asian development bank...7. project completion report number lao people’s democratic republic...

ASIAN DEVELOPMENT BANK PCR: LAO 25109

PROJECT COMPLETION REPORT

ON THE

PRIMARY HEALTH CARE PROJECT (Loan 1348-LAO[SF])

IN THE

LAO PEOPLE’S DEMOCRATIC REPUBLIC

June 2002

CURRENCY EQUIVALENTS

Currency Unit – Kip (KN)

At Appraisal At Project Completion (31 August 1994) (31 October 2000)

KN1.00 = $0.0014 $0.0001262 $1.00 = KN715 KN7,920

ABBREVIATIONS ADB – Asian Development Bank BME – benefit monitoring and evaluation IMPE – Institute of Malariology, Parasitology and Entomology HW – health worker Lao PDR – Lao People's Democratic Republic LWU – Lao Women’s Union MOPH – Ministry of Public Health PCU – project coordination unit PHC – primary health care PIO – project implementation office TA – technical assistance TB – tuberculosis

NOTES

(i) The fiscal year (FY) of the Government ends on 31 December. (ii) In this report, "$" refers to US dollars.

CONTENTS

Page

BASIC DATA ii

MAP v

EXECUTIVE SUMMARY vi I. PROJECT DESCRIPTION 1 II. EVALUATION OF DESIGN AND IMPLEMENTATION 2

A. Relevance of Design and Formulation 2 B. Project Outputs 2 C. Project Costs 6 D. Disbursements 7 E. Project Schedule 7 F. Implementation Arrangements 8 G. Conditions and Covenants 8 H. Related Technical Assistance 8 I. Consultant Recruitment and Procurement 9 J. Performance of Consultants, Contractors, and Suppliers 9 K. Performance of the Borrower and the Executing Agency 9 L. Performance of the Asian Development Bank 10

III. EVALUATION OF PERFORMANCE 10 A. Relevance 10 B. Efficacy in Achievement of Purpose 10 C. Efficiency in Achievement of Outputs and Purpose 11 D. Preliminary Assessment of Sustainability 11 E. Environmental, Sociocultural, and Other Impacts 11

IV. OVERALL ASSESSMENT AND RECOMMENDATIONS 12 A. Overall Assessment 12 B. Lessons Learned 13 C. Recommendations 13

APPENDIXES 1. Project Framework 15 2. Planned and Actual Key Project Outputs by Components 18 3. In-Service Training 22 4. Cost Summary by Category of Expenditure and Financing Arrangements 24 5. Loan Disbursements 25 6. Project Implementation Schedule 26 7. Compliance with Major Loan Covenants 28 8. TA 2291: Institutional Strengthening of the Ministry of Public Health 36 9. Consulting Services 38 10. Indicators for Benefit Monitoring and Evaluation 39 11. Benefit Monitoring and Evaluation 41

BASIC DATA A. Loan Identification 1. Country 2. Loan Number 3. Project Title 4. Borrower 5. Executing Agency 6. Amount of Loan 7. Project Completion Report Number

Lao People’s Democratic Republic 1348-LAO(SF) Primary Health Care Lao People’s Democratic Republic Ministry of Public Health SDR3.4 million ($5.0 million equivalent) PCR: LAO 690

B. Loan Data 1. Appraisal – Date Started – Date Completed 2. Loan Negotiations – Date Started – Date Completed 3. Date of Board Approval 4. Date of Loan Agreement 5. Date of Loan Effectiveness – In Loan Agreement – Actual – Number of Extensions 6. Closing Date – In Loan Agreement – Actual – Number of Extensions 7. Terms of Loan – Interest Rate – Maturity – Grace Period

5 Jul 1994 23 Jul 1994 17 Nov 1994 18 Nov 1994 19 Jan 1995 17 Feb 1995 18 May 1995 4 May 1995 0 31 Oct 2000 6 Dec 2001 0 1.0 percent per annum 40 years 10 years

8. Disbursements

a. Dates Initial Disbursement

12 Jun 1995

Final Disbursement

14 Sep 2001

Time Interval

6 years, 3 months

Effective Date

4 May 1995

Original Closing Date

6 Dec 2001

Time Interval

6 years, 7 months

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b. Amount ($ million) Category or Subloan Original Allocation Amount Disbursed Civil Works 0.481 1.279 Medical Equipment and Furniture 0.728 0.737 Office Equipment 0.066 0.071 Essential Drugs 1.250 0.594 Training (including instructional materials) 1.005 0.584 Vehicles (and others means of transport) 0.353 0.318 Consulting Services 0.235 0.386 Local Expenditure (Project Implementation) 0.111 0.269 Local Expenditure (Monitoring) 0.151 0.136 Local Expenditure (Unallocated) 0.127 0 Service Charge during Construction 0.114 0.106 Unallocated 0.357 0 Imprest Account (Balancing Figure) 0.022 0

Total 5.000 4.481

C. Project Data 1. Project Cost ($ million) Cost Appraisal Estimate Actual Foreign Exchange Cost 3.681 3.201 Local Currency Cost 2.569 2.119 Total 6.250 5.320

2. Financing Plan ($ million) Cost Appraisal Estimate Actual Implementation Costs ADB-Financed 5.000 4.481 Borrower-Financed 1.250 0.839 Total 6.250 5.320

ADB = Asian Development Bank. 3. Cost Breakdown by Project Component ($ million)

Component Appraisal Estimate Actual

A. Base Costs 1. Strengthening of Primary Health Care 3.239 2.786 2. In-service Training 1.104 0.658 3. Monitoring Pharmaceutical Sector 0.185 0.802 4. Benefit Monitoring and Evaluation 0.296 0.165 5. Project Implementation (including consulting

services) 0.411 0.683

6. Taxes and Duties 0.279 0.120 Subtotal (A) 5.514 5.214

B. Contingencies 1. Physical Contingency 0.227 0.000 2. Price Escalation 0.394 0.000

Subtotal (B) 6.250 5.214 C. Service Charge 0.115 0.106

Total 6.250 5.320

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4. Project Schedule

Item Appraisal Estimate Actual Civil Works Contract Date of Award 4Q, 1994 1Q, 1996 Completion of Work 2Q, 1997 3Q, 1999 Equipment and Supplies First Procurement 1Q, 1995 4Q, 1995 Last Procurement 1Q, 1999 4Q, 2000 Q = Quarter

5. Project Performance Report Ratings

Rating Implementation Period

Development Objectives

Implementation Progress

From 30 June 1998 to 30 November 1999 Satisfactory Satisfactory From 31 December 1999 to 31 December 2000 Highly Satisfactory Highly Satisfactory D. Data on Asian Development Bank Missions

Name of Mission

Date No. of

Persons

No. of Person-

Days Specialization of Membersa

Appraisal 5-23 Jul 94 4 76 d, g, i, f Inception 11-18 May 95 1 8 d Review 1 23-27 Sep 95 1 5 d Review 2 16-25 Mar 96 2 20 d, k Review 3 25 Sep-3 Oct 96 1 9 d Review 4 5-12 Mar 97 1 8 a Review 5 27 Oct-3 Nov 97 1 8 a Midterm Review 13-29 May 98 2 34 a, k Special Loan Administration 1 28 Sep-6 Oct 98 2 18 b, k Review 6 17-25 Nov 98 2 18 a, d Review 7 19-23 Apr 99 1 5 d Special Loan Administration 2 29 Nov-2 Dec 99 2 8 h, j Review 8 7-11 February 00 1 5 d Review 9 11-19 Sep 00 1 9 d Project Completion Reviewb 21 Jan-1 Feb 01 2 24 d, k a a–senior health specialist, b–senior project specialist, c–programs officer, d–health specialist, e–project specialist,

f–counsel, g–procurement specialist, h–education specialist, i–control officer, j–associate operations analyst, k–assistant project analyst, l–staff consultant.

b The project completion report was prepared by Dr. W. Azmin, Health Specialist.

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EXECUTIVE SUMMARY 1. The Project was the first Asian Development Bank (ADB) health intervention in the Lao People’s Democratic Republic (Lao PDR), one of the least developed countries in Asia. Before the 1980s basic health coverage was provided through the commune system, which has collapsed. In the early 1990s the Ministry of Public Health (MOPH) developed a primary health care (PHC) delivery system through small externally-assisted projects, but they used different PHC delivery strategies and were inadequately standardized. MOPH later revised its health policy and systematically increased PHC coverage through large-scale projects, such as the Primary Health Care Project discussed in this report. The new health policy further increased PHC coverage in 200i under the ADB-assisted follow-on Primary Health Care Expansion Project. 2. The Project set out to support the Government’s National Health Policy, which focused on improving PHC services. The Project’s objectives were to (i) improve the health care delivery system; (ii) improve health management and the skills of health workers; (iii) increase the use of cost-sharing mechanisms; (iv) enhance the involvement of the private sector; and (v) increase the resources devoted to recurrent costs. The Project used a pilot approach in two mountainous provinces, Xiengkhuoang and Oudomxai, as well as Thathom district in Xaisomboun Special Zone. These areas were selected based on the following criteria: (i) highly rural populations; (ii) limited external assistance; (iii) presence of large ethnic populations; (iv) lack of health infrastructure; and (v) budgetary resources lower than those of other provinces. 3. The priority given by ADB to the Lao PDR health sector development strategy, and the objectives of the Project themselves can be regarded as relevant at the time of approval, as well as at project completion. The Project is in accordance with the ADB operational strategy that emphasizes improving the health of women and disadvantaged ethnic groups in the Lao PDR, development of human resources for health, and cost-sharing schemes. The Project aimed to expand public health care services toward decreasing the morbidity and mortality caused by preventable diseases. The Project built 73 small health centers and three small district hospitals, and renovated five existing district hospitals. Furthermore it created revolving funds in health centers and district hospitals for drug purchases, which are performing reasonably well. It also provided various types of training to 5,970 staff. Training materials were prepared to provide for continuing training. The public pharmaceutical factories and private pharmacies were monitored to ensure good manufacturing practice and compliance with MOPH drug policy. MOPH has shared the lessons learned from the Project with other provinces and in the formulation of the follow-on project. Most of the outputs were completed within the stipulated time. 4. Project implementation generally was efficient and there were no major issues. The implementation arrangements, management structures, and procedures were in accordance with the loan agreements. The Project cost was $5.32 million (84%) compared with $6.25 million estimated at appraisal. The organization and management of the Executing Agency in MOPH, and with the provincial implementing agencies, were satisfactory. Project management was effective and recruiting was efficient. Counterpart funding was timely and adequate. 5. The revolving drug funds established at health centers and district hospitals are replenished monthly and are generating income for further drug purchases. The fact that health workers are recruited locally, trained regularly, and supervised in terms of their management of the revolving drug fund, contributes to the sustainability of health centers and district hospitals. Adequate maintenance funds being devoted to health centers and district hospitals will further

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assure their sustainability. Village health committees approve the lists of the poor or medically indigent and participate in the management of health centers through feedback meetings. Supervision by provincial-level project implementation offices and district health offices improves the management. Overall, the revolving drug funds, as managed in part by the communities, were practical and acceptable. The near future will make clear whether these funds can be sustained by the communities. Technology and basic medical equipment available at health facilities are appropriate and were functioning at the time of project completion. The management of the district and provincial hospitals left much to be desired, but Government ownership of and commitment to the Project is high. 6. The Project has contributed to improved living conditions in remote rural communities, in particular the poor and ethnic minorities in upland and highland areas. It has increased health awareness and promoted positive health-seeking behavior. It has given some work to communities in that they participated in the construction of health centers. The Project has given communities opportunities for experience in the management of health centers. The Project has also given job opportunities to health personnel, and has provided a large amount of in-service training to existing health workers. The Project has had positive impacts on institutional development at the levels of MOPH as well as provincial and district health offices. 7. There were further impacts on rural development, starting from the increased accessibility to public health care in remote mountainous regions; the health education or/and information, education, and communication activities that have increased awareness among the rural population regarding the need for a clean environment and better personal hygiene; better social organization and empowerment of women; and the reduction in morbidity and mortality due to malaria and other common diseases.

I. PROJECT DESCRIPTION

1. The health status of the Lao People’s Democratic Republic (Lao PDR), particularly among its rural population, was low in the early 1990s. There was a high health burden due to preventable diseases, and chronic malnutrition was widespread. Beyond provincial capitals, the health care infrastructure was rudimentary with limited accessibility and low quality of care, particularly at the rural health facilities. At that time, the Government established a primary health care (PHC) policy that focused on disease prevention, strengthened preventive and curative services at peripheral health facilities, increased accessibility, and upgraded the skills of health workers. To implement this policy, the Government requested Asian Development Bank (ADB) help to develop strategic mechanisms for delivering basic curative and preventive services. Emphasizing the importance and cost-effectiveness of PHC investments, ADB introduced the Primary Health Care Project with the following medium-term objectives: (i) expanding access to basic curative care and preventive services through the establishment of PHC services at the village level, (ii) enhancing the quality of care provided by both the public and private sectors through effective training for health workers, and (iii) improving the quality of drugs available to consumers through tightened monitoring of the pharmaceutical sector. The long-term objective of the Project was to decrease the mortality and morbidity caused by diseases that can be prevented or easily treated, first in the pilot area and subsequently in other provinces. The Project would pilot test a PHC approach provided by trained health workers deployed in a network of village level health posts. It was also in accordance with ADB’s operational strategy that emphasized improving the health of women and disadvantaged ethnic groups.1 2. The Project consisted of four main components: (i) strengthening the delivery of PHC services in the rural areas, (ii) in-service training, (iii) monitoring of the pharmaceutical sector, and (iv) benefit monitoring and evaluation. The Project2 was designed to expand access to basic curative and preventive services through the establishment of a PHC services delivery network in two northern provinces of the Lao PDR (Xiengkhouang and Oudomxai), and in Thathom district in the special zone of Xaisomboun. The Project aimed to assist implementation of the Fifth National Social-Economic Development Plan, 1996-2000, and support the Fifth Development Planning Program of the Ministry of Public Health (MOPH). It would provide wide-ranging basic training for staff at MOPH as well as at provincial, district and health centers. It would provide civil works, basic medical equipment and supplies, furniture, transport, staff development fellowships (in country and abroad), and international and domestic consulting services, and it would cover incremental recurrent costs, including salaries of project staff. The project scope was based on the capacities of agencies responsible for overall project management and implementation, including planning, staff training, procurement, and evaluation, as well as institutional capacity building of the Project Coordination Unit (PCU). In addition, the Project would contribute to enhanced educational development for children. There would be specific benefits including improvements in health status, efficiency, and increased accessibility and equity of health services, as well as poverty reduction and economic gains with equity. There would be improved delivery of PHC services with rationalization in the deployment of health workers and improved distribution of financial resources. The Project would play a catalytic role in promoting and establishing a systematic and community-based delivery of PHC services in the rural areas.

