medicine in the National University of Laos, began an informal collaboration in 1991 with the US non-profit Health Frontiers, run by Karen Olness, professor of paediatrics, family medicine, and international health at Case Western Reserve University, Cleveland, OH, USA, and her husband Hakon Torjesen, assistant professor in global health at Case Western. The pair had lived in Laos for 5 years in the 1960s and were keen to return and put their expertise to good use.

Together with Lao faculty, Health Frontiers wrote a paediatrics curriculum for the medical undergraduates, and later an outline for a Lao residency in paediatrics. In 1997, after 5 years of discussions with various government departments, the first class of six residents enrolled. In 2001—at the request of the MoH—an internal medicine residency enrolled its first intake of six.

Initially, both 3-year programmes relied heavily on western volunteer doctors who would commit to spending a year or more in Laos to oversee and lead ward rounds and lectures. But the initial intake was deliberately chosen from the central Vientiane hospitals Mahosot, Mittaphab, and Setthatirat so that they would eventually become teachers.

Now pre-existing Lao staff and the graduates of the first few years of the residencies do most of the day-to-day ward rounds and lectures, says Elizabeth Clarke, a US internist who is the current Health Frontiers administrator for the internal medicine residency. As well as the slowly increasing responsibility for patients, residents also attend English classes, and are given computer training.

The UHS-Health Frontiers programmes graduated five paediatricians and seven internists this year, taking the total graduates to 61 and 43, respectively. All the graduates have practised after medical school before coming to residency and prospective residents must gain the approval of their hospital director to go to Vientiane to train. They keep their MoH jobs and Health Frontiers also provides a small monthly stipend of US$20—30 to cover expenses such as study materials. Funding for Health Frontiers comes from personal donations and some organisations.

Not all the training occurs in Laos. When the programmes first began, there were no subspecialists in Laos, so residents were sent to Khon Kaen University in Thailand, which accepted Lao trainees for 6 months during which they rotated in specialties such cardiology and endocrinology. Health Frontiers raises the money for transport and accommodation and the Thai faculty do all the training pro bono.

All students are required to return to their original jobs for an agreed period, and Clarke says that most stay in their positions—she can bring to mind only two graduates who have left medicine to begin other careers, and one of them went to work with a health-based NGO.

Part of the reason for this, it is thought, is that the bulk of the training occurs in Laos, curricula are developed by the Lao faculty with input from Health Frontiers, rather than the other way around, and because graduates are trained in an environment that is similar to that which they will work in, they can hit the ground running when they return to their provincial or district hospital. The residents also see the evidence-based medicine approach used by the volunteers and learn how to adapt it to the Lao context.

“Also there's a cultural component. Our residents love Laos and wouldn't be happy to move anywhere else but Laos”, says Clarke.

The courses have proved popular, says Olness, with up to 30—40 physicians applying for the six spaces on each course per year.

The UHS now has a range of international partnerships in postgraduate education, including nine residency programmes, three fellowship programmes (in cardiology, gastroenterology, and endocrinology), and four Master's programmes (in public health, family medicine, dental public health, and periodontics).

The University of Calgary has collaborated with UHS on the development of a family medicine residency programme, which enrolled its first class in 2005. The programme takes new medical graduates and provides 2 years of training in primary care, 1 year in Vientiane and the second at provincial sites, with the aim of boosting Laos' primary care service and the number of doctors working in rural areas. It has graduated more than 150 family physicians, more than 70% of whom work in rural areas. Lao faculty completely implement the programme, with University of Calgary staff serving as mentors.

The anaesthesiology, radiology and imaging medicine, and surgery residencies have been run for 5 years entirely by the Lao faculty after their establishment with the help of the University of Bordeaux, the University of Lyon, and University of Strasbourg, respectively. The obstetrics and gynaecology residency grew out of work with the University of Freiburg in Germany, which continues to be involved in the programme.

Vang says residencies and fellowships expose the doctors to the global network in their specialty, as well as “getting more experience in self learning, in using electronic training packages available on the internet, and critical reading of medical research to inform their daily practice…this way not only do they benefit but their patients do too”.

Olness agrees: “The need of faculty to teach well and to continue their education is a much more highly valued concept now. There's pride in what's been accomplished. This has all happened in the last 14 years—it's a huge change.”

Menorath says that no data are available for the effect that the training has had on health indicators, but that anecdotally, “doctors [who have had training] are more confident, are more able to make decisions alone” and that referrals to larger hospitals have been cut as expertise increases in district and provincial hospitals. Health indicators for Laos have improved in general in the past 15 years, with the World Bank stating that mortality for children younger than 5 years has decreased from almost 115 in 1995 to just under 59 children per 1000 in 2009, for example.

The aim is that the UHS staff will eventually take over all the teaching and administration of every residency. This should help reduce the reliance on donors. “Of course I hope that one day all postgraduate training will happen without help from donor countries. This might happen if the Lao Government can provide funding to cover the costs of these training courses and when we get enough local specialists with better facilities to deal with daily teaching and learning”, says Vang.

And, for now at least, he is enthusiastic about continuing to collaborate with partner institutions. “The key to success has been collaboration—we have worked with our partners in the spirit of respect. Our training programmes need this collaboration with foreign universities. Medical science is developing rapidly and we need to keep up.”

Katherine Nightingale

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