‘Training Citizens for Universal Health?’

Fieldnotes – Attapeu Nursing School, Southern Laos, 6 March 2025

Fig. 1 Entry gate of Attapeu Public Health School

‘Come, come, elders of the People, come receive public health service! We welcome you!’ It’s two days before Women’s Day – a national holiday in the Lao People’s Democratic Republic. Today, the Public Health School of Attapeu, a small province in the country’s South, offers free Health Checks to the elderly. The students spun a large banner across the corridor. It reads: ‘Activity to help society’ and promises free health checks.

The principal calls everyone to take a photo: first the students and staff. Then guests, the village leader, a representative from a French NGO which sponsored the event, and myself take position as directed. After the photo, the principal gives a speech and emphasises the importance of community support. To train these nurses includes activities to help society. She applauds her students for being good citizens, including taking care of the school environment. After the principal’s speech, the village leader agrees with her, and thanks the school for this activity. Next, the NGO worker explains that these students can check the villagers’ health, and if they find something unusual people should go to the hospital – here, we don’t have the equipment and medicine.

At the reception desk, the nursing students take the villagers’ details, measure their blood pressure, and give them a number to wait to be examined by a teacher with doctor training. Whenever a new person arrives, a student welcomes them, guides them to a chair and hands them a water bottle.

By 10:30, students Souk and Vanouli give a presentation that focuses on good and bad habits of people with high blood pressure. Souk’s voice is loud and emphatic; he points a lot at the audience. The phrase ‘develop oneself’ falls many times. Behind my back, I hear a woman whisper to another: ‘And we give health education to ourselves, too?’ They giggle.

The next two students, Duan and Lom, present on diabetes. At the end, they ask questions and choose a person from the audience to answer. If the answer is correct, they tell everyone to applaud – a pattern I remember from our school lessons. At the end, Duan tells the audience: ‘Now you know, and you can tell others in your family, in your village, about this illness.’

11:30, it’s lunchtime and the atmosphere is jolly. The villagers slowly leave. Students offer drinks to the remaining guests and Lao music streams through the loudspeakers.  A teacher tells the youngest male student to take an elderly woman home. As he drives off with the lady sitting sideways behind him, teachers and students cheer “whhhooooiii!!!”

Fig. 2 Front of Attapeu Public Health School

Fig. 3 Map of Laos

My paper explores in what ways health in Laos is imagined as a common good, and what commoning health in Laos looks like in practice. My data stems from eleven months of fieldwork at a public health school in Attapeu between 2024 and 2025 for my PhD studies. Attapeu lies in the far-South of the country, borders Cambodia and Vietnam, and has a population of around 150,000 people. During  my fieldwork I lived in the school dormitory, accompanied thirty nursing students to class and other activities, and conducted open-ended interviews and document analysis.

Background: Socialism and health care in Laos

Efforts to render health a common good in Laos are part of an ongoing socialist project of transforming society. Between 1953 and 1975 a socialist movement supported by North Vietnam fought against a US-controlled royal government that followed French colonialism. In midst aerial attacks, revolutionaries ran hospitals in Liberated Zones, activities for health prevention, and provided treatment and vaccinations in remote locations. Nursing training, as this quote from the mid-60s shows, was linked to a political mission of gaining the population’s trust:

‘After six months, we were capable of preventing diseases and treating other typical illnesses. We then went out to practise what we had learned… They told us to eat and live together with the people. Our duty was to take care of the ill and act in such a way that people would believe and support the Neo Lao [Lao Front] … we didn’t take payments.’ (Sweet 2015, 174, own emphasis).

To this day, Lao health workers are trained in both medicine and politics. After the socialist takeover in 1975, free and government-managed health services expanded, with support from the Soviet Union, Vietnam and Cuba.

Fig. 4 An abandoned corridor of Attapeu’s former provincial hospital, now the Public Health School

But these days, Laos’ health care sector is mainly defined by lack. Historian Kathryn Sweet sums up the situation of Laos’ health care sector as an ‘under-funded, under-developed and under-used patchwork’ (Sweet 2015, ix) – a situation that emerged through decades of colonisation, violent struggle, international political interference, and aid dependency.

When the Soviet Union began to collapse in the 1980s, Laos transitioned to a market-oriented economy and introduced structural adjustment programs imposed by the IMF. User fees returned, the private sector grew, as well as aid and influence from global health organisations. But in the last two decades, Laos has made large progress towards Universal Health Coverage via various social security schemes, initially for civil servants and salaried workers, then also for self-employed and informal economy workers, and special funding for Mother-and-Child care. In 2016, the National Health Insurance Fund was implemented which by 2018 covered 94% of the population, financed through fixed co-payments and government subsidy (Bodhisane and Pongpanich 2022). Yet, issues with high expenditure for patients, such as chronic disease patients, remain. Actual out-of-pocket costs are often higher than expected, and often medication must be bought privately from pharmacies (Chaleunvong et al 2020).