1 The Lao PDR has 47 ethnic groups. 2 ADB. 1993. Technical Assistance to Lao PDR for Essential Drugs Project. Manila.

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3. In addition to the project loan, an advisory technical assistance (TA) was approved for assistance in project implementation, to ensure successful in-service training of health workers, and to help spread the benefits of lessons learned from the Project to the rest of the country.3

II. EVALUATION OF DESIGN AND IMPLEMENTATION

A. Relevance of Design and Formulation

4. The Project scope was comprehensive and supported the Government’s National Health Policy to strengthen the PHC delivery system in the pilot project areas. This was in accordance with ADB's strategy for health sector development in its developing member countries with a major thrust in PHC.4 The overall purpose was to increase accessibility and expand health services at affordable prices in the pilot areas toward improving the health status of the people throughout the Lao PDR (Appendix 1). 5. The Project design focused on strengthening the health network by establishing health centers and renovating the district hospitals, and laid the foundation for a referral system in the project areas. The aim was to increase accessibility to PHC services and improve the quality of care of services provided. The project design envisaged active participation by stakeholders in planning, construction of health facilities, and provision of PHC services. The project formulation was sound and generated a strong commitment at central and provincial levels. Under the Project, the health sector evolved to perform better and became able to assist in furthering the Government’s PHC policy through an ADB-assisted follow-on project.5 The peripheral facilities, known as health posts, were renamed health centers during project implementation, linked to district hospitals, and brought into a referral system.6 The training program established was basic, including development of skills in management and supervision, and in monitoring of the pharmaceutical sector. It was a short-term strategy and targeted quantitatively at service providers such as private drug stores. As a pilot project, it was envisaged that the lessons learned would be shared with other provinces in the Lao PDR. B. Project Outputs

6. The evaluation of implementation is based on (i) the indicators set at appraisal; (ii) a baseline household survey conducted by the Bureau d'Etudes Lao (BEL) in June 1996; (iii) regional TA on capacity building and participation;7 (iv) TA on institutional strengthening of MOPH (footnote 3); (v) a small household survey in 1999 and a facility survey in 2000 in the project areas; (vi) National Health Survey in 2001; (vii) midterm review by ADB in May 1998; and (viii) utilization indicators collected regularly for evaluation of health centers (Appendix 2).

3 ADB. 1995. Technical Assistance to Lao PDR for Institutional Strengthening of the Ministry of Public Health.

Manila. 4 ADB. 1991. Health, Population and Development in Asia and the Pacific. Manila. 5 ADB. 2000. Report and Recommendation of the President to the Board of Directors on a Proposed Loan to Lao

PDR for the Primary Health Care Expansion Project. Manila. 6 The Lao PDR’s existing health system had three tiers: basic health units/dispensaries, health posts, and district

hospital. However, the Project determined that a simplified two-tier system (health centers and district hospitals) would be more manageable and cost effective for a small country.

7 ADB. 1996. Technical Assistance on Facilitating Capacity Building and Participatory Activities. Manila.

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1. Strengthening Primary Health Care

a. Establishment of Health Centers

7. Seventy-three health centers were established under the Project (compared with 70 planned at appraisal): 37 in Oudomxai, 32 in Xiengkhouang, and 4 in Thathom district, Xaisomboun Special Zone. Each center covers 3,000–4,000 rural population, thus the accessibility to PHC in the project areas was improved as there existed no health centers before this. The design, tendering procedures, and quality of construction for health centers were satisfactory.8 Each center, about 35 square meters in size, provides an examination/treatment room and a room for maternity and child health activities. Health centers in remote areas lacked access roads, encountered construction problems, and have limited accessibility.9 Community participation during construction of health centers was considerable, although there were problems of poor quality and untimely delivery of materials. All health centers are now operational, with an average of two health workers at each center deployed from district hospitals: one who staffs the center, and one for outreach services. They work full time, are fully paid, and receive per diems for outreach activities. Many health workers were provided with accommodation and land for cultivation and income generation. However, only 30% were government employees. Many health workers were contractual, and hired for about one year with possible confirmation. Each center is managed by a village health committee,10 and receives an average of 3-5 outpatient visits per day with diseases including malaria, diarrhea, and respiratory infections. Serious patients are referred to district hospitals after short observation. Outreach activities in remote areas provide immunization for infants and pregnant women, and vitamin A supplements for children.11 In some areas, female health workers have limited outreach activities because of inadequate security during the visits to the villages. Overall, the health centers and their outreach activities have had a significant impact upon the availability of PHC services. Sixty two percent of the population surveyed indicated that, particularly in remote areas, PHC services at health centers are satisfactory.12

b. Provision of an Adequate Supply of Essential Drugs

8. Essential drugs are provided annually as drug kits, estimated to be adequate for about 1,000 people. Each kit contains a fixed number and types of drugs, but should be flexible according to the needs of the catchment population. The drugs are sold locally at agreed prices, registered, and the revenues are deposited into a revolving drug fund, which averages about $160.00 monthly and can be used to cover operational costs for the health centers, including per diems for outreach activities, maintenance, and supplies. The records are kept at health centers and district hospitals. The prices for drugs are readjusted annually to account for inflation and currency fluctuation, and the drugs are purchased at the nearest district hospital or provincial health department, whichever is nearest to the health center. Generally, the revolving drug fund system has been relatively satisfactory in terms of price setting, income generation, and utilization, and has contributed to the sustainability of PHC service delivery in the rural 8 Most health centers were built of wood, which is not sufficiently durable. Construction, particularly in remote areas,

should be of concrete. In terms of space, health center buildings are not adequate for providing curative, promotive, preventive, pharmaceutical, supervisory, and management activities.

9 Before this, there were no institutional service delivery points where we could compare utilization. 10 The village is the lowest level in the Lao PDR health care system. The villagers will establish health facilities,

manage them through village health committees, and provide PHC services themselves. 11 Services are sometimes available from traditional healers, birth attendants, or nongovernment organization

representatives. 12 The survey was conducted under a regional TA. ADB. 1996. Technical Assistance for Facilitating Capacity Building

and Participation. Manila.

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areas. The essential drugs are limited in number and low cost, thus the amount spent on essential drugs is far below what was expected at appraisal ($1.25 million versus $0.594 million).

c. Health Education 9. There was good collaboration between the district health offices and the Lao Women’s Union for implementation of the health education program, which was conducted informally in the villages. The information, education and communication activities on immunization and disease control, carried out by health workers and provincial and district hospital staff, played a key role in mobilizing people, but were not adequately documented. The objectives were to raise public awareness for disease prevention, including the use of bednets impregnated with mosquito repellent and preventive measures under maternal and child health. Lao Women’s Union members and village health volunteers participated actively in the community-based birth spacing program. After training, volunteers participated in initiatives to promote the use of contraceptives. The campaigns for use of impregnated bednets were carried out in collaboration with the Institute of Malariology, Parasitology and Entomology (IMPE). IMPE claimed that the increased use of such bednets has contributed to the reduction in the morbidity and mortality rates due to malaria.

d. Establishment of an Integrated Supervisory System 10. An integrated supervisory checklist was established under the Project to enhance supervision of HCs and DHs.13 The health workers concentrated on project targets, quality of care, and on updating the revolving drug fund through maintenance of accounts for the proceeds of drugs sales. The Project assisted in the development of the checklist, training of supervisors, provision of per diems, and transportation for supervisory activities. However, a formal assessment was not conducted due to inadequate information available. A practical health information system comprising 17 basic data items were set up at health centers and compiled monthly. The information was aggregated at district hospitals and provincial health departments for submission to MOPH. The quality of PHC services at health centers has generally improved, as indicated by the average 20% increase in the checklist scores obtained at a sample of health centers. The knowledge and skills of health workers have improved, and the performance of health centers was satisfactory.

e. Renovation and Construction of District Hospitals

11. At appraisal, it was agreed to renovate five district hospitals and construct three new ones in districts without hospitals. Each district hospital has a catchment population of about 30,000, and receives the essential and basic drug kits similar to those provided to health centers; in addition, they receive anti-tuberculosis drugs, injectable antibiotics, anti-malarial drugs, and medical supplies for basic laboratory diagnostic services.14 The Project constructed 13 The Integrated Supervisory Checklist contains 20 indicators for use by provincial staff during monthly supervision of

staff of health centers and district hospitals. The supervisors give a score for each item on the list, to serve as focal points for capacity building, training, and for guiding and organizing district health teams. It was envisaged that the provinces will become strategic units in planning, financing, training, providing technical assistance and supervising. The district offices will be the micro-planning and financing units, and provide guidance to villages for policy and development plan implementation.

14 Each hospital has 15-30 wooden beds, bed occupancy of 15-50%, and lengths of stay averaging 2-7 days. The catchment population is sparse and transportation is difficult. There are few staff and minimal support services. Thus, utilization is low and their referral capacity is not higher than health centers.

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three new district hospitals at Mok and Nonghet in Xiengkhouang and at Thathom district in the Xaisomboun Special Zone, and renovated five existing hospitals at Nga, Namo, Houn, and Pakbeng in Oudomxai, and Kham in Xiengkhouang. The quality of construction/renovation was satisfactory. The support for hospital development was small and district hospitals continue to operate with minimal basic medical equipment and supplies, poorly trained staff, and inadequate budgets. The collections made from the revolving drug fund, cost-sharing scheme, and government operating budget were only adequate for provision of basic curative services.

2. In-Service Training

12. The two major thrusts to enhance the performance of the country’s health care delivery system are (i) improving the skills and knowledge of health workers, and (ii) strengthening the capacity of the provincial and district health departments. Although 4,245 staff were expected to receive training, 5,970 staff attended the basic training sessions: 4,971 in strengthening of PHC services, 340 in management and supervision, 305 in monitoring of the pharmaceutical sector, and 354 in benefits monitoring and evaluation. While there was no formal assessment made on staff trained, based on the rapid post-training assessment, most health workers for PHC services expressed satisfaction and the need for regular in-services training (Appendix 3).

a. Establishment of Guidelines and Provision of Training for Health Workers

13. The Project assisted MOPH, including Department of Health Personnel, School of Public Health, IMPE, the Maternal and Child Health Institute, and the National Tuberculosis Center in the preparation of simple and clear guidelines for prevention, diagnosis, and management of common diseases like pneumonia, diarrhea, malaria, tuberculosis, and micronutrient malnutrition. The guidelines for training of health workers and outreach services were incorporated into the PHC training modules. The modules and subsequent training included instructions on (i) outreach activities, (ii) data recording, (iii) rational use of drugs, and (iv) actions for improving the quality of care. During project implementation, training modules for health workers were developed and field-tested. Training videos were produced, audio-visual equipment was procured, and per diems were provided for trainers and trainees. Training and re-training incorporating a participatory approach and simple learning techniques to improve the skills and performance of about 150 health workers. Tests given before and after training (combining multiple choice questions and exercises) showed an increase in the average scores of trainees. Nevertheless, the majority of health workers surveyed 1 year after training indicated a need for refresher training.

b. Training of District and Provincial Management Staff

14. The Project supported 105 MOPH provincial health managers for a 3-month course in health service administration and 134 MOPH staff for a 1-month short course in health administration, conducted by the School of Public Health in Vientiane. About 98 district health staff undertook supervision training. Twenty-one Provincial Health Department (PHD) staff went on a study tour to Vietnam and 36 visited other provinces within the Lao PDR, although assessment of the study tours was not possible due to inadequate documentation. The Project also strengthened the School of Public Health by providing textbooks, medical journals, and funds for operational research in the project areas.

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3. Monitoring of the Pharmaceutical Sector

15. During project implementation, provincial and district pharmacists monitored closely the private pharmacies to regulate the quality of the drug supply.15 A monitoring instrument was developed; MOPH pharmacists were trained and provided with transportation. MOPH’s Food and Drug Department coordinated the inspection of private pharmacies conducted by the district health departments. The average scores achieved by the private pharmacies were found to be in compliance with MOPH regulations. During project implementation, 94 private pharmacies were inspected in Xiengkhouang, 65 in Oudomxai, and 5 in Thathom district. The Project provided training for the private pharmacists in the rational use of drugs; measures for compliance based on drugs indicators; adequate case management of pneumonia, diarrhea, and malaria; and distribution of contraceptives. Under the Project, the Food and Drug Department completed training of about 202 private sector pharmacists on good pharmaceutical practices.16 MOPH pharmacists and staff from the state-owned pharmaceutical factories received training in good pharmaceutical manufacturing practices. Under the quality assurance program, the drugs produced at these factories were tested by the Food and Drug Department and all samples met the minimum standards for efficacy and good quality.

