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Impact of Out-of-Pocket Expenditures on Families and Barriers to Use of Maternal and Child Health Services in the Lao People’s Democratic Republic

COUNTRY BRIEF

Out-of-Pocket Spending on Maternal and Child Health in Asia and the Pacific

Impact of Out-of-Pocket Expenditures onFamilies and Barriers to Use of Maternal and

Child Health Services in the Lao People’sDemocratic Republic

Evidence from the Lao Expenditure and Consumption Survey2007–2008



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Background

The Lao People’s Democratic Republic (the Lao PDR) has madeprogress in the past decade toward achieving the health relatedMillennium Development Goals (MDGs), but health outcomesremain among the worst in Asia and the Pacific. The maternalmortality ratio, at about 580, is the second highest in Asia, andis two to four times higher than that of the country’s immediateneighbors (WHO, UNICEF, UNFPA, and World Bank 2010).Basic, effective maternal and child health interventions are stillbeyond the reach of large segments of the population. Therate of skilled attendance at birth is one of the five lowest inthe world (UNICEF 2012), and reported rates of use of publicfacilities (0.2 curative care contacts per capita per year) are alsoamong the lowest. Progress in expanding service coverage haslikewise been limited. Skilled birth attendance, for example, fellfrom 21% in 2000 to only 20% in 2006, while the percentageof children seeking care for possible pneumonia declined from36% to 32% during the same period (UNICEF 2000, 2008).

According to national health accounts estimates prepared by theWorld Health Organization (WHO) (WHO 2012), out-of-pocketspending by households accounts for 51% of financing for the

health sector. Government spending as a share of gross domesticproduct in 2010 is the lowest in the region, at 1.5%, comparedwith 2.9% in Thailand, 2.7% in the People’s Republic of China,2.6% in Viet Nam, and 2.1% in Cambodia, and has not increasedin real terms in the past decade. Donors make major contributionsto overall public sector spending, but their funding fluctuates fromyear to year, causing difficulties in financial management.

The government health system covers most of the populationand is supplemented by both nongovernmental organizationand private providers. The government health infrastructure islimited and concentrated in urban areas. Ratios of hospital beds,doctors, and nurses to population are also among the lowestin the world (OECD 2010). Government healthcare servicesare underused and private healthcare, although expanding,is limited. Overall rates of use of modern medical care in theLao PDR are therefore very low. Healthcare services used tobe funded fully by the government and were officially providedfree of charge at government health facilities, but in 1996 thegovernment introduced user fees. The low budgetary resourcesmade available for government health services have since led toa high reliance on user fee revenues by the facilities. Althoughthe government has set up a number of insurance and safety net

Summary

• Limitedprogresshasbeenmadeinthepastdecadeinreducingthehighlevelsofmaternalandchilddeaths in the Lao People’s Democratic Republic (Lao PDR). Women and children are inadequatelycovered by basic healthcare services.

• Theuseofmedicalservicesisalsoverylowinthecountry,comparedwithothercountriesintheregion.

• In2007,therewerelargeinequalitiesintheuseofhealthcareservices.Richfamiliesandthoselivingin urban areas were almost twice as likely as poor families and those living in the countryside to seekmedical treatment.

• This inequalityinhealthcareuseexistsmainlybecause(i) thepoorarelesslikelythanthe richtorecognize that they are ill, and (ii) the poor are less likely than the rich to pursue treatment even whenthey know they are sick.

• Difficultyofaccesstomedicalfacilitiesandthecostoftreatmentarethemainreasonswhytreatmentis not sought.

• Theuseofinpatientcare,wheretheproblemsofphysicalaccessandthecostbarriersaregreater,is much more unequal than the use of outpatient care. Nonpoor families use inpatient care twice asmuch as poor families, both for children and adults.

• Mosthealthcarevisitsforbothchildrenandadultsinvolveself-medication,withmedicinesthefamiliesthemselves purchased.

• Ashospitals rely on user fees, 89% of child admissions result in financial costs tohouseholds. Admission costs are higher on average at public hospitals than at private clinics, indicating that thecost barriers to care in public services are quite high.