In sum, many elements of socialised health care are missing in Laos today: health care is not universal, equal or free. Yet, in this paper I want to focus on the social and political dimension of Laos’ project of universal health: How does the Lao state continue to mobilise health workers and ordinary citizens to work together towards the vision of health as a common good?

What this looks like in practice, I will explore now along the ethnographic vignette from the beginning.

 ‘The State focuses on improving and expanding public health services to take care of and promote the people’s health’ (Article 25, revised constitution of Lao PDR 2015)

Health care at the Women’s Day event was framed as a gift by the state and its nurses to the people. To celebrate a national holiday, the school offered a free service to the community. Gestures of hospitality included free drinks and even a lift home. The event’s make up – banners, music, free snacks, and group photos – aimed to produce a sense of sociality and solidarity between the state workers, the local community, its authorities and international supporters.

Any form of common good and commoning relies on social relations, and this includes the state’s efforts. As anthropologists Holly High and Pierre Petit (2013)  write, the Lao state can be best understood as a social relation and produced by the actions of real people: those who campaign, and those who come.

This performance of the giving state contrasts to many actual experiences of health services in Laos where people must pay, bring their own food and bed sheets, and need to take care of their own transport – reasons for why many people in Laos do not use services.

But public events highlight the state’s efforts in delivering the promise of health care as is captured in its constitution. Laos, so nursing students learn in politics class, is not yet a socialist country, but ‘in an historical phase of building and reforming society on a socialist path,’ and health care is part of this project.

‘Build the learner to be a good citizen of the nation’ (Department for Education and Scientific Research, 2016, Philosophy of Higher Diploma of Nursing Course, 1)

Fig. 5 Nursing students tidy up the schoolyard

Central to this project is to train health care workers as model citizens. At the Women’s Day event, the principal portrayed her students as tidy, helpful, and skilled. A teacher explained to me, that nursing education was about producing citizens who contribute to and take care of what belongs to everyone – from shared school facilities to public health itself.

In politics class, students learn about good citizenship under the title of ‘Revolutionary morals and qualities of good citizens.’ This means having a drive for self-improvement, directed towards the common good. Emphasis was on self-organisation, to take responsibility, cooperate and act in and for unity. In practice, students organised to clean their school environment, prepared and shared meals, frequently checked in with teachers as to who would teach what lesson, and managed the expenses for their education including expensive festivities and gifts for their teachers to, in the words of students, ‘show solidarity.’

As they pooled their resources, from physical labour to money, students approached their training as a common good. They shared an interest in developing their knowledge and pursue a career as civil servant. However, in Laos, chances for state employment are slim: due to empty public pockets, almost a third of Laos’ over 7800 nurses who worked in public service in 2024 were volunteers waiting for a government position (UHS 2025). I know people who volunteered for up to ten years after their training, and others who dropped out of the profession. Sacrifice and reliance on families and communities to support state workers is also part of realising health as a common good in Laos.

‘Raise consciousness about being master of one’s own health, that of one’s family, and community’ (Department of Public Health Attapeu, 2024, 10^th Five Year Public Development Plan 2026-2030, 2)

Despite this burden, nurses I spoke to were motivated by the prospect of taking a leading role in their society and in the development of public health.

Laos’ current public health reform strategy holds the vision “Health for all, by all” and explains that all citizens must contribute and take responsibility to advance public health. Health as a common good is not only framed as the government’s or state worker’s responsibility – it’s everybody’s.

The Women’s Day Event foregrounds a focus on people’s own responsibility and duty in matters of health. Health education is provided as a service by the state, but the emphasis is on
developing oneself, as exclaimed several times by the presenters. Members of the audience took this message with a mixture of resignation and humour.

When I asked students what in their mind needed to change to advance public health in Laos, the first thing they mentioned was that people had to shift in beliefs and behaviours.

To raise consciousness about ‘being one’s own master’ in matters of health, Lao nurses regularly venture out to communities to educate and train the population in behaviours that promise healthier futures, from vaccination, nutrition, to family planning and collective clean-ups.

Importantly, public health does not imagine ‘the People’ as a homogenous mass. A wide-spread discourse in Lao socialist politics is that the urban, educated, and ethnic Lao-Tai, Buddhist population – which also dominates the nursing profession – will lead the rural, less educated, and ethnic-minority populations to become more developed. Health care in Laos parallels a nation-building project, which as scholars of Laos point out, entails cultural homogenization and stigmatization of population groups that fall short of the imagined ideal of modern Lao citizens.