4. Benefit Monitoring and Evaluation

16. Project benefit monitoring and evaluation (BME) was regularly conducted in the project areas to assure satisfactory progress. The observations were submitted to the policy makers for review. The Council of Medical Sciences conducted surveys to evaluate the performance of the health care delivery system. The project implementation offices (PIOs) and provincial health offices participated actively in the National Health Survey. Limited baseline household, health facility, and pharmacy surveys were conducted. Qualitative approaches were adopted including focus group discussions to assess client satisfaction and interviews with individual health workers to assess their performance. The lessons learned and experiences gained are envisaged to be shared with other provinces or other projects implemented in the Lao PDR through (i) study tours for health staff to other provinces, (ii) national workshops to discuss particular issues such as monitoring of private pharmacies, and (iii) periodic visits to the project areas by high-level staff of MOPH. Provincial and district officials from Xiengkhouang and Oudomxai visited Savannakhet province to exchange lessons on PHC implementation in remote upland and highland areas. Exchange experiences between Xiengkhouang and Oudomxai provinces were organized. To influence higher authorities, senior MOPH and other government officials were invited to visit the project areas and review the progress achieved. The ADB Midterm Review Mission in May 1998 drew lessons from the progress to that point, and many representatives from the government, bilateral and multilateral aid agencies, and nongovernment organizations attended the meeting and provided feedback. C. Project Costs

17. At the time of appraisal, the total cost of the Project was estimated at $6.250 million equivalent, consisting of $3.681 million equivalent (58.9%) foreign exchange cost and $2.569 million equivalent (41.1%) local currency cost. ADB approved a loan of SDR3.404 million ($5.0 equivalent) from its Special Funds resources to finance the entire foreign exchange cost and $2.569 million equivalent of the local currency cost. The loan financed 80% of total project cost, 15 Private medical services in the Lao PDR are limited to small clinics and pharmacies/drug stores, mostly run by

unqualified pharmacists and poorly trained health workers. 16 Good practice includes ensuring that pharmaceutical products are manufactured, packaged, stored, and distributed

in accordance with quality standards and procedures, appropriate to their intended use.

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and the Government financed 20% from its own resources. As of 29 April 1996, the revised loan closing showed that there was a shortfall in the civil works category. The total project cost was $5.320 million, including allowance for physical and price contingencies and for service charges on the ADB loan during project implementation. Of the total actual cost, $3.201 million (60.17%) comprised the foreign exchange cost, and $2.119 million equivalent (39.83%) the local currency cost. The Government financed about $0.839 million (15.77%), for mostly civil works and furniture. Overall, the Project did not have a cost overrun, although the civil works cost was higher than expected at appraisal, due to additional costs for transportation and construction of health centers in remote areas. About $0.21 million was cancelled as savings in December 2001. The estimated project costs at appraisal, the financing plan, and the actual expenditures are in Appendix 4. D. Disbursements

18. The disbursement of loan proceeds was made largely through the imprest account and direct payment procedures in accordance to the financial regulations of the Ministry of Finance and ADB Guidelines on Imprest Fund and Statement of Expenditures Procedures. A statement of expenditures with a ceiling of $50,000 per contract was used for all eligible items under the imprest account. The initial disbursement was made on 13 June 1995 and the final disbursement on 14 September 2001. The disbursement period of 6.3 years was due to the delay in submission of withdrawal application with official receipts from the provinces for the final liquidation. The actual loan disbursement was $4.481 million (84.23%) against the total project cost of $5.32 million. The annual turnover ratio was 1.11, 1.84, 1.70, 1.19, 1.48, and 1.24, respectively, for each year from 1996 to 2001.17 Appendix 5 summarizes the actual quarterly disbursements from June 1995 to December 2001. E. Project Schedule

19. The Project was approved on 19 January 1995, declared effective on 4 May 1995, and closed on 31 October 2000 as scheduled, with a 5-year implementation period. There was no delay in loan effectiveness and no loan extension. Overall, project implementation was carried out according to schedule as in the agreement between ADB and the Lao PDR Government (Appendix 6). Project implementation was well managed by the PCU and assisted by the TA consultants. There were some delays in implementation of project activities but all activities ended within the stipulated time. The construction unit of MOPH and the PCU coordinated well with provincial health offices, and completed the construction of health centers and district hospitals as scheduled. The international consultant for training organized and managed training programs with a domestic consultant and completed all training activities as scheduled. There was some delay in procurement of civil works, basic medical equipment, and supplies, including essential drugs. The completed project facilities, particularly health centers, took more than 1.5 years to become fully operational. The delay was due to administrative procedures and general procurement mechanisms in the public sector. The loan account was closed on 6 December 2001 due to the delay in submission of the final withdrawal application for liquidation due to delay in receiving official receipts from the provinces. The tuberculosis (TB) training materials were included together with the training materials prepared for health centers and district hospitals. The Final Health Facility Survey conducted covered the activities for the third and fourth health facility surveys.

17 Turnover ratio = liquidation/average fund balance.

8

F. Implementation Arrangements

20. The implementation arrangements were established as agreed at appraisal. The MOPH was the Executing Agency. It established a PCU and a steering committee comprising members of different departments of MOPH and chaired by the minister of public health. The steering committee guided the PCU during project implementation. The PCU managed the health projects financed by ADB and the World Bank. A technical committee was also established to facilitate project implementation, composed of different departments of MOPH and related institutions (e.g., Department of Hygiene and Disease Prevention, School of Public Health, Food and Drug Department, Department of Health Personnel, National Tuberculosis Center, Maternal and Child Health Institute, and IMPE). All key decisions were made centrally by MOPH and carried out by the PCU. PIOs were established at the provincial level in Xiengkhouang and Oudomxai. The PIOs helped to collect information on benefit monitoring, project implementation, supervision, and evaluation. The PCU coordinated and supervised PIOs regularly, and maintained strong networking relationships. The establishment of the PCU and PIOs was delayed at the beginning of project implementation due to lack of capacity and familiarity with ADB procedures, since this was the first ADB-funded health project for MOPH. Centralized decisions during project implementation slowed the momentum. For example, the provincial project implementation plans and disbursement of funds needed the approval of MOPH, and extra efforts were needed to bring disbursement to the required levels.18 The PCU should be authorized to utilize the counterpart disbursements in accordance with its own annual plan, and it should coordinate project and counterpart budgets through better budget planning. G. Conditions and Covenants

21. The implementation arrangements prepared at appraisal were organizationally sound and functional. The loan covenants were complied with as shown in Appendix 7. However, the audited financial statements and BME report were submitted with some delay due to lack of familiarity with reporting procedures by the health centers and district hospitals. H. Related Technical Assistance

22. Appendix 8 summarizes the findings of the advisory TA on institutional strengthening of MOPH (footnote 3). The main objectives were to (i) assist in the implementation of the Project, (ii) ensure that the in-service training was successful in improving the competency of peripheral health workers, and (iii) ensure that the rest of the country benefits from the lessons learned in the project areas. One international consultant, a specialist in health project management, was engaged for 24 months and extended for another 12 months; another was engaged as an in-service training expert to work with MOPH for 12 months, and was extended for another 4 months. The consultants were recruited by ADB following its own Guidelines on the Use of Consulting Services. MOPH provided counterparts and worked with the training specialist. The management consultant worked with the head of the PIOs and task managers in the PHC committee, School of Public Health, and Department of Food and Drug. The TA fully met its objectives and scope, particularly in improving management of the delivery of PHC services and staff training. 23. A regional TA on capacity building and participation was linked to the Project (footnote 7). The objectives were (i) to study community perceptions about health centers in terms of overall satisfaction, utilization, prices of drugs and any informal payment, availability, and 18 MOPH gained experience in project implementation, but there are still gaps between capacity and requirements,

particularly in decision-making and disbursement of funds.

9

treatment by the health workers, and suggestions for improvement of services; and (ii) to assess issues related to health workers, such as recruitment, assignment, deployment, housing and agricultural land provided, training received and future training, supervision, recording and reporting, difficulties with any improvement to health centers, revolving drug fund, and whether there was a need for more female staff. The beneficiaries were the decision makers and stakeholders in MOPH, Ministry of Finance, PCU, PIOs, provincial health department staff, health workers, and communities. The study was based on sampling and random interviews conducted with heads of households in villages, health workers, and chiefs of health centers, as well as on focus groups with local authorities (including village leaders and representatives of the Lao Women’s Union at the village level) in Oudomxai and Xiengkhouang. The study was constrained by difficult communications due to differing dialects in the villages. I. Consultant Recruitment and Procurement

24. Five domestic consultants were recruited to strengthen the PCU for a total of 247 person-months following ADB Guidelines on the Use of Consulting Services (Appendix 9). The consulting services were for 153 person-months for administration and finance and 94 person-months for equipment procurement. The contribution of the consultants enhanced the PCU’s capacity. At appraisal, it was only planned for 120 person-months for administration and finance and 20 person-months for training and materials development. The recruitment of a domestic consultant for procurement of goods encountered some minor delays. J. Performance of Consultants, Contractors, and Suppliers

25. The inputs are considered generally satisfactory and working relationships cordial among all parties. The services provided by the international consultants were extended until project completion due to lack of experienced staff in MOPH, and the extensions ensured that PCU outputs remained on schedule. Despite a financial downturn and other problems encountered during construction, there were delays, range of 1-5 months as compared with the construction period estimated at appraisal. The construction of health centers during the first year of implementation encountered delay due to slow finalization of building drawings and award of contracts, and lack of experience with the construction of health centers, particularly in remote areas and during rainy seasons. The construction materials used generally conformed to specifications and were acceptable to stakeholders. The quality of work was deemed satisfactory. There were delays in government procurement procedures, particularly during the first year of project implementation, which resulted in further delay in the distribution of essential drugs, but this was resolved during the remaining implementation period. Generally, there were no serious deviations from the agreed specifications, with regard to impregnated bednets, insecticides, basic medical equipment, and other supplies. Overall, the performance by the civil works contractors, suppliers of basic medical equipment, and domestic and international consultants was satisfactory. K. Performance of the Borrower and the Executing Agency

26. At appraisal, the country’s development plans clearly emphasized the Borrower’s commitment to strengthening the delivery of health care services, particularly PHC services. Throughout project implementation adequate counterpart funds were provided within the acceptable period, in kind and cash for construction of the new facilities. Overall, the performance of the Borrower is considered satisfactory. The MOPH steering committee and technical committee have guided the PCU and carried out their tasks satisfactorily. The PCU guided, coordinated, and monitored major activities, and resolved project implementation issues and inter-ministerial problems, including the participation of district governors in the

10

management of PHC service delivery. The communities participated in the construction of health centers. Project activities were coordinated with other departments of MOPH and the aid community, including the World Bank. The PCU staff worked well with the TA consultants on the training programs and project management. MOPH and the PCU assisted and cooperated well with ADB review missions. Although the Project was the first health project funded by ADB in the Lao PDR, the documentation on contracts, disbursement, procurement, consultancy services, health facilities, drawing plans, fellowships, and other staff training programs was satisfactory. The PCU and PIOs established good working relationships or teamwork, systematic integrated supervision, scheduling of activities, and effective monitoring of project activities within MOPH. The institutional development strengthened the health care delivery system particularly at the provincial and district levels. L. Performance of the Asian Development Bank

27. Overall, ADB performance was satisfactory. The relationships developed with MOPH, PCU, and PIOs were mutual and were maintained throughout project implementation. During project implementation, ADB fielded six loan review missions totaling 47 person-days to supervise the Project. A midterm review was carried out in May 1998 and resulted in minor changes. The Project benefited from ADB field visits to the project sites. ADB’s Resident Mission in the Lao PDR also provided considerable support during the later stage of project implementation.