• Theshareofout-of-pocketmedicalspendingintotalhouseholdspendingisstillnothigh,however,and financially impoverishing spending is modest, because of the low use of healthcare services inthe Lao PDR compared with other countries.

• Toimprovetheuseofmaternalandchildhealthservices,theLaoPDRmustprovidebetterphysicalaccess to the services and lower the financial barriers to access.



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In the LECS4, the proportion of those reporting illness increaseswith income, both among adults and children (Figure 2).Illness reporting is more likely for individuals (11.5%) andchildren (13.3%) in the richest quintile than for those in thepoorest quintile (9.8% and 10.3%, respectively). No similar variations in reporting are seen with increasing education,suggesting that financial barriers have a greater influence onthe ability to recognize illness.

% r

e p o r t i n g

a n y s i c k n e s s i n p a s t 3 0 d a y s

Figure 1: Illness Reporting in the Lao People’s DemocraticRepublic and Other Asian Countries, Recent Years


schemes to protect patients from these charges, the schemes havehad limited coverage so far. Officially mandated fee exemptionsfor the poor have been implemented only partially, benefiting lessthan 10% of patients (Thome and Pholsena 2009). The heavyreliance on out-of-pocket expenditure is likely to be a significantbarrier to access to essential maternal and child healthcareservices in the Lao PDR.

Data Source

This policy brief presents findings from analysis of the LaoExpenditure and Consumption Survey 2007–2008 (LECS4)(Lao Statistics Bureau 2008). This national survey of 8,296households (48,021 individuals) collects data on householdconsumption and living standards, and includes a module onhealthcare use and spending. Using the detailed householdconsumption section of the survey, this policy brief groupsthe population into equal quintiles of consumption per adultequivalent, as a measure of relative living standards and

socioeconomic grouping.

The health module can be used to examine inequalities inaccess to care by mothers and children (defined here as lessthan 5 years of age), and some aspects of spending. Butthe small size of the survey sample, as well as the lack of questions about the pregnancy status of women, means thatonly spending and use patterns in the case of sick children canbe assessed. Further, the expenditure question in the healthmodule was not well designed. It asks only about expendituresresulting from inpatient treatment, and not about those fromoutpatient treatment.

Perception of Illness and Treatment Seeking

Ill individuals must first realize they are sick before they look for healthcare. LECS4 asked whether individuals had been sickin the previous four weeks. In total, 10.1% of all individualsand 10.9% of children below 5 years were reported to havebeen sick.

However, the self-reporting of illness in a survey is anunreliable indicator of the real level or distribution of illnesswithin the population, as it depends critically on the abilityof individuals to recognize and respond to the symptoms of illness. This is apparent when a comparison is made of thelevels of reported illness in the past 30 days in the Lao PDRand other Asian countries with comparable or better healthstatus (Figure 1).

Self-reported illness is also an unreliable measure of differencesin health status within a population. The people of the Lao PDRare less likely than those in most other countries in the regionto report illness, especially when it comes to illness in children.This suggests that the failure to recognize illness is an importantfactor behind the low use of healthcare services in the Lao PDR.

% r

e p o r t i n g a n y s i c k n e s s i n p a s t 3 0 d a y s

Pakis tan Lao PDR Cambodia PNG Bangladesh Timor-Leste

0

5

10

15

20

25

30

35

40

45

All Children

Lao PDR = Lao People’s Democratic Republic, PNG = Papua New Guinea,PRC = People’s Republic of ChinaSources: Authors’ analysis of LECS4 data set and analyses of Asian Development Banktechnical assistance project.

Q = quintileLao PDR = Lao People’s Democratic Republic

Source: Authors’ analysis of LECS4 data set.

0

2

4

6

8

10

12

14

All Children

Poorest RichestQ2 Q3 Q4

Figure 2: Illness Reporting in the Lao People’s DemocraticRepublic, by Socioeconomic Status, 2007−2008

Quintile



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This gradient in reported illness is not consistent withother evidence indicating that ill health among childrenis higher in rural areas, in cases where mothers have lesseducation, and in the central part of the Lao PDR (StatePlanning Committee and National Statistical Center 2000). A reduced responsiveness to illness could be one reason for the inadequate use of healthcare by poorer families.

