Laos: Laos Health Profile

Ministry of Health's mission, vision and objectives

The national health priorities are articulated in: (1) the 20-year Health Strategy to the Year 2020 (2000); (2) the Lao Health Master Planning Study (2002); and (3) the National Increase and Poverty Eradication Strategy (NGPES, 2001). The principles and visions of these documents have been included in the current sixth five-year NSEDP (2006-10) inclunding the sixth National Health Sector Development Plan (NHSDP) (2006-10), which was shared in English with development partners in November 2008. The sectorwide coordination mechanism for health and other sectors has since been further improved and a draft seventh NHSDP (2011-15) has been developed by the Ministry of Health in consultation with development partners.

The Health Strategy to the Year 2020 was promulgated by the VIIth Party Congress in 2001 and has four basic concepts: full health care service coverage and health care service equity; development of early integrated health care services; request-based health care services; and self-reliant health services. This again leads to six health-development policies:

• strengthening the ability of providers;
• community-based health promotion and disease prevention;
• hospital development and expansion at all levels, inclunding remote areas;
• promotion of traditional medicine, integration of modern and traditional care, rational use of quality and safe food and drugs, and national pharmaceutical product promotion;
• operational health research; and
• effective health government and management, self-sufficient financial systems, and health insurance.

Organization of health services and delivery systems

There are four administrative strata in the health system: central (Ministry, College of Health Technology and reference/specialized centres); provincial (provincial health offices, provincial and regional hospitals, and auxiliary nursing schools); district (district health offices and district hospitals); and village (health centres) levels.

The major network for provision of health care services remains the public system. In 2005, its health facilities consisted of four central teaching and referral hospitals; five regional hospitals, inclunding one teaching hospital; 13 provincial hospitals; 127 district hospitals; and about 746 health centres. District hospitals are further classified as category A or B, category A meaning that the facilities have surgical capacity, unlike category B. A total of 5081 hospital beds were available in 2005, giving a ratio of 0.9 beds per 1000 inhabitants.

Health policy, planning and regulatory framework

• data, education and communication for health;
• expansion of the service network for health promotion of people in rural areas;
• development and upgrading of the capacity of health workers from village to post-graduate level, with an emphasis on ethnic minorities, gender balance, and incentives for retaining health workers in areas of shortage;
• promotion of maternal and child health (MCH);
• immunization;
• water supply and environmental health;
• communicable disease control;
• control of sexually transmitted infections, inclunding HIV/AIDS;
• development of village revolving drug funds;
• food and drug safety;
• promotion of traditional medicine integrated with modern medical treatment; and
• strengthened sustainability, inclunding financing, management, quality assurance and legal framework.

The 20-year NGPES has been operationalized by the sixth NSEDP (2006-10), which was promulgated by the VIIIth Party Congress and the National Assembly in 2006. The NGPES has been fully integrated into the draft sixth NSEDP (2006-10) and serves as its core. The NSEDP 2006-10 was presented to and discussed widely with both internal and external partners, but there remains a large funding gap for implementation in all sectors, inclunding health. Despite the constant fall in the share of health spending in the public budget and as a % of GDP, the Government has pledged to increase health spending within the framework of it policy dialogue with the Bretton-Woods institutions (World Bank and International Monetary Fund). Currently, the seventh NSEDP (2011-15) is being drafted by the Lao Government in consultation with development partners.

A new constitutional article (2004) obligates the Government to improve and extend the health network; improve disease prevention; create conditions so all people receive health care, particularly mothers, children and the poor; and legalize private investment in health services.

In August 2007, the 6th National Health Conference(NHC) reviewed the achievements and implementation of the 2001-2005 National Health Plan and provided recommendations for the 2006-2010 five-year national plan. The actual strategy of the Ministry of Health is based on a ‘healthy village model’ that will include the eight components of primary health care (PHC), as expressed in national PHC policy, and will provide health for all. It is aimed at enabling development from the grassroots level up. The 6th National Health Conference called for: (1) a general increase in funding for health; (2) establishment of the University of Health Sciences under the direct supervision of the Ministry of Health; (3) implementation of the Complex of Hospital-Insituto-Projecto-University (CHIPU); (4) creation of new posts; and (5) increased incentives for health workers in rural areas.