III. EVALUATION OF PERFORMANCE

A. Relevance

28. The Project supported the Government’s National Health Policy to improve PHC services. The Project initiated the much-needed development of human resources for health and cost-sharing schemes. The Project is in accordance with ADB’s operational strategy that emphasizes improving the health of women and many disadvantaged ethnic groups in the Lao PDR. It provided positive health-seeking behavior, increased awareness in health and reproductive health and better childcare, among women. The priority in the context of the country’s health sector development strategy and ADB’s development strategy for the Lao PDR were relevant at the time of approval, and remained highly relevant at project completion. Project design is rated as highly relevant. B. Efficacy in Achievement of Purpose

29. The Project was pilot tested in two mountainous provinces (Xiengkhuoang and Oudomxai) and in Thathom district in Xaisomboun Special Zone. These areas were selected based on the following criteria: (i) highly rural populations, (ii) limited external assistance, (iii) presence of large ethnic populations, (iv) lack of health infrastructure, and (v) budgetary resources lower than other provinces. The immediate objective was achieved successfully in terms of building health centers and hospitals and renovating existing hospitals. Affordable PHC services were provided to the communities, in particular remote uplands and highland areas. Adequate basic training was provided to a large number of health workers and supported by health education campaigns. The Project aimed at decreasing the morbidity and mortality caused by preventable diseases in the project areas and subsequently in other provinces. In the project areas, the infant mortality rate dropped from 125 per 1,000 live births in 1996 to 82 per 1,000 live births in 2001; the under-5 mortality rate fell from 175.8 in 1996 to 106 in 2001. The percentage of fully immunized children (aged 12-23 months) increased from 20.0% in 1996 to

11

32.4% in 2001.19 Based on analysis of the achievement of the project objectives in each component, it is concluded that the efficacy of the Project is satisfactory. C. Efficiency in Achievement of Outputs and Purpose

30. Project implementation generally was efficient and there were no major issues, although economic analysis following ADB guidelines for health sector projects was not possible due to lack of baseline and reliable data required for computation. The implementation arrangements, management structures, and procedures were in accordance with what was agreed in the Loan Agreement. The organization and management of the Executing Agency and the PIOs was satisfactory. The counterpart funding was timely and adequate. The financial audited reports were submitted on time with no major issues. ADB project review missions were regular and timely, and contributed to the improved delivery of PHC services and health sector performance. There was efficiency in recruiting consultants, basic training provided to health workers, health volunteers, supervisors, and managers. Despite some delays in procurement of basic medical equipment, essential drugs and supplies, and motorcycles, all project activities were completed within the stipulated time. D. Preliminary Assessment of Sustainability

31. The PCU organized regular meetings with MOPH staff and PIOs from Xiengkhouang, Oudomxai, and Thathom (Xaisomboun) and discussed the strengths, issues, and difficulties encountered. A revolving drug fund was established to generate income through sales of drugs for the operation of health facilities. The drugs sold at almost cost price and were replenished monthly at the district hospitals. The village health committees approved the lists of the poor in the villages. Trained health workers were recruited locally, and after further training, supervised management of the revolving drug funds; adequate maintenance of these funds will contribute to the sustainability of health centers and district hospitals. The village health committees participated in the management of health centers through feedback meetings to assure operational efficiency. The operating and financial performance of the revolving drug fund was practical, acceptable, and managed partly by the communities. Parts of the revolving drug funds have been utilized for the maintenance of health facilities, which raises a minor concern about the long-term sustainability of the funds. The PHC services available at health centers and district hospitals are sufficient to meet the communities’ basic curative and preventive needs. Supervision by PIOs, provincial health offices, and district health offices will help ensure effective supervisory management and sustainability of the revolving drug funds. Adequate funds and skills should be available for continued operation and maintenance of health centers and district hospitals. There is appropriate technology and basic medical equipment available at the health facilities to operate the Project, and the completed facilities were operating at the time of evaluation. Government ownership of and commitment to the Project is high. E. Environmental, Sociocultural, and Other Impacts

32. Overall, the Project has helped improve environmental awareness. The construction of peripheral health centers and district hospitals, particularly in remote upland and highland areas, was carried out in accordance with government regulations. Each health center has a small incinerator for waste and appropriate disposal. The buildings were designed and constructed taking into account environmental factors, including use of natural lighting and good ventilation. 19 Children are considered fully immunized who have received BCG, DPT3, OPV3 and measles vaccines according

to the immunization schedule of 4-week intervals and complete within 12 months after birth. Full immunization may also include other vaccines such as hepatitis B.

12

The buildings were environment friendly for patients, relatives, and staff, as they were not crowded; have ample spaces for families to meet together; and lush trees surrounded the area. The Project has contributed to the well-being of rural communities, in particular poor and ethnic minorities in the outreach mountainous areas, and has increased job opportunities for health personnel with more in-service training. In some centers the landscaping was attractive. The Project has had a positive impact on institutional development. The rural population in the project areas have developed positive health-seeking behavior and increased health awareness. Health workers received adequate in-service training, and provincial and district health staff received supervisory skills training. Communities participated in the construction and management of health centers. There were also other development impacts, including increased accessibility to PHC by the rural population, particularly the poor. Information, education, and communication activities have increased awareness among the rural population for clean environment and better personal hygiene. MOPH along with provincial and district health offices are being organizationally strengthened. There were positive impacts on social organization and the empowerment of women in the sense that they actively sought a positive behavior on health, increased awareness on personal, family, and reproductive health, and studied ways on better childcare; and a reduced rate of morbidity and mortality due to malaria has enabled the rural population to be more productive economically.

IV. OVERALL ASSESSMENT AND RECOMMENDATIONS

A. Overall Assessment

33. The project design was pragmatic and provided an innovative approach for health sector reforms on the expansion and increase of PHC services in Xiengkhuoang and Oudomxai provinces and in Thathom district. The Project has strengthened the health care network, and there is an increased accessibility and coverage for about 0.5 million people, including those in remote mountainous areas. The Project was the first ADB-funded health project for the Lao PDR and is rated successful based on its transition economy and among the least developed countries. The priority given to the health sector in the development strategy of the Lao PDR, and the objectives of the Project are found to be relevant at the time of approval, and also at project completion. There was effectiveness of project management and efficiency in recruiting. 34. The Project built 73 small health centers, three small and basic district hospitals, and equipped five existing hospitals with emergency services. Improving the health facilities, particularly with provision of emergency services, improves the quality of care, strengthens the referral system, and enhances the reliability of the PHC delivery system. The Project has created revolving drug funds that are generating income for further drug purchases. These essential drugs are replenished monthly at the district hospitals and at the health centers and other drugs, including antibiotics, are purchased from private pharmacies. Technology and basic medical equipment available at health facilities were basic and functioning at the time of project completion. Outpatient visits have increased. The Project has also provided various types of basic training to 5,970 staff. Training materials were prepared to provide for continuing training. The public and private pharmaceutical sectors were monitored to ensure compliance with MOPH drug policy and good manufacturing practice. As envisaged, MOPH has shared the lessons learned from the Project with other provinces. While inadequately documented, this Project has contributed to the formulation of the Primary Health Care Expansion Project (footnote 5). 35. Project implementation generally was efficient, with no major issues, and most of the outputs were completed within the stipulated time. The implementation arrangements, management structures, and procedures were in accordance with the loan agreements. The

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organization and management of the Executing Agency and the PIOs were satisfactory. Government ownership of and commitment to the Project is high. The health administration was strengthened with increased capacity building for MOPH, and provincial and district health offices have benefited from the annual exercises of project planning, budgeting, and management, in particular the integrated and decentralized and supervisory management of PHC services. The Project has contributed to the well-being of the rural communities in the remote uplands and highland areas, in particular the poor and ethnic minorities. It encouraged promotive health for healthier living; improved personal hygiene; provided access to basic curative care; and reduced incidence of vitamin A deficiency through immunization. Appendixes 10 and 11 describe some gains in the pilot areas, but it will take some time for Project’s benefits to be fully realized. The Project has provided (i) opportunities for the communities to participate in development, (ii) job opportunities to health personnel, (iii) a significant amount of in-service training to existing health staff, and (iv) opportunities for experience with the management of health centers. The Project has had a positive impact on institutional development at MOPH as well as at provincial and district health offices. Overall, the Project is rated as successful.20 B. Lessons Learned

36. Since the Lao PDR health care delivery system is in its early stage of development, a national policy on development of health facilities is essential to achieve optimal coverage of health services. Its implementation will require mapping and a facility survey based on population norms approved by MOPH. Operational policies should be developed for the use of district hospital buildings and health centers. The buildings should be simple in terms of materials and construction and they should include adequate water supply, power supply, cleanliness, and landscaping. PHC services should be made affordable and community-based, particularly outreach services. The cost-sharing system established under the Project has generated income for purchases of essential drugs. Payment for drugs has not been reported as an impediment to care in any of the project facilities. The funds received are essential for maintaining the centers and for assuring adequate supplies of drugs. However, health facilities cannot operate on the revolving drug fund alone, and the management committee should explore options for more cost sharing and community financing. The methods for training of health workers in the Lao PDR are simple and participatory, using modules and verbal presentation of technical materials followed by exercises, role-plays, and actual practice in a supervised setting. The regular retraining received by health workers has helped them to maintain an acceptable quality of care and performance under the integrated supervision and decentralized management at the provincial and district levels. C. Recommendations

1. Project-Related

a. For the Government

37. For future monitoring, benefit and evaluation activities should be strengthened and indicators developed at the start of project implementation to determine the overall impact and social benefits of the Project. The project performance management system for the Project should be integrated with MOPH’s health management information system. There should be clear definitions of expected health and other related outputs and impacts, and they should be well integrated for future projects. The communities and stakeholders should continue to

20 This report is part of a sample of about 50% of all project completion reports prepared this year that has been

independently reviewed by the Operations and Evaluations Division. The review has validated the rating given.

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participate actively in identifying and solving problems at village levels, and they should assist in the development and evaluation of the health policies and initiatives. 38. MOPH should undertake the following actions to improve operational efficiency:

(i) Adequate budget should be allocated, in addition to the community or self-financing system such as cost-sharing scheme for the project facilities. Options for financial schemes, such as user fees for health facilities, or prepaid system while taking into account their affordability, should be studied to address difficult working conditions, low staff salaries, and low per diems for outreach activities.

(ii) Staff training should be coordinated with relevant departments in MOPH and

related agencies. The curriculum for training of health workers, particularly in-services training of PHC staff, should be assessed and retraining provided for skills enrichment. Contractual workers should be given permanent government jobs after a certain period of service, as an incentive to good performance.

39. MOPH should delegate project administration to the PCU and PIOs with clear lines of command established for decentralized management.

b. For ADB

40. If ADB is to conduct a project performance audit, it is best to do so in or after the second quarter of 2004 when project facilities will have been fully operational for some time and project impact will be easier to measure.

2. General

41. There should be mapping of health care facilities, including health centers and district hospitals. The hospitals should develop operational policies (whole hospital and department policies), standard designs, and master plans for the provincial and district hospitals. Also, unit costs for different hospital services should be computed for cost-sharing scheme and budget purposes. 42. A prospective human resources development plan for the health sector should be developed for improved health care delivery system performance.

Appendix 1 15

PROJECT FRAMEWORK

Design Summary Indicator/Target Monitoring Instrument Risks/Assumptions

A. Goal: To improve the health status of the people in Lao PDR B. Objectives/Purpose: 1. Improve the primary health care (PHC) coverage, in particular of women, children, and the poor 2. Increase the quantity and quality of health services available to rural population

• Infant mortality rate declines

by 15% from 125 to 106.3/1000 live births

• Under-5 mortality rate drops from 175.8 to 149/1000 live births

• Percent of under-5 who are moderately or severely malnourished declines by 10 percentage points

Increased access to PHC services as indicated by: • 50% increase in villagers’ use

of public health facilities compared to baseline

• increased coverage of immunization to 80% and vitamin A supplementation to 50%

• case-finding of tuberculosis (TB) increases 200%

Improved quality of services as indicated by: • 80% of health workers

demonstrate adequate knowledge and skills of 5 important diseases.

• TB treatment completion rates increase to 70%.

Improved quality of drugs available to consumers as indicated by: • 70% of drugs sold meet

international standards.

Household survey Lao Social Indicator Survey Health facility survey Benefit monitoring and evaluation (BME) Household survey at beginning, midterm and project completion, Lao Social Indicatory Survey, Health facility survey, BME 1. Examination of

health facility records

2. Examination of

health facility records of TB patients

Political stability Continuing security Enabling environment • socio-economic

development • policy development • capacity/institutional

development Natural disasters Adequate data are available from targeted population/ beneficiaries. A. TB is as prevalent as

indicated by the World Health Organisation.

B. Consumers are willing

to pay for quality drugs.

16 Appendix 1


C. Project Components 1. Strengthening PHC in the

project area

a. Development of physical infrastructure

b. Distribution of essential

drugs

2. In-service training of peripheral health workers

3. Monitoring of pharmaceutical

sector

4. Implementation of BME and

development of management capacity

• 70 rural health posts are constructed and equipped.

• 8 district hospitals are

refurbished or rehabilitated.

• 80% of health posts and district hospitals have stock of at least 10 of 12 essential medicines.

• All health workers in project

area receive training on 5 major diseases.

• 80% of trainees demonstrate

adequate knowledge of TB, ARI, malaria, diarrhea, micro-nutrient malnutrition.

• 80% of private and public

pharmacies are visited by MOPH supervisor at least twice per year.

• 30% increase in scores

private pharmacies is obtained on a standardized monitoring instrument that uses quantifiable indicators.

• Pharmaceutical factories are

visited at least 3 times per year.

• Data on targets are available

on schedule.

• Systematic supervision of health posts and district hospitals is carried out at least 6 times a year.

1. Project progress

reports and review missions

2. Health facility

survey 3. Project progress


4. Special follow-up

studies after initial training

5. Pharmacy surveys 6. Pharmacy surveys 7. Project progress


8. Project progress


9. Health facility

survey

1. Health posts

maintained by community and Ministry of Public Health (MOPH)

2. Drugs are properly

priced. 3. Health workers are

motivated to learn. 4. Private pharmacies can

influence quality of drugs.

5. Private sector is willing

to change incorrect but profitable practices.

6. Factories can improve

quality without new equipment.

7. MOPH will use data. 8. Supervision methods

are culturally acceptable.

Appendix 1 17


D. Activities 1. Strengthening of PHC in the

project area

a. Development of physical infrastructure

b. Development of essential drugs

2. In-service training of peripheral

health workers

a. Development of training materials

b. Training c. Careful follow-up

evaluation 3. Monitor pharmaceutical

sector

a. Develop monitoring instrument for private pharmacies

b. Implement regular pharmacy visits

c. Hold regular workshops for MOPH staff on manufacturing practices

d. Visit factories regularly 4. Implement BME and develop

management capacity

a. Conduct household surveys

• $1.5 million • Implement cost recovery • 4 person-months of short-term

consulting services • 1 long-term consultant (1 year) • $1.1 million • $0.9 million • 1 long-term consultant

(2 years) • $0.5 million • Total cost: $6.3 million

1. Project progress


2. Project progress

reports and review Missions

3. Project progress


4. Pharmacy surveys 5. Project progress


6. Project progress


1. In spite of inducements

health workers do not move to health posts.