Being sick does not automatically lead to seeking medicaltreatment. In many countries the poor when sick are less likelyto obtain treatment than the rich. Medical treatment is defined

here as consisting of visits to government or private medicalproviders, but excluding the self-purchase of medicines frompharmacies, revolving drug funds, etc. This definition is similar to the definition used in comparable surveys in other countriesin the region. The overall rate of use of medical care by thosereporting sick in the Lao PDR (20.5% overall, and 16.8% inchildren) is quite low compared with the rate of use in other countries, where typically 60%–90% of those who are reportedas sick obtain medical treatment (Figure 3).

There are also inequalities in the use of medical care duringperiods of illness. The poor in the Lao PDR are less likely tobe taken for treatment when sick than the nonpoor (12.8% of sick children in the poorest quintile versus 21.5% in the richestquintile). People in the rural areas are also significantly lesslikely to be taken for treatment (19.1% of all sick individualsand 15.4% of sick children) than those living in urban areas(24.0% of all sick individuals and 20.7% of sick children).

Excluding cases where the illness is not considered seriousenough to require treatment (84% overall and 88% in children),the three main reasons why sick persons do not seek treatmentare the difficulty of access to treatment (55%, 51%), the highcost of treatment (21%, 25%), and the poor quality of treatment

Figure 3: Use of Healthcare Services in the Lao People’sDemocratic Republic and Other Asian Countries, Recent Years

Lao PDR = Lao People’s Democratic Republic

Sources: Authors’ analysis of LECS4 data set and analyses of AsianDevelopment Bank technical assistance project. R e

a s o n s f o r n o t t a k i n g t r e a t m e n t ( % )

0

10

20

30

40

50

60

70

80

90

100

Poorest Richest Urban Rural Ruralwithoutroads

Q2

Quintile Sector

Q3 Q4

No cure possible

Too expensive

Not good quality

Difficult to get to

14

3

25

58

46

27

23

4

20

6

19

55 55 58

40

57

18

20

5

14

1027

10

5 3621

19

5

57

20

20

3

Figure 4: Barriers to Treatment of Illness in the

Lao People’s Democratic Republic, 2007−2008



PakistanLao PDR Cambodia BangladeshTimor-Leste

All Children

% o

f i n d i v i d u a l s s i c k i n p

a s t 3 0 d a y s

o b t a i n i n g m e d i c a l t r e a t m e n t s

0

10

20

30

40

50

60

70

80

90

100

(5%, 4%). Overall distance to facilities and high costs are moreimportant to the poor and those living in rural areas, especiallyrural areas without roads, than to the nonpoor and those livingin urban areas (Figure 4). The survey responses do not varymuch with other characteristics such as education.

Lack of physical access to treatment emerges as the major factor behind inadequate and unequal use of healthcare whenmothers and children are sick in the Lao PDR. Cost of care isanother consideration. A reinforcing factor is low responsivenessto illness in the population as a whole.

Use of Health Services The combination of reduced awareness of illness and reducedlikelihood of seeking treatment among the poor results in alarge inequality in overall rates of use of medical treatment.Sick children and adults in the richest quintile use outpatientmedical care more than thrice (3.2 times) as much as thosein the poorest quintile.

Use of health services also varies by age: it is higher amongyoung children than among young adults, and increasesamong older adults (Figure 5). In 2007–2008, infantsaccounted for 3.4% of all reported outpatient medicaltreatment, and children (<5 years), for 12.5%. The useof maternal health services could not be estimated, asthe LECS4 did not ask respondents to give the reasons for visiting a medical provider.