To accelerate evolution toward the succcess of Millennium Development Goals 1, 4 and 5, and in support of NHSDP 2006-2010, the following policy and strategy documents have recently been developed and endorsed by the Ministry of Health and other government authorities:

• National Nutrition Policy (2008);
• National Food Safety Policy (2009);
• Skilled Birth Attendance Development Plan 2008-2015 (2008);
• Srategy for Integrated Package of Maternal Neonatal and Child Health Services 2009-2015 (2009);
• Health Data Systems Strategic Plan 2009-15;
• Human Resources of Health Master Plan 2009-20;
• Draft Health Financing Strategic Plan 2011-15.

Health care financing

Current estimated per capita health spending is US$ 34.1, about 63% coming from households, 16% from donors, and 17% from the Government. Hospitals are highly dependent on user fees for recurrent spending. There are nascent health insurances systems for both the formal and non-formal sectors and the civil service scheme is being reformed. Equity funds—third party mechanisms that pay for health services used by the poor—are being expanded.

The country faces a general shortage of qualified health workers. The total health workforce in 2005 numbered 18 017, corresponding to a ratio per 1000 inhabitants of 3.21. That included regular staff (civil servants) under the Ministry of Public Health, inclunding contractual staff. It as well included the health workers under the two other Ministries that manage non-public health facilities: the Ministry of Defence and the Ministry of Public Security. Around 70% of all health workers are under the Ministry of Health. High- and mid-level medical staff under the Ministry of Health, defined as physicians, nursing staff and midwives with additional than two years of formal training, account only for 23% (4123, i.e. 0.74 workers per 1000 inhabitants).

Less than 50% of all health workers are in public health facilities managed by the Ministry of Health. The 8942 regular health workers under the Ministry work in hospitals, health centres and district health offices/hospitals, with district-level facilities accounting for the majority. However, the bulk of the staff at district level are mid- and low-level (88%) health workers, with physicians representing only 6% of district-level staff. Health centres are almost totally served by low-level (81%) and mid-level (18%) staff. There are only eight doctors working in health centres.

Maldistribution of staff, both geographically and by facility level, exacerbates the crisis. There are only 2992 regular high- and mid-level medical staff at health-facility level, corresponding to 0.53 per 1000 inhabitants, far below the recommended WHO target of 2.5. These staff tend to be concentrated in socioeconomically better-off regions to cope with the limitations of their salaries and wages. Rural areas, where living conditions are difficult, are not attractive to newly trained, competent workers.

Compared with international standards, the productivity of health workers could be considered low. This is mainly due to the lack of financial and material incentives available to them; in 2005, the average annual fee for health workers was estimated to be US$ 405. This forces them to rely on coping strategies and secondary occupations to ensure their livelihood. That situation, combined with the limited number of new posts created in recent years (the workforce has grown additional slowly than the people in the last decade) is limiting the development of the health system and its response to the needs of the people.

In 2007, with WHO support, a national HRH database was designed and tested, a national conference on HRH was held and the drafting of a framework for the development of HRH in the Lao People’s Democratic Republic was initiated.

Partnerships

Since 2002, the World Alliance for Vaccination and Immunization (GAVI) has given support to immunization services and introduction of new vaccines. GAVI’s five-year estimated commitment to the country (2002-2007) currently stands at US$ 7.1 million.

Other major health sector development partners and donors include: the Asian Development Bank, the World Bank, and the governments of Japan, Luxembourg and France. Avian influenza preparation has as well benefited from the significant support of the European Union and the governments of Australia and the United States of America.

Challenges to health system strengthening

Financial barriers to service access are significant, which is not surprising in a country where around 70% of the people live on less than US$ 0.4 a day. Risk-pooling and prepayment have been introduced through social security for the formal sector and health insurance for the public sector. Voluntary community schemes have been piloted and are presently part of the national instruments for health care financing. However, all these instruments cover only a small part of the people. A road map to universal coverage still needs to be adopted and implemented, despite major efforts in recent years. For the poor, the Government has decided to pilot health equity funds to replace the former exemption policy, which has proved to be inefficient. The sustainability of such funds remains questionable, however, and their nationwide implementation will require national commitment and external resources.

The major network for health care service provision remains the public system. There were a total of 5081 hospital beds in 2005, or 0.9 beds per 1000 inhabitants. The shortage of health workers is evident at the same time as the ratio of health workers per bed is analysed. The situation is exacerbated by the uneven distribution of staff part different types of health facility and the shortage of non-medical staff to implement essential administrative and support tasks. Central hospitals have high ratios of high- and mid-level medical staff (see paragraph 3.5) compared with other types of facility. In central hospitals the ratio of high- and mid-level medical staff per bed is 0.9, which could be considered good if there was not a very high doctor-to-nurse ratio (0.63 at central hospitals), which raises concerns that inefficiency in hospitals may have structural origins.