2. MOPH can distribute

drugs from province to health posts.

3. Village committees are

trustworthy and cooperative.

4. Agreements on

standards are consistent with World Health Organization guidelines.

5. MOPH is able to

develop objective indicators.

6. MOPH can have

cooperative relationship with private sector.

7. Factories are willing to

cooperate with efforts to improve procedures.

8. Peace and order

situation is stable in the project provinces.

PLANNED AND ACTUAL KEY PROJECT OUTPUTS BY COMPONENTS

Project Component/Key Area

Appraisal Actual

Strengthening of Primary Health Care

• Health Centers

70 new health centers (HCs) will be established in underserved areas in Xiengkhouang and Oudomxai provinces and Thathom district in a phased manner.

73 HCs were completed ahead of schedule and are fully operational. The health workers (HWs) at HCs are adequately trained and provided with basic medical equipment and essential drugs. Each HC provides (i) basic curative care; (ii) child health through Expanded Program on Immunization, nutrition through vitamin A; (iii) reproductive health through birth spacing for family planning; and (iv) preventive health services for malaria control, tuberculosis (TB), and acute respiratory disease. Accessibility to health care, particularly with the outreach services, has increased.

• Essential drugs An adequate supply of 12 critical medicines as drug kit will be provided.

One drug kit is provided annually for every 1,000 population. Also provided are basic medical equipment and supplies, and cold chain equipment for Expanded Program on Immunization and motorcycles.

• Revolving drug fund A cost-sharing, revolving drug fund using a simple accounting system will be established in all HCs and monitored under the Ministry of Public Health (MOPH) regular supervision at district level.

Village health committees participate in management of the revolving drug fund, including operating costs, maintenance and repair of HCs, outreach activities, and subsidies for the poor. The revolving drug funds are closely monitored by MOPH.

• Health education Basic topics in PHC would be covered at HC and district levels.

Information, education and communication or health education were provided in villages by MOPH and the Lao Women’s Union including talks and posters.

• Regular and systematic supervision Regular and systematic supervision of HWs at district hospitals and HCs will be established.

A supervisory instrument was developed, tested and implemented. It has provided guidance to supervisors and HWs at HCs, facilitated the follow-up actions, and improved performance of HWs. The PHC teams at the district and provincial levels regularly supervised HWs at HCs, while the supervision at the district hospitals was limited.


Appraisal Actual

• Renovation and Construction of Hospitals Three new district hospitals will be constructed and

8 existing district hospitals will be renovated. Drug kits similar to those provided at HCs, and additional resources for diagnosis and treatment of TB and malaria, will be provided to these hospitals.

Three new district hospitals were constructed at Mok, Nonghet in Xiengkhuoang, and Thathom in Xaisomboun Special Zone, and 5 existing district hospitals were renovated at Nga, Namo, Houn, and Pakbeng in Oudomxai, and Kham in Xiengkhouang. The hospitals were provided with gravity feed water supply schemes. A hostel was also provided at Oudomxai for staff accommodation during training. Adequate maintenance was also provided.

In-Service training

• Establishment of clear guidelines The Project will develop clear guidelines for HWs at the village level for prevention, diagnosis, and management of pneumonia, diarrhea, malaria, micronutrient malnutrition, and TB according to World Health Organisation and MOPH protocols. In addition, the manual and subsequent training will include instructions on outreach activities, recording, rational use of drugs, and means to improve patience care.

Training and guidelines for the training of health workers at HCs and outreach services were developed, tested, and implemented.

• Standardized training High quality, standardized training will be provided to HWs at the peripheral level in the project area. The training will be manual-based and use video tapes, role playing, simulation, and actual case management.

Training and guidelines for the training of HWs at HCs at the outreach services were completed. The provincial trainers and supervisors have received training at the central level and developed standardized training for HWs in the provinces and districts. In addition, training was conducted for the village HWs in the use of impregnated mosquito bednets, birth spacing in family planning and reproductive health, and teachers as volunteers for malaria control program.

• Training of managerial staff The Project will finance the training of district and provincial-level managerial staff in health services administration conducted by the School of Public Health in Vientiane.

Managerial staff attended management training courses at the School of Public Health in Vientiane, which has been strengthened with provision of upgrading of the library, a PHC training center near Vientiane, and operational research activities.


Appraisal Actual

Monitoring of the pharmaceutical sector

• Monitoring of private pharmacies Private pharmacies will be monitored through regular visits by provincial pharmacists.

About 250 staff of private pharmacies have been trained at the provincial level. Supervision was carried out for good manufacturing practice and maintenance of affordable drug prices. A standardized set of indicators and observations have been incorporated for monitoring of private pharmacies by MOPH pharmacies.

• Training of private pharmacy staff Private pharmacy staff will be trained in the rational use of drugs; means to ensure compliance; and the management of pneumonia, diarrhea, malaria, and TB including the proper referral of serious cases to the appropriate health facility.

In 1999, there were about 168 private pharmacies in Xiengkhouang, Oudomxai and Thathom, Xaisomboun. The provincial health offices have provided training for about 248 private pharmacy staff. Supervision was also carried out for good manufacturing practice and maintenance of affordable drug prices.

The Food and Drug Department of MOPH has conducted several training courses for private pharmacies. Training and supervision will be incorporated into the required annual re-registration and will be coordinated through the district hospitals. Since 85% of these workers have previous health care training, the curriculum and teaching materials will be adapted from the HW training materials produced by MOPH.

• Training of MOPH pharmacists MOPH pharmacists and staff of Government-owned pharmaceutical factories will receive training.

Training was provided to MOPH pharmacists and staff from the Government-owned pharmaceutical factories in good manufacturing practices, including improving standards of hygiene, maintenance of equipment, and laboratory testing. Drugs have been tested in the laboratory for quality control.


Appraisal Actual

Benefit Monitoring and evaluation (BME) • Periodic Health Facility Survey Periodic health facility and pharmacy surveys will be

conducted to evaluate the performance of the health care system in the project area and compare it with that in non-project provinces. Household surveys and focus group discussions will also be conducted to examine project impact.

The Council of Medical Sciences at the National Institute of Public Health has completed data collection for the National Health Survey and submitted a draft report to MOPH. PIOs and the provincial health offices in Xiengkhouang, Oudomxai and Xaisomboun have participated in the National Health Survey. Project Coordinating Unit indicators for a BME report are given in the Project Administration Memorandum.

• Dissemination of lessons learned

Lessons learned will be disseminated through study tours, national workshops, and periodic visits by high-level MOPH officials.

The Government officials from Xiengkhouang and Oudomxai visited each other’s provinces and Savannakhet province to share the lessons on improving delivery of PHC services under the Project. Senior MOPH officials also visited the project areas. A midterm review meeting, organized in Vientiane in May 1998, was attended by many government officials, aid agencies, and nongovernment organizations.

Source: Ministry of Public Health, March 2002.

22 Appendix 3

IN-SERVICE TRAINING Number of Staff

Activity Duration (Days) Planned Actual

Strengthening of Primary Health Care

Training for PIO Trainers 10 35 70 Retraining 5 35 30

Training for District Supervisors 21 60 86 Retraining 10 60 106

Training for Health Workers at HCs 30 160 154 Retraining 10 160 154

Supervision at HCs 21 60 73

Birth Spacing for Health Workers 30 160 80 Retraining 3 160 80 Birth Spacing for Village Health Volunteers 5 750 810

Training for Traditional Birth Attendants 5 100 96

Expanded Program on Immunization for District Health Staff

14 70 75

Retraining 4 35 35

Drug Revolving Fund for Provincial and District Health Staff

5 70 75

Revolving Drug Fund for Hospital Staff 5 35 75

IBN Training for Zones Staff 5 70 67 IBN Training for Trainers 5 25 25 IBN Training for Health Workers 5 160 160 IBN Training for Village Health Volunteers 5 750 2,386 Malaria Control Program for School Teachers 90 200 210 Training in Lab Diagnosis for Malaria 45 60 60 Malaria Control for District Hospital Staff 11 35 30 Clinical Training for District Hospital Staff 10 35 35

3,285 4,971 Management and Supervision

Management Training at SPH (3 months) 90 100 105 Management Training at SPH (1 month) 30 100 134 Monitoring and Supervision 10 20 6 Study Tour (International) 14 20 12 Study Tour (In-Country) 14 70 78 English Language 180 10 5

320 340 Monitoring of the Pharmaceutical Sector

Training for Supervisors on Private Pharmacies 120 110 138 Retraining 47 55 60 Private Pharmacies on Good Manufacturing 60 55 63 Monitor Private Pharmacies 10 35 24 Drug Testing 5 35 24

290 305

Appendix 3 23

Number of Staff Activity

Duration (Days) Planned Actual

Benefit Monitoring and Evaluation

Evaluate Supervision of HCs 10 48 48 Monitoring on IBN by IMPE 10 7 7 Evaluate Drug Kits at HCs 10 35 26 Use of Revolving Drug Fund 10 55 75 Evaluate Revolving Drug Fund at HCs and District Hospitals

10 35 32

Health Facility Survey 5 85 83 Household Survey 5 85 83

350 354

Total 4,245 5,970 IMPE =Institute of Malariology, Parasitology, and Epidemiology, HC = health center, IBN = impregnated bednets, PIO = project implementing office, SPH = School of Public Health. Note: The Project has provided training to 5,970 staff from the provincial health departments, district health departments, district hospitals, health centers, school teachers, traditional birth attendants, and village health volunteers compared with the planned 4,245. Source: Ministry of Public Health, February 2002.

Appraisal ActualCategory of Expenditure Foreign Local Foreign Local Foreign Local Local Local

Currency Currency Total Currency Currency Total CurrencyCurrency Total Currency Currency

I. A. Civil Works 0.382 0.315 0.697 0.382 0.101 0.483 1.102 0.177 1.279 0.214 0.312B. Furniture & Medical Equipment 0.604 0.190 0.794 0.604 0.128 0.732 0.712 0.03 0.737 0.062 0C. Essential Drugs 1.156 0.144 1.300 1.156 0.100 1.256 0.594 0 0.594 0.044 0D. Office Equipment 0.061 0.004 0.065 0.061 0.004 0.065 0.066 0.005 0.071 0 0E. Consulting Services 0.149 0.088 0.237 0.149 0.088 0.237 0.228 0.158 0.386 0 0F. Training & Material Development 0.512 0.592 1.104 0.512 0.497 1.009 0.075 0.510 0.585 0.095 0.073G. Transport 0.344 0.026 0.370 0.344 0.010 0.354 0.318 0 0.318 0.016 0.003H. Monitoring and Evaluation 0 0.222 0.222 0 0.152 0.152 0 0.136 0.136 0.070 0.029I. Project Implementation Cost and

Recurrent Costs 0 0.174 0.174 0 0.112 0.112 0 0.269 0.269 0.062 0J. Land Acquisition & Development 0 0.272 0.272 0 0 0 0 0 0 0.272 0.040K. Taxes and Duties 0 0.279 0.279 0 0 0 0 0 0 0.279 0.382

Base Cost Total 3.208 2.306 5.514 3.208 1.192 4.400 3.095 1.280 4.375 1.114 0.839

II.A. Physical Contingencies 0.130 0.097 0.227 0.130 0.041 0.171 0 0 0 0.056 0B. Price 0.228 0.166 0.394 0.228 0.086 0.314 0 0 0 0.080 0

III. 0.115 0 0.115 0.115 0 0.115 0.106 0 0.106 0 0

Total Project Cost 3.681 2.569 6.250 3.681 1.319 5.000 3.201 1.280 4.481 1.250 0.839

ADB = Asian Development BankSource: Asian Development Bank Estimates.

