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of opium detox in Luang Prabang and other projects in other regions of the country. The challenge for any project that the Consortium undertakes is to make that project sustainable into the future, beyond Consortium involvement. Programs, including the War Victim’s Assistance Project proceed in phases. The first phase includes mapping a plan and identifying true needs as well as responding to issues like how to best use donations or incorporate donated technology. In the second phase ownership is shifted closer to the community, and staff participation at all levels is increased. Capacity building, to prepare local staff to be more involved in project management. A Project Management Committee follows up on the year’s work plan and oversees working groups including training, equipment, which addresses equipment needs by assessing use and gaps in use, hospital rehabilitation, which attends to construction of emergency rooms and surgery rooms, and a pharmacy committee which works on cost recovery and management training. A fifth group works on issues specific to war victims. In developing this system, the consortium worked closely with its government counterpart, the National Rehabilitation Center and with the Ministry of Health and the Department of Curative Medicine and the Department of Public Health. The goal of this cooperation was ensuring that inputs are sustainable and that the project will continue to serve war victims beyond the NGOs involvement.

Stephane Rousseau

Cambodia’s health coverage plan was completely restructured and is now based on operational health districts. The Ministry of Rural Development works at the village level, while the Ministry of Health works at the operational health district level. In Cambodia, “maintaining,” as used in the title of this panel, is hardly accurate, as a system has to be totally developed, almost from scratch. Laos and Vietnam had similar experiences emerging from war, but Cambodia has the added experience of Khmer Rouge genocide that left the country without doctors. Challenges to Reform and Restructuring

The major bottlenecks to national health reform are the skills of health professionals and the salary or lack thereof available to health care providers.

The concept of quality care can differ between health professionals and the community. The difference is a place that the private sector has a hold on, so it is important to work on rural communities’ conceptions of quality and understanding of quality health care. Community participation, thus, plays a significant role in approaching reforms. Community participation, though, is jeopardized by the basic demands of poverty—housing, food, etc. Sustainability of the system is another challenge—it must be well established, but this requires constant and consistent funding.

Another challenge is incorporating NGOs into the national health policy. NGOs usually try to maintain and defend their independence, but the Ministry of Health is open to input from NGOs, and when they are invited to participate in policy planning, it is easier to incorporate them into the national health plan.

A final important challenge to address is the difficulty of law enforcement. The Ministry of Health works hard to prepare a system, but it then has to implement it and enforce laws.

Questions

The first question was on what the three countries are doing to control mosquitoes and mosquito borne diseases such as dengue and malaria.

Speakers from Laos and Cambodia responded. In Cambodia, people living in areas once controlled by the Khmer Rouge had been out of reach of the government for many years, and malaria is most endemic in these areas. The government is undertaking programs to reach out to these areas with education on causes and prevention of malaria, but better research on drugs is also vital to controlling these diseases. Outreach, though, is the most essential component of control, especially to border regions where people historically have not taken precautions.

In Laos, 80% of people are in remote areas and forest covers more than a third of the country. Because people dislike nets, they do not sleep under them. Outreach and education are necessary to helping people understand the importance of nets, but Laos needs external financial assistance to establish better health education. As a side note, Mr. Vilay added that AIDS control and health education are difficult in Laos because people are embarrassed about sex and won’t talk openly about it. So health education needs in Laos are broad and should address a variety of diseases and health care issues that are presently problematic in Laos.

Another question addressed involvement of the private sector and how the governments can and should preserve access to health care for poor people while they are doing business with the private sector. Dr. Mam Bun Hong responded that Cambodia’s user fees guarantee care for the poor because the government cannot maintain services without money, so those who can pay must subsidize care for the poor. In Laos, it is a budgeting issue. User fees and cost recovery mechanisms cannot be the objective of the system because it will not solve the ultimate problem, and poverty is complex and in many regions, seasonal.