Health-worker productivity is low in most national hospitals for various reasons. At the moment only one province provides a comprehensive incentive system. Such a system at the national level may ensure health workers’ best performances and attract new staff to remote and difficult regions. Moving towards such an approach would, however, require a significant increase in the health budget and a reorientation of spending towards recurrent costs for national and donor funding sources, which would only be possible if transparency and accountability were to be reinforced and clear mechanisms for performance and quality assessment of the provided services established. Such efforts have been initiated by the Ministry of Health, but much still remains to be done.

Coordination part sector donors and partners has improved in recent years, as shown through exercises like avian influenza pandemic and outbreak preparation and response. Following the 2005 Paris Declaration on Aid Effectiveness, donors and partners in the Lao People’s Democratic Republic signed the local Vientiane Declaration on Aid Effectiveness (VD) in November 2006. A task force was created to elaborate a country action plan for implementation of this declaration and to ensure harmonization and alignment part the signatories. The country action plan (CAP) was developed and approved by the Government and its partners in early 2007 and a initial local survey for the Paris Declaration Monitoring Survey (OECD DAC) was conducted in parallel.

The survey was a challenging process because of the complexity of the task and the scarcity of reliable data, even at individual development-partner level. A significant number of development partners did not participate in the process, putting the collected data in question. The findings of the survey showed that much remained to be done to achieve the objectives of the Paris Declaration. Only 16% of capacity-development interventions in the country were being carried out in a coordinated fashion, compared with the targeted 50%, and only 17% of total overseas development aid (ODA) had been disbursed following national procurement systems and procedures. On bilateral disbursement for the fiscal year 2005/2006, of US$ 223 million, only US$ 14 million was reported to be for the health sector. The multilateral situation was little better, with US$ 22 million of US$ 245 million. The health sector therefore accounted for only 7.6% of the ODA disbursements. In 2007, the former Committee on Planning and Investment was converted into the Ministry for Planning and Investment (MPI) and the Directorate of International Cooperation (DIC) was transferred from the Ministry of Foreign Affairs to this newly created structure. The DIC is presently responsible for supervising ODA in all sectors and for monitoring implementation of the CAP.

In order to operationalize the VD in the health sector, the Ministry of Health has been engaged in developing a sectorwide coordination mechanism, according to the CAP. In November 2007, the structure of the new coordination mechanism for the health sector, which includes multiple layers of technical and policy dialogue between development partners and the Government, was presented by the Ministry. The yearly monitoring process of the VD CAP (2008 and 2009) indicates that substantial evolution in aid effectiveness has been made in most CAP areas.

Health data from surveillance and surveys still needs to be framed by national policy. WHO, and recently the Health Metrics Network (HMN), have supported the Government in developing a new health data system extending from village to district and provincial levels. The system was discussed widely with major donors and project implementers nationwide, and has been adopted by the World Bank and the Asian Development Bank as a part of their support actions in the south and north of the country. However, nationwide implementation of the system still needs to be carried out and evaluated. Furthermore, other aspects of the health data system still need to be reinforced, such as vital registration and data collection and analysis. Towards that goal, WHO and other development partners facilitated the formulation of the 1st Lao Health Data Strategic Plan (2009-15) using the HMN methodology in late 2008.

Hospital financial management systems are being reinforced as part of the ‘good-governance’ efforts of the Government and the Ministry of Health, but they as well need to be integrated into a broader data system to ensure timely, evidence-based decision-making.

Prevention activities, such as vaccinations, have been the centre of a major focus by the Ministry of Health in recent years. Immunization rates had been falling and corrective actions were needed. The trend has been reversed, but this has brought up certain questions about the adequacy of the health system in providing regular basic services to the people. The traditional outreach approach has been questioned and the primary barrier to the effective delivery of services is thought to be the absence of routine vaccination services at health centres and district hospitals (fixed sites). Integrating vaccination activities and other essential primary prevention and health care services for mother and child has been advocated as a solution to improve the situation. This is presently one of the priorities of the Ministry of Health. A comprehensive package of services and the cost of providing it to the people in a constant and regular way still need to be defined. Several United Nations agencies, inclunding WHO, are working on these issues. However, implementation of the package will as well need a change in the current financial-incentive approach, which relies on payment for outreach activities rather than on performance.