ADB Financing ADB Financing

COST SUMMARY BY CATEGORY OF EXPENDITURE AND FINANCING ARRANGEMENTS($ million)

Appraisal Estimate Actual Government

Service Charge

Contingencies

Base Cost

Total Cost

Appendix 5 25

Year Quarter Amount Cumulative Amount Cumulative Total

1995 II 0 0 0 0 0III 0 0 0 0 0IV 1,035 1,035 11,416 11,416 12,451

1996 I 19,817 20,852 43,379 54,795 75,647II 163,946 184,797 60,112 114,907 299,704III 308,043 492,841 57,383 172,290 665,131IV 142,529 635,370 22,777 195,067 830,437

1997 I 202,412 837,782 11,485 206,552 1,044,334II 230,246 1,068,028 63,596 270,148 1,338,176III 220,019 1,288,047 90,250 360,398 1,648,445IV 280,574 1,568,621 20,947 381,345 1,949,966

1998 I 160,480 1,729,101 26,785 408,130 2,137,231II 372,709 2,101,811 243,211 651,341 2,753,152III 0 2,101,811 48,298 699,639 2,801,450IV 337,384 2,439,195 3,536 703,175 3,142,370

1999 I 0 2,439,195 22,957 726,132 3,165,327II 350,783 2,789,978 7,553 733,685 3,523,663III 484,624 3,274,602 14,110 747,795 4,022,397IV 16,891 3,291,493 59,827 807,622 4,099,115

2000 I 362,985 3,654,478 0 807,622 4,462,100II 19,017 3,673,494 8,241 815,863 4,489,357III 252,175 3,925,669 23,477 839,340 4,765,009IV 336,230 4,261,899 0 839,340 5,101,239

2001 I 0 4,261,899 0 839,340 5,101,239II 0 4,261,899 0 839,340 5,101,239III 191,964 4,453,863 0 839,340 5,293,203IV 27,349 4,481,212 0 839,340 5,320,552

Asian Development Bank Government

LOAN DISBURSEMENTS($ million)

Activity1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

A. Strengthen Primary Health Care (PHC)

1. Build 70 Health Centers

a. Design Phase

b. Build and Staff 10 HCs(Build 31 HCs)

c. Evaluate HC Construction, etc.d. Build and Staff 30 HCs

2. Health Education

3. Ensure Essential Drug Supply

a. Design Phase

b. Year 1 Supply

c. Year 2 Supplyd. Year 3 Supplye. Year 4 Supplyf. Year 5 Supply

4. Improve Supervision

a. Develop Checklist for HC

b. Develop Checklist for District Hospitalsc. Implement Systematic Supervision

5. Rehabilitate and Construct District HospitalsB. In-Service Training of HWs

1. Gathering Resources for Training

2. TB Training Materials Development

PROJECT IMPLEMENTATION SCHEDULE

1995 1996 1997 1998 1999 Year and Quarter of Implementation

2000

A C T I V I T Y1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

3. Outreach Activities Materials Training

4. Malaria Training Materials Development

5. CDD and ARI Training Materials Development

6. Training Implementation

7. Training Private Pharmacies Staff

C. Monitoring of Pharmaceutical Sector1. Supervision of Private Pharmacies

2. Improve Manufacturing Practices

D. Benefit Monitoring and Evaluation

1. Baseline Household Survey

2. Smaller Household Survey

3. Midterm Review

4. Completion Household Survey

5. Health Facility and Pharmacy Surveys

6. Devise Standard HC Survey

7. First Health Facility Survey

8. Second Health Facility Survey

9. Third Health Facility Survey

11. Final Health facility Survey

- appraisal schedule- actual schedule

Source: Asian Development Bank estimates.CDD = Diarrheal Disease Control, ARI = acute respiratory infection.

Year and Quarter of Implementation1995 1996 1997 1998 1999 2000

28 Appendix 7

COMPLIANCE WITH MAJOR LOAN COVENANTS

Covenant Reference

in Loan Agreement

Status of Compliance

A. Conditions of Disbursement

1. If the amount of Loan allocated to any

category (other than Category VII) appears to be insufficient to finance all agreed expenditures in that Category, the Asian Development Bank (ADB) may, by notice to the Borrower, (i) reallocate to such Category, to the extent required to meet the estimated shortfall, amounts of the loan which have been allocated to other Category but, in opinion of ADB, are not needed to meet other expenditures, and (ii) if such reallocation cannot fully meet the estimated shortfall, reduce the withdrawal percentage applicable to such expenditures in order that further withdrawals under such category may continue until all expenditures thereunder shall have been made.

Schedule 3, para. 7 (a) and (b)

Complied with

2.

The Borrower shall establish an Imprest Account within 60 days after the Effective Date at the Bank of the Lao People’s Democratic Republic (BOL), Banque pour le Commerce Exterieur Lao (BCEL) or another Borrower-owned bank to ensure the timely release of the proceeds of the Loan for the purpose of making payments for project implementation. The establishment, management and liquidation shall be in accordance with the ADB’s Guidelines on Imprest Fund and Statement of Expenditures Procedures dated November 1986.

Schedule 3, para. 8

Complied with

B. Standard Covenants

3. Audited accounts and auditors report to be submitted not later than nine (9) months after the end of each fiscal year.

Schedule 3, para. 8 (b)

Complied with

4.

Quarterly reports on the carrying out of the Project and on the operation and management of the project facilities to be submitted.

Section 4.07 (b)

Complied with

Appendix 7 29

Covenant Reference

in Loan Agreement


5.

Project Completion Report to be prepared and furnished not later than six (6) months after physical completion of the Project.

Section 4.07 (c)

Complied with

Project-Specific Covenants 1. Executing Agency and Project Management

6. A Steering Committee shall be established within one month after the Effective Date. The Steering Committee shall be chaired by the Ministry of Public Health (MOPH) and shall oversee the implementation and operation of the Project.

Schedule 6, para. 1

Complied with

7. MOPH shall be the Executing Agency for the Project. For the administration of the Project, MOPH shall, within one month after the Effective Date, establish a Project Coordinating Unit (PCU). The PCU shall be headed by a director (the PCU Director) who shall be an official of MOPH. The PCU Director shall work full-time in the PCU. The PCU Director shall be nominated by the Borrower and the appointment shall be subject to the ADB approval.

Schedule 6, para. 2

Complied with

8. In the central office of MOPH, the seven entities which are involved in the Project (Departments of Hygiene and Preventive Services, Food and Drugs, Health Organization and Human Resources for Health, and the School of Public Health, the National Tuberculosis Center, the Institute of Maternal Child Health, and the Institute of Malaria, Parasitology and Entomology) shall each, within one month after the Effective Date, appoint a Project Coordinator who will be responsible to the PCU Director.

Schedule 6, para. 3

Complied with

30 Appendix 7

Covenant Reference

in Loan Agreement


9. Schedule 6,

para. 4 Complied with

MOPH shall, within one month after the Effective Date, establish Project Implementation Offices (PIOs) in the provincial health offices of Xiengkhouang and Oudomxai provinces. Each PIO shall be staffed by at least two full-time staff acceptable to ADB who shall be responsible for coordinating all project activities in their respective province.

2.

Project Implementation

10. The Borrower shall cause the health

centers to be provided under Part A (i) of the Project to be constructed, to the extent possible, by the local communities themselves. In any event, the Borrower shall ensure that the local communities shall be responsible for constructing fencing and a water supply for each health center.

Schedule 6, para. 5 (a)

Complied with

11. MOPH shall take appropriate measures to encourage health workers currently stationed at the district level to relocate to the health centers constructed under Part A (i) of the Project. Such measures may include offering the following inducements to health workers who are willing to relocate: (i) living quarters next to each health center; (ii) access to farm land provided by the local administration; (iii) an appropriate form of transportation, such as bicycle; and (iv) proper equipment and materials.


Complied with

12. The drugs provided under Part A (ii) of the Project shall be distributed by MOPH once a year to health centers in the form of health kits containing sufficient quantities for 1,000 people for one year. The number of health kits distributed to a health center shall depend on its catchment population.


Complied with

Appendix 7 31

Covenant Reference

in Loan Agreement


Public and private sector drug

distributors shall be contracted to clear the drugs through customs, package them into kits and ship them to the districts. Distribution of drugs to health centers shall depend on the presence of an MOPH health worker.


Complied with

13. MOPH shall set the prices of the drugs, center a list of official prices of drugs in front of each health center, and develop a simplified accounting system acceptable to ADB. The accounting system shall be implemented in all health centers and districts and shall be monitored as part of the regular supervision conducted by MOPH district staff.

Schedule 6, para. 6(b)

Complied with

14. The proceeds from the sale of drugs in each health center shall be managed by a village-level health committee comprising village leaders, the health worker(s) and representatives of the Lao Women’s Union (LWU). Existing village health committees shall be utilized for this purpose. The village health committee shall oversee the use of the revenues from the sale of such drugs and decide on subsidies for the poor. Such revenues shall be used exclusively to help defray operating expenses of the health centers, including per diems for health workers conductive outreach activities, maintenance and repairs, kerosene, transportation of patients and purchase of additional drugs in the event that the health center should run short of essential drugs. The collection and use of funds from the sale of essential drugs shall be under the supervision and authority of the district government and in accordance with the financial laws and regulations of the Borrower.

Schedule 6, Paras. 6(c)

Complied with.

16. The Ministerial Decision on Cost Recovery and Resource Mobilization shall be issued within twelve (12) months after the Effective Date.

Schedule 6, para. 6 (e)

Complied with

32 Appendix 7

Covenant Reference

in Loan Agreement


17. MOPH shall, in accordance with a

project implementation schedule agreed upon with ADB, conduct health education seminars and workshops on basic topics in public health care under Part A (iii) of the Project, aimed particularly at women in cooperation with LWU at the district level, focusing on use of anti-malaria bednets, immunization, micronutrient malnutrition, and other topics in maternal and child health. MOPH shall ensure that LWU members attend regular district meetings and become sources of health education for women in their village.

Schedule 6, Para. 7

Complied with

18.

MOPH shall, in accordance with the agreed project implementation schedule, introduce regular and systematic supervision and support of health staff at district hospitals and health centers on the basis of the supervisory checklist developed under Part A (iv) of the Project.

Schedule 6, para. 8

Complied with

19. MOPH shall ensure the improvement of health workers’ skills and knowledge through in-service training under Part B of the Project. The Borrower shall cause training of district and provincial level managerial staff in health services administration to be conducted by the School of Public Health in Vientiane.

Schedule 6, para. 9

Complied with

20. MOPH shall ensure the quality of the drug supply and shall cause the knowledge and skills of private pharmacy operators to be improved through monitoring of private pharmacies in the project area based on regular visits of pharmacists, and utilizing the standard set of objective indicators and observations developed under Part C of the Project.


Complied with

Appendix 7 33

Covenant Reference

in Loan Agreement


21. Training of private pharmacy staff in the

rational use of drugs means to ensure compliance, the management of pneumonia, diarrhea, malaria and tuberculosis including the proper referral of serious cases to the appropriate facility. MOPH shall ensure that the training and supervision will be incorporated into the required annual registration, which shall be coordinated through the district hospitals.


Complied with

22. Training of MOPH pharmacists and staff from Borrower-owned pharmaceutical factories in “Good Pharmaceutical Manufacturing Practices”, including improving standards of hygiene, maintenance of equipment, and laboratory testing.

Schedule 6, para. 10 (c)

Complied with.

23. The Borrower shall ensure that project area governments provide (i) sufficient land for the district hospitals, health centers and staff housing to be constructed under the Project to health workers stationed in the health centers; and (ii) the use of at least three hectares of arable land situated within a reasonable distance of the health centers, all in a timely manner and in accordance with the project implementation schedule.

Schedule 7, para. 11

Complied with

24. Within twelve (12) months after the Effective Date, MOPH shall issue a Ministerial Decision pertaining to the use of the staff housing to be constructed under the Project. Specifically, such housing shall only be used by the health worker so long as she/he is actively working for MOPH in the adjacent health center. The house shall remain the property of MOPH and may not be sold, leased or encumbered; provided, that ownership of the house may be ceded to the health worker after five years of satisfactory service.


Complied with

34 Appendix 7

Covenant Reference

in Loan Agreement


3. Decentralization of Staffing Decisions

25. Within one year after the Effective Date,

MOPH shall issue guidelines delegating authority in matters of the deployment of staff currently working at the district level to the District Health Officer concerned.


Complied with

4. Increasing Health Allocations 26. The Borrower shall increase public

annual per capita health expenditures in the project area to the level of the national average by 30 April 2000.


Complied with

27. In order to provide a basis for comparison for the purposes of subparagraph (a) of this paragraph, the Borrower shall, not later than three months after the close of each financial year, furnish ADB with the actual allocations given to the health sector in the project area and the national totals.


Complied with

28. The Borrower shall develop a budget proposal during the last year of project implementation which shall include provisions for sustaining the health centers during the following year. The Borrower shall ensure that this budget and subsequent ones shall contain a specific line item for the provision of essential drug kits.


Complied with

5. Midterm Review 29. The Borrower and the Bank shall jointly

undertake a midterm review of the Project by December 1997.


Midterm Review was fielded in May 1998.

6. Environmental Considerations

30. Schedule 6, para. 17

Complied with

MOPH shall ensure that the location, design and construction of the project facilities will take into consideration the preservation of the environment and natural resources. Optimal use of local materials, natural light, and natural ventilation shall be systematically

Appendix 7 35

Covenant Reference

in Loan Agreement


considered. Refuse handling and

disposal measures for hazardous medical waste (such as syringes and needles) shall be specifically addressed in the design of the health centers and hospitals. MOPH shall submit to ADB for approval the designs of the health centers and hospitals to be constructed under the Project.

31. MOPH shall cause (i) periodic health facility and pharmacy surveys to be undertaken to evaluate the performance of the health care system in the project area and compare it with that in other provinces of the Borrower; and (ii) household surveys and focus group discussions to be conducted to examine project impact.


Complied with

32. MOPH shall disseminate the lessons learned in the project area through: (i) the conduct of study tours for health staff from other provinces; (ii) the conduct of national workshops to discuss particular issues, such as monitoring pharmacies, supervision of health workers, and use of essential drug kits; (iii) the use of the project area as a laboratory for the School of Public Health; and (iv) periodic visits to the project area by high-level MOPH officials.