Anthropologist Holly High has described Lao socialism as political culture with a ‘civilizing mission’ along a ‘single-path of development.’ The aspiration of health as a common good must be understood within ‘a long-running socialist political project of not only improving life for Lao citizens, but doing so by making new socialist people, with “civilized” habits, modern dispositions and unified values.’ (Holly High 2021,147)

How the logic of levels of development operates was observable at the nursing school. To improve oneself means to show respect towards teachers, to comply with regulations and directions, and to emulate their ways. In community-based work, this logic of self-improvement as a matter of compliance, cooperation and emulation matters to how nurses see their role vis-à-vis patients. Students put it like this: ‘They, the teachers, are like parents. We, the students, are like children…our teachers develop us, we develop communities.’

The emphasis on taking responsibility for improving oneself and one’s circumstances unfortunately at times creates situations where patients, especially from remote and rural communities, feel disrespected and mistreated by health care staff (High 2025). The avoidance of health services has been recognised as problem by several scholars of Laos, such as my Lao supervisor Sysavanh Phommachanh and her colleagues (2019), and as a gendered one: pregnancy and childbirth are particularly politicised in the drive for development. The government’s strategy as well as many nurses I spoke to see a major barrier to improvement of national health outcomes as a matter of ‘wrong beliefs’ or lack of desire to change behaviours.

Health issues in rural and remote Laos have much to do with infrastructural challenges such as inadequate facilities and road systems, as well as with mismanagement in Laos’ drive for rapid socio-economic development, so recent studies suggest. Malnutrition in Attapeu has been linked to dwindling access to forest foods and clean water, as internationally owned rubber or banana plantations expand. Short-term incentives have led farmers to replace rice paddies with unsustainable cash crops such as cassava. While deals with international corporations help to build health infrastructure, some projects ironically put public health at risk. In nursing training, I found that these structural challenges to health as a common good were not as much discussed as the idea that realising universal health required all individuals and communities to develop themselves.

Health as common good: a single-path development?

On my daily way to Attapeu’s morning market, I walked past a sign that reads ‘Public Health Model Village’.

‘We must make each village into a Public Health model village’, Intavong (pseudonym), an official at Attapeu’s Public Health Department tells me. For this certification, a village must meet eleven indicators which were agreed upon with the United Nations, so that Laos can leave the list of ‘least developed countries.’ Intavong tells me: ‘We have responsibility to the UN, we must show them that we reach the indicators.’ ‘And will you achieve the indicators as planned by next year?’ I ask. ‘Yes, of course, definitely,’ he answers with a confident voice.

As we’ve discussed many times over this conference, the ‘commons’ as a relational concept demands to ask ‘whose common good is it?’ While people in Laos approach health and care as a common good in various ways as they build on social relations and mutual aid, the state’s work is to organise society along the same track. Central to the ongoing project of universal health in Laos is training nurses to train others, in how to follow.

Silvia Federici writes that today’s commoners ‘reject the imposition of a unitary model of social and cultural life… [there are] many roads to the common, corresponding to our different historic and cultural trajectories and environmental conditions’ (Federici 2018, 20). This ethic clashes with the one-path developmentalism that underpins health as a common good in Laos.

Yet, I admit that I also felt enchanted by the nursing students’ dedication, their ability to self-organise as a group, how they helped each other through their training, and their conviction that a better future was possible if people tried. When I asked nursing student Duan if she had any worries about the future, or anticipated problems, she responded in a calm voice:

‘I have the hope that my family will develop itself, to do better, to have better health…There will be no problems, will not have difficulties. I think it will be better. Because we come learn, we take lessons. When we develop, it makes it better than before.’

References

Bodhisane, Somdeth, and Sathirakorn Pongpanich. 2022. The influence of the National Health Insurance Scheme of the Lao People’s Democratic Republic on health access…’ Health Research Policy & Systems (20, 1),1-11.

Chaleunvong, Kongmany, Phoummalaysith, B., Phonvixay, M., Sychareun, V., Durham, J., and D. Essink. 2020. ‘Factors associated with patient payments exceeding National Health Insurance fees and out of pocket payments in Lao PDR’. Global Health Action, 13.

Department for Education and Scientific Research. 2016. ‘Coursebook Higher Degree of Nursing Diploma Ctd.’ Vientiane: Government of Lao PDR.

Department of Public Health Attapeu. 2024. ‘10^th Five Year Public Development Plan (2026-2030)’, Attapeu, 2 October 2024.

Mekong Eye. 2024. ‘Fruits of Spoil: Laos’ Forests Disappearing As Plantations Flourish,’ 16 December 2024, accessed on 27 August 2025. URL: https://earthjournalism.net/stories/fruits-of-spoil-laos-forests-disappearing-as-plantations-flourish

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High, Holly. 2025. ‘Technobirth and Motherlore,’ Substack Revolutions in Reproduction, 9 July 2025. URL: https://revolutionsinreproduction.substack.com/?utm_campaign=pub&utm_medium=web

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Phommachanh, Sysavanh, Essink, D., Wright, E., Broerse, J., and M. Mayxay. 2019. ‘Overt versus covert observations on health care providers‘ care and communication during antenatal care visits in Lao PDR,’ Journal of Global Health Sciences 1, e11.

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