Complied with

Appendix 8 36

TA 2291-LAO: INSTITUTIONAL STRENGTHENING OF THE MINISTRY OF PUBLIC HEALTH

A. Description 1. The technical assistance (TA) was to assist in the implementation of Loan 1348-LAO(SF)1 and to strengthen the capacity of the Ministry of Public Health (MOPH), in particular in areas of management, in-service training, and monitoring and evaluation. The consultants were expected to help health staff in the project provinces of Xiengkhouang and Oudomxai to gain experience in project management. B. Objectives and Scope 2. The main objectives were to (i) assist in the implementation of the Project, (ii) ensure successful in-service training to improve the competency of peripheral health workers, and (iii) ensure that the lessons learned in the project areas are disseminated for the benefit to the rest of the country. C. Inputs Evaluation 3. Two international consultants were recruited following the Asian Development Bank’s Guidelines on the Use of Consulting Services. A specialist in health project management was engaged for 24 months and extended for another 12 months, and in-service training expert was engaged for 12 months and extended for another 4 months. Office equipment (vehicle, two desktop computers, printer, fax machine, and mobile phone) was procured on time and was shared between the consultants and the Project Coordinating Unit. The equipment facilitated the consultants’ and PCU’s work. The office equipment was turned over to MOPH in working condition after the TA was completed. MOPH, as the Executing Agency, provided counterparts and worked with the training specialist. The management consultant worked with the head of the project implementation offices and task managers in the primary health care (PHC) committee, School of Public Health, and Department of Food and Drug. D. Outputs Evaluation 4. The project activities were closely monitored and assessed throughout implementation, with regard to targets, but were inadequately documented. The in-service training consultant helped MOPH staff at the district levels to develop training modules, and to design and implement an appropriate evaluation of the in-service training program. The consultants conducted courses for trainers on the use of the training modules and audio-visual equipment. They also helped MOPH staff to ensure the sustainability of the Project and that lessons learned in the project areas would be shared with other provincial health departments in the country. The Government has increased attention to the improved delivery of health services and staff training at the national, provincial, and district levels. E. Overall Assessment and Rating 5. The TA is considered successful and has fully met its objectives and scope, particularly in improvements in the management in delivery of PHC services and staff training. The PHC

1 ADB. 1995. Report and Recommendation of the President to the Board of Directors on a Proposed Loan to Lao PDR on Primary Health Care. Manila.

Appendix 8 37

approach and strengthened delivery health care system under the Project have identified and discussed issues on the establishment and delivery of PHC services. F. Major Lessons Learned 6. Rural health facilities should be systematically planned according to the needs and wishes of the communities they serve, determined by consultation with them. The buildings should be simple, with practical space and layout, and adequate basic facilities. There should be sufficient numbers of adequately trained staff for static and outreach services, regular supervision, and community involvement. 7. Establishment of a network of health centers is an effective strategy to increase the accessibility and quality of care through expanded PHC services to rural communities. Activities are provided through community-based outreach services, and patients are referred as needed to district hospitals for specialized care. 8. Integrated supervision of staff at health centers and district hospitals are essential for quality care.

CONSULTING SERVICES

Appraisal Actual Person-Months Commencement

Year Person-Months Commencement

Year Component Domestic Foreign Domestic Foreign Domestic Foreign Domestic Foreign

1. Administration and Finance 120 0 1995 – 153 47 1995 1995

2. Equipment Procurement 0 0 94 0 1995

3. Training and Materials Development 20 4 1995 – 0 0 –

4. Project Management 0 12 – 1995 0 0 –

– = not available. Note: A full-time Ministry of Public Health staff member was provided as counterpart training officer during the project period. Source: Ministry of Public Health, February 2002.

INDICATORS FOR BENEFIT MONITORING AND EVALUATION

Indicator Achievement at Project Completion

Method of Data

Collection

Responsible for Data Collection

and Analysis

1. Input Indicators

80% of health centers (HCs) have adequate supply of essential drugs, defined as having stock at least 10 out of 12 essential drugs.

More than 80% of HCs have adequate supply of essential drugs.

household survey Project Coordinating Unit

2. Process Indicators 80% of health workers in HCs to have acceptable knowledge and case management skills to deal with tuberculosis (TB), malaria, diarrhea, pneumonia, and micronutrient malnutrition.

Health workers at more than 80% of HCs have acceptable knowledge and basic case management skills.

health facility survey provincial health offices

70% of drugs sampled at point of sale found to meet USP XXIII standards upon laboratory testing.

Not documented adequately pharmacy survey Department of Food and Drug

3. Output Indicators Immunization coverage expressed as fully immunized children to reach 80% overall. Coverage in catchment area of health posts should reach 90%.

Achieved 32.4% overall household survey provincial health offices

50% of children from 6 months to 5 years of age receive vitamin A supplements twice a year.

Achieved more than 200 times of target

household survey provincial health offices

50% of households use insecticide-impregnated bednets for children so as to reduce the incidence of malaria.

Increase of use by 24% household survey provincial health offices

200% increase in the absolute number of TB cases diagnosed (baseline: 88 diagnosed in 1993).

No reliable data available provincial and district hospital records

provincial health offices

Increase to 70% the proportion of diagnosed TB cases that receive a full course of treatment and become sputum negative (baseline: about 30%)

No reliable data available provincial and district hospital records

provincial health offices

50% increase in villagers’ use of public health facilities, for services other than immunization, compared to baseline (such as utilization of antenatal care)

Increased by 139% of the target household survey provincial health offices

Indicator Achievement at Project Completion

Method of Data

Collection

Responsible for Data Collection

and Analysis

4. Impact Indicators

Infant mortality rate per 1,000 live births: using direct technique employed during Lao Social Indicator Survey, decrease by 15%.

Reduction by 34.4% of the baseline


Under-5 mortality rate per 1,000 live births using indirect technique employed during Lao Social Indicator Survey, decrease by 15%.

Reduction by 39.7% of the baseline


Percent of children aged 5 less than 2 standard deviation below the median weight for age decreases by 10 percentage points.

No reliable data available household survey Project Coordinating Unit

5. Summary Indicators 30% increase in scores private pharmacies obtain on a standardized monitoring instrument that uses quantifiable indicators

Survey done but not documented adequately

pharmacy survey Department of Food and Drug

By project completion, 75% of health posts built will be “fully functioning”, defined as having full time, paid worker with adequate knowledge and a sufficient supply of essential drugs.

All 73 HCs are fully functioning before project completion.

health facility survey Department of Food & Drug

Sources: Ministry of Public Health, January 2002. Primary Health Care Project Household Surveys. Lao National Health Survey, 2001.

Appendix 11 41

PROJECT BENEFIT MONITORING AND EVALUATION A. Introduction 1. Under the project benefit monitoring and evaluation (BME) system, information collected included: (i) verifiable indicators from a household survey conducted by the Bureau d'Etudes Lao in 1996; (ii) "benchmark" data from participatory evaluation on the community perceptions about health services in Xiengkhouang and Oudomxai provinces under regional technical assistance (TA) on facilitating capacity building and participatory activities, 1996;1 (iv) a health facility survey conducted in Xiengkhouang and Oudomxai provinces in 2000; and (v) the countrywide Laos National Health Survey, 2000. The purpose of the countrywide survey was to (i) collect essential, accurate, systematized, and timely information on the quantitative and qualitative performance of the project components; (ii) identify problems and opportunities for timely analysis and response; and (iii) assess and quantify the project’s impact after project completion. B. Major Findings

1. Household Survey, 1996 2. The population in Oudomxai and Xiengkhouang provinces are mainly Lao Theung and Lao Soung but resemble the general population of the Lao People’s Democratic Republic (Lao PDR). Communications are constrained by the language, and accessibility is difficult because of the mountainous nature of the regions and aggravated by prolonged rainy seasons. The rainy seasons and lack of labor during the planting and harvesting season affected the construction period for health centers. 3. The figures for the infant mortality rate of 80 per 1,000 live births and under-5 mortality rate of 176 per 1,000 live births from the study vary widely from national figures. The reliability of the data was also uncertain. The National Expanded Program of Immunization Program coverage was low due to socio-cultural, geographic, and logistical problems. Vitamin A supplementation, when provided together with the immunization program, could have a significant impact in reducing infant and child mortality (Table A11.1). The high percentage of unsafe deliveries and low level of antenatal care suggests the need for improved maternal and child health services in the project area. Only about 60% of mothers breastfed immediately after delivery. The health centers constructed will provide family planning services to meet the high unmet demand and their services will contribute to the control of HIV/AIDS.2 The malaria control program will continue to focus on reducing transmission by the use of impregnated bednets. The curative and preventive services should be improved at district and provincial levels, particularly the management of malaria, diarrhea and acute respiratory illness among children. An oral iodine supplementation program is for pregnant women and children as an immediate measure, and the salt iodization program is intended as a long-term intervention.

1 ADB. 1996. Technical Assistance for Facilitating Capacity Building and Participatory Activities Project. Manila. 2 HIV/AIDS = Human Immunodeficiency Virus/Acquired ImmunoDeficiency Virus

Appendix 11 42

Table A11.1: Household Survey, 1996, and National Health Survey, 2001

Indicator Oudomxai (%)

Xiengkhuoang (%)

Project Area (%) Sources NHS (%)

Infant Mortality Rate per 1,000 live births

125.0 1994LSIS 82

Under-5 Mortality Rate per 1,000 live births

125.2 213.3 175.8 1995HHS 106

Maternal Mortality Rate per 1,000 live births

200LNHS 530

Fully Immunized Child 16.2 22.8 20.0 1995HHS 32.4 (aged 12-23 months) (EPI target of 85%) Under 5: Vitamin A Supplementation (6 months to 5 years)

0 0 1.39 1995HHS 28.8

69.2 64.6 66.7 1995HHS 82.7 Under 5: Impregnated Bednets

Ordinary Bednets % of villagers using public health services other than immunization

12.0 1995HHS –

% of villages receiving four EPI visits per year

21.3 39.2 32.8 1995HHS –

% of EMWRA in rural areas using modern contraceptive method

0 0 0 1995HHS 67.9

% of EMWRA who know at least one modern contraceptive method

9.0-18.0

1995HHS

72.1

Total Fertility Rate 9.7 7.9 8.6 1995HHS – (6.6 1993LSIS) % of EMWRA received tetanus toxoid 7.0 1995HHS 45 (49.0% nationwide) % of EMWRA seeking antenatal care

12.0 1995HHS 28.7

(87% at hospitals) % of EMWRA aware of HIV/AIDS 40 1995HHS 52.8 – = not available. EMWRA = Ever-Married Women of Reproductive Age, EPI = Expanded Program of Immunization, HHS = Household Survey, 1995, HIV/AIDS = Human Immunodeficiency Virus/Acquired ImmunoDeficiency Syndrome; LNHS = Lao National Health Survey, 2001, LSIS = Lao Social Indicator Survey, 1993/94, NHS = National Health Survey, 2001. Source: Ministry of Public Health, January 2002.

2. Regional Technical Assistance, 1998 4. Accessibility to health centers is often difficult due to their location with poor access roads; travelling time by walking can range from 40 minutes to 10 hours. However, the conjecture that many patients are satisfied with the services provided at the health centers is based on services utilization, the increased number of outpatients and referral cases, competitive drug prices and patients’ willingness to pay, and the availability and attitudes of health workers. Many villagers agree that health workers are available at health centers and provided satisfactory services.

Appendix 11 43 5. Some health workers made home visits. Health Workers who were from the same community as their patients showed positive interpersonal relationships with them. Communities from distant villages appreciated health workers at health centers who were available, polite, and friendly. The community would prefer female health workers to provide services on birth spacing. Many villagers expressed the view that the quality of care was more important than the price of drugs, which were lower than at the private pharmacies. The number of poor or medically indigent people who were given cost exemptions was low for both provinces. Thus, poverty is not a barrier to the accessibility for primary health care (PHC) services. There were no reports on any formal payment beyond the official prices of drugs. 6. The workers at health centers knew the catchment population and their tasks and responsibilities. The relationships between health workers and the communities were assessed by the study team based on (i) rules and regulations for encouraging health personnel to work in rural areas; (ii) governmental and social support; (iii) communities’ socio-cultural perspective; (iv) distance from homes to health centers; (v) availability of essential drugs, staff, and quality of care; and (vi) population characteristics, including educational attainment and knowledge of PHC. More than half of the health workers in the project area were satisfied due to (i) deployment in their home areas; (ii) strong commitment and support provided by local authorities; (iii) incentives such as agricultural land and housing provided to health center staff in Xiengkhouang province; (iv) opportunities for temporary staff to be regularized as government staff; and (v) meeting their basic needs, including house, agricultural land, and recognition as those who contribute to the welfare of the community. There were more health workers in Xiengkhouang who were satisfied with the houses and land received than there were in Oudomxai province. There were also more health workers in Xiengkhuoang who would like to continue working at the health centers. Several health workers complained of assignment to unknown areas, minimal support from local authorities, uncertain of duration of assignment, lack of refresher training, family problems, reward system not proportional to work load, and the need for more than one staff member at each health center in remote areas. 7. All health workers received intensive pre-service and in-service modular training at provincial levels before deployment, and were being supervised monthly by the district and provincial health departments. They discussed issues related to curative and preventive services, including drug control and birth spacing. Health center staff prepared monthly reports from compilation of their daily records as part of the health management information system under the Ministry of Public Health (MOPH). The majority of health workers expressed the importance of outreach services; however, only a third of health workers reported providing regularly PHC outreach services. More than half reported irregular outreach visits due to heavy workload, while a third attributed it to inadequate travel allowances. Most health workers were satisfied with the regular supply of basic medical equipment and supplies, and these provisions were adequate and appropriate

3. Household Survey in Oudomxai and Xiengkhuoang Provinces, 1999 8. The provincial household survey was carried out by the Council of Medical Sciences in Oudomxai and Xiengkhuoang provinces in 1999. The objective was to evaluate the progress achieved by the Project based on similar criteria to those used in the Baseline Household Survey in 1996. The main findings are summarized in Table A11.2. There were significant increases in the fully immunized children, anti-tetanus immunization for pregnant women, vitamin A supplementation, use of impregnated bednets by children under 5 years of age, and contraceptive prevalence rate. However, more outreach visits were deemed to be required to improve

Appendix 11 44

immunization services, increase the utilization of public facilities, improve reproductive health, and treat diarrhea.

Table A11.2: Provincial Survey Results Summary

Oudomxai Xiengkhuoang Key Area BLS 1996 1999 BLS 1996 1999 1. Fully Immunized Child

(aged 12-23 months) 22.1% 25.9% 9.2% 21.9%

2. Tetanus Toxoid Immunization (women aged 15-49 years)

7.0% 36.0% 7.0% 36.0%

3. Under 5: Vitamin A Supplementation 1.4% 36.6% 1.4% 43.3% 4. Under 5: Use of Impregnated Bednets 64.7% 80.8% 69.9% 72.8% 5. Contraceptive Prevalence Rate 13.8% 19.1% 6. Knowledge on Family Planning

(at least one contraceptive method, married women)

lower 83.1% lower 67.3%

7. Outreach Visit of EPI 15.8% 23.0% 8. Health Center Visits 14.4% 6.7% BSL = Baseline Household Survey, EPI = Expanded Program of Immunization. Source: Ministry of Public Health, January 2002.

4. Health Facility Survey, 2000 9. The survey was carried out by the National Institute of Public Health in Oudomxai and Xiengkhuoang provinces from June 1999 to June 2000. The main findings are summarized in Table A11.3. In Xiengkhuoang, the provincial hospital and district hospitals at Mok, Nonghet, and Kham were included. In Oudomxai, the survey included Oudomxai provincial hospital and district hospitals at Namo, Houn, Pakbeng, and Nga. In all provincial and district hospitals surveyed, there were more key hospital areas such as operation theaters and delivery rooms, nursing areas, minor equipment, infrastructures (power and water supply), and utilities such as toilets. Between 1996 and 2000, there was an increase in population coverage for district hospitals at 1.5 percent and 66 percent for Xiengkhuoang and Oudomxai, respectively. There were also significant increases in paramedical and auxiliary staff and essential drugs in all provincial and district hospitals.

Table A11.3: Utilization of Hospital Services before Project and at Completion Oudomxai Xiengkhuoang Key Area 1996 2000 1996 2000

A. District Hospitals Hospital Beds 13 16 15 15 Outpatient Visits 1,913 1,236 1,012 1,192 Inpatient Admission 476 350 379 308 Bed Occupancy Rate 42% 13% 29% 20% Average Length of Stay 2.0-7.0 days 3.9-7.0 days B. Provincial Hospitals Hospital Beds 82 82 69 70 Outpatient Visits 9,916 8,931 9, 210 22,450 Inpatient Admission 4,217 4,007 1,723 2,808 Bed Occupancy Rate 36% 63% 39% 63% Average Length of Stay 2.0-7.0 days 3.9-7.0 days

Note: Data on the Average Length of Stay for both provinces in 1996 are the same. Year 2000 data is not available. Sources: Health Facility Survey, National Institute of Public Health, Ministry of Public Health, 2000.

Appendix 11 45 10. There have been improvements in the reproductive health services (including the birth spacing program, pre- and postnatal care, child health services through the vitamin A supplementation program, and immunization program), and in the control of communicable diseases (through the malaria insecticide-impregnated bednets program, tuberculosis service, diarrheal control program, and acute respiratory infection program). The utilization of hospital services has increased particularly with diagnostic services for malaria and tuberculosis. However, there seems to be bypassing phenomena3 for unprecedented demand for provincial hospitals.

5. Lao PDR National Health Survey, 2001 11. This was the first nationwide health survey using a multiple indicators cluster survey carried out the National Institute of Public Health and MOPH, and in cooperation with the National Statistical Center of the State Planning Committee. The main objective was to collect community-based information on the health status and morbidity of the population of the Lao PDR. The main findings were that (i) accessibility to villages is limited and worsened by heavy rainfall, particularly in the northern areas; (ii) the distance from villages to a health facility (health center, district hospital, pharmacy) ranges from 4 to 96 km; (iii) the PHC is limited to services provided by inadequately trained health workers, including traditional birth attendants and village health volunteers; (iv) the basic drugs available in villages are chloroquine, paracetamol, some antibiotics and rehydration salts; (v) overall, the mortality rates were lower than in the past years; and (vi) the life expectancy has also improved to about 57 years for males, 61 years for females, and 59 years for both males and females. The maternal mortality rate was about 530 per 1,000 live births, the infant mortality rate was about 82 per 1,000 live births, and the under-5 mortality rate was about 106 per 1,000 live births. 12. Overall, the health situation has improved. Countrywide 2.5% of urban respondents reported illness 2 weeks prior to the interviews and 0.7% reported injuries or accidents. The percentage was higher among the females, in the rural areas, and in the central region. Among those who were ill, 45.4% sought treatment, out of which 18.5% went to pharmacies due to their easy accessibility. About 52.9% used self-medication, particularly in rural areas, with low education, and in the southern provinces. Countrywide, 52% of households had access to safe drinking water; 75.5% in urban areas, and 37.6% in rural areas. In the north, only 43% of households have access to safe drinking water. Of urban households, 67.1% use latrines while in the rural areas, only 19% use latrines. In the southern provinces, only 19.2% of households use latrines while 37.3% of households countrywide use latrines. 13. Under the malaria control program, countrywide 92.4% of households possess mosquito nets, while only 22.2% use impregnated mosquito nets. The percentage is lower in the northern provinces. Of those with a history of fever, 44.8% seek medical treatment at a pharmacy or hospital. Only 33.5% had a blood test done for malaria and about half were found to be positive. Overall, about 2.9% of the population surveyed has had a positive blood test for malaria (dipstick test). Children under 5 years and adults aged 45-49 years have a higher incidence of malaria than other age groups. Among women interviewed countrywide, one third did not know about HIV/AIDS and its transmission. However, more women in the central region knew about HIV/AIDS. Educated women are four times more likely to know about HIV/AIDS prevention. Countrywide about 1% of children under 5 years had acute respiratory illness 2 weeks prior to their interviews; about 15.5% were hospitalized, 12% received treatment at outreach services, 6.8% were treated at health centers, and 36% received private treatment. Countrywide about 6% of children under 5 years had 3 Bypassing phenomena are conditions where patients seek treatment directly at provincial hospitals instead of the

district hospitals.

Appendix 11 46

diarrhea 2 weeks prior to their interviews. About 95.5% were treated with oral fluids at home. More than half of the mothers interviewed knew at least two indications for referral to a health facility. 14. Among women who delivered 1 year prior to the interviews on reproductive health, only 35% received some form of antenatal care and 28.7% from trained health worker. Only 45% of pregnant mothers received tetanus immunization. Among women who delivered 1 year prior to the interviews, only 21.4% were delivered by a trained health worker: 28.8% in the central region and 16.4% in the northern provinces. Only 79% of married women knew of one contraceptive method; 32.2% of married women are currently using contraceptives, of which 29% are using modern methods and 3% traditional methods. The oral contraceptive pill is the most popular modern method, followed by injections, intrauterine devices, female sterilization, and condoms, while periodic abstinence is the most popular traditional method. Contraceptive prevalence is higher in urban areas and among educated women. 15. About 69.3% of children aged 12-23 months received BCG (tuberculosis) vaccination under the child health program by the age of 12 months. About 83.2% received their first dose of Diptheria-Pertussis-Tetanus, while 67.5% received the second dose, and only 52.8% received the third dose. Only about 81.2% of children aged 12-23 months received the first dose of polio by the age of 12 months and only 57.1% the third dose. Only about 32.4% were fully immunized by the age of 12 months. Among the children under 5 years of age in the sample, 15.4% were found to be moderately or severely wasted (too thin for their height); 30 percent wasting was found among children 12-23 months age. Stunting (too short for their age) was found among 40.7% of children under 5; 55% stunting was found among those 48-59 months. Forty percent were underweight (too thin for their age) and 54% were underweight among those 24-35 months old. The prevalence of malnutrition was higher in the southern provinces. The survey findings on breastfeeding and food supplements were that 95% of the children were breastfed and 75.1% received breastfeeding within 2 years of age. 16. On vitamin A deficiency and supplementation, the survey findings were: 28.8% children aged 6-59 months received vitamin A supplementation in the past 6 months; 3%of children aged 6-59 months have problems of sight after sunset. Dry blood spots for serum retinal level were collected from 1,114 persons, including 419 children under 5 years and 695 females aged 12-49 years. Of those tested, 44.9% of children under 5 years, 26.5% of females aged 12-19 years, and 32.7% of people in the central region had serum retinal levels less than 0.7umol/L.Overall, 30.9% of the study population had low serum retinal levels that suggested vitamin A deficiency. 17. On iodine deficiency, the survey findings were as follows: 76% of the survey sample population, households in the central region, and urban areas had adequate iodized salts. Nine percent of children aged 6-12 years had goiter of grade1+2 (higher in the southern provinces and among females); 6.2% of children had clinically diagnosed goiter, grade 1 by palpitation; and 7% aged 8-12 years had iodine deficiency. It was most common in the southern provinces, among females, and in the rural areas. 18. On iron deficiency, 26% of the sample population had moderate anemia (hemoglobin 7-10.9 gm%). It was most common in the southern provinces, among females, in rural areas, and in people under 5 years and above 60. Approximately 1% of the sample population had severe anemia (hemoglobin less than 7 gm%), and 3.6% of mothers who delivered recently gave a history of taking iron tablets during their pregnancy.

Appendix 11 47 C. Conclusion 19. The Project has strengthened the delivery of health services in Oudomxai and Xiengkhouang provinces. Household surveys indicated that (i) communities were satisfied with the services provided at health centers; (ii) the attitudes and behavior of health workers were acceptable; (iii) essential drugs provided were affordable; and (iv) people were willing to pay for services provided. Areas for suggested further improvements include (I) provision of adequate incentives for health workers at health centers, including outreach services; and (ii) increased local understanding and participation in decision making by health workers and communities. 20. The Project-constructed health centers exceeded the number planned at appraisal, and all are fully operational. Thus, the Project should continue to emphasize the training of health workers and their deployment to health centers, adequate supply of basic medical equipment and supplies, and monitoring and supervision of health centers. The more supervision of health centers and village-level outreach services will assure better delivery of PHC services. The outreach services were limited by the number of staff available to perform them and by inadequate travel allowance. Trained staff were available and willing to provide PHC services of acceptable quality of care. The attrition rate was low. The communities demanded more drugs, including injectables and infusion fluids. Currently there are only 21 drugs included in the essential drug list approved by MOPH. In conclusion, the present PHC approach is workable in developing countries like the Lao PDR. D. Recommendations 21. The focus group proposed adding additional drugs to the standard 21 essential drugs for emergency and seriously ill patients from remote areas, including injections, infusion fluids, sterilized materials, and syrups and mixtures for children. Simultaneously, it was suggested that there be increased efforts to promote education in correct treatment and problem solving. The prices of drugs should continue to be competitive, and lower than at the private pharmacies. Health workers suggested improving the management of revolving drug funds that is not covered by the current guidelines. There should also be adequate water supply at health centers and nearby houses; health education on birth spacing; and 24 hours medical coverage. 22. The communities recommended (i) bigger buildings for curative services and privacy for pregnant mothers during delivery; (ii) preventive services including sanitation and advice on construction of latrines; (iii) need for a regular medical supply in daily curative services; (iv) assignment of more qualified staff or medical assistants to health centers; (v) outreach preventive services including health education; (vi) additional drugs on the essential drug list; (vii) more health promotion on personal hygiene and maternal and child health, including antenatal care and examination of children under 5 years; (viii) outreach antenatal care for pregnant mothers living in hilly areas; (ix) promotion of a healthy lifestyle with positive health-seeking behavior; (x) more health workers from hill tribes with similar cultures to that of their patients; and (xi) availability of a prescription after every medical examination. 23. There is a need for formulation of comprehensive PHC and national policies for rural health development. The policies should address the following key issues: (i) health infrastructure and mapping; (ii) human resources development, particularly post-basic training for PHC services; (iii) skills and management of health personnel at district and provincial levels; (iv) financial management; (v) supervisory management; (vi) demographic data; (vii) disease control and surveillance system; (viii) utilization of health services; (ix) socio-cultural information; (x) ecological and environmental information; and (xi) community participation as health partners.

Appendix 11 48

24. Operational policies, staff mix and tasks and responsibilities for health facilities should take into account their catchment population. Standard plans should be developed for health care facilities with participation by MOPH and related government agencies. Hospital staff should assist health center staff with problem-based hands-on training. An effective referral system in terms of services provided, supervision, and staff training should be established. 25. Investment in health development, including human resources development, contributes to sustainable development, while linking to development in related sectors including education, water supply and sanitation, and local authorities. There is a need for community participation in health development. The aim must be to establish partners who will promote a participatory approach, alliances, and synergistic actions for sustainability in development. 26. A more systematic approach should be adopted in personnel training and development for health centers with a special focus on quality of care and increasing accessibility for underserved areas. PHC services should be improved through development of minimum package of activities to include (i) curative services for outpatients, emergency, preventive services, and common and chronic illnesses; (ii) preventive care including health education, immunization, nutrition supplementary program, disease surveillance for common communicable diseases; and (iii) managerial activities including catchment population, health management information system, follow-up services, district health monthly reviews, and actions for improvement of the delivery system. 27. Health workers pointed out a systemic problem of low staff motivation due to low salaries, poor working conditions, and low traveling allowance. There is a need to establish self-financing schemes for health centers, including user fees, cost sharing, or some form of revolving funds. Provision of agricultural land and a house should be used as an incentive to health workers, and to help them establish some form of income generation.

asian development bank...7. project completion report number lao people’s democratic republic...

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