5

I n p a t i e n t a d m i s s i o n s p e r c a p i t a p e r y e a r

0.025

0.020

0.015

0.010

0.005

0.000

Quintile Sector

Poorest Richest Urban RuralQ2 Q3 Q4

All Children

Figure 5: Use of Outpatient Medical Treatment in the LaoPeople’s Democratic Republic, by Age Group, 2007−2008

Figure 6: Outpatient Medical Care for Children in theLao People’s Democratic Republic, 2007−2008

Figure 7: Use of Inpatient Medical Care in the Lao People’sDemocratic Republic, by Socioeconomic Status and Sector,2007–2008

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

0

2.3

1.6

1.1

0.7

1.6

3.43.3

1–4 5–9 10–17 18–44 45–64 65+

% o

f i n d i v i d u a l s s i c k a n

d s e e k i n g

t r e a t m e n t i n t h e p a s t 3 0 d a y s

Age group (years)



When individuals seek outpatient medical care, they do somostly from public providers. Public hospitals and health centersaccount for 54% of all outpatient visits, and for 50% of childvisits (Figure 6). However, use patterns differ more significantlybetween urban and rural residents, than between incomegroups. Rural residents use public health centers more thanurban residents, while urban residents make more use of centralhospitals, suggesting that physical access and transport barriersare the major determinants of use. Private clinics, doctors, andnurses account for 34% of all outpatient care use (37% amongchildren), and a higher share of such use among the nonpoor.

Other

Private doctors, nurses, clinics

Other public hospitals

Traditional

Public health centers

Central hospitals

% o

f c h i l d r e n s e e k i n g c a r e b y p r o v i d e r

0

10

20

30

40

50

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Urban RuralPoorest

Quintile Sector

Q2 Q3 Q4 Richest

21

10

35

15

2

7

55

2

61

39

43

35

5

6027

9

6

13

32

10

40 34

3

41

6

8

38

22

22

3

15

41

5

28





However, medical providers are not the main source of healthcarein the Lao PDR. Healthcare visits are made primarily to purchasemedicines, and most involve self-medication. Other studiesreveal that private pharmacies and revolving drug funds are theprincipal sources of such medicines (Svhakhang et al. 2008).The self purchase of medicines occurs 1.6 times more often thanthe use of any medical provider. In any given month, 6.7% of individuals (6.6% of children) purchase medicines, and 64.9% of these purchases (61.9% among children) involve self medication.Rates vary little by income level, but are highest (71.5%) in ruralvillages without access to roads (59.9% in urban areas, 63.3% inrural with roads).

Inpatient service use in the Lao PDR, about 2% a year, is one of the lowest in Asia (WHO 2011; OECD 2010). It is also highlyunequal, with the richest quintile more than twice as likely asthe poorest, and urban residents 1.3 times more likely thanrural residents, to use such care. Inequalities in the case of children are similar (Figure 7).

Cost of Hospital Admission

The LECS4 design severely limits the analysis of costs of healthcare visits, as only costs associated with inpatientadmissions, and not those incurred in outpatient visits or thepurchase of medicines, are elicited. With hospital admissions,respondents are asked to provide the combined costs involvedin each hospital stay, as well as the costs of transport to thehospital.

Almost all inpatient visits (99.6% overall, and 100% where childrenare concerned) incur treatment costs, and most visits (87.9%overall, and 77.7% for children) also entail travel costs. Treatment




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0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0

Out-of-pocket spending as a % of total household expenditure

India Viet Nam

BangladeshCambodia

PRC Australia

NepalKyrgyz Republic

Sri LankaPhilippinesIndonesiaLao PDRThailandMalaysiaMaldives

FijiTimor-Leste

O

u t - o f - p o c k e t h e a l t h s p e n d i n g p e r c a p i t a p e r

y e a r ( K N ‘ 0

0 0 )

300

250

200

150

100

50

0Poorest Richest Urban RuralQ2 Q3 Q4

Quintile Sector

922

38

66

275

121

66

Figure 10: Out-of-Pocket Medical Spending in the Lao People’sDemocratic Republic, by Socioeconomic Status and Sector,2007–2008

Figure 9: Share of Out-of-Pocket Medical Spending inHousehold Budgets in Regional Countries, Recent Years

costs for each hospital admission average KN1,199,332(KN671,037 for children) and travel costs KN200,214 (KN105,981 for children).1 These costs vary considerably by typeof provider: admissions are most expensive at central hospitalsand at treatment facilities abroad. The costs for children aresimilar, although somewhat lower (Figure 8). Admission costsare generally higher at public hospitals than at private clinics,although the data do not permit accounting for differences incase mix and treatment. The average cost of an admission for a child, including transport, at a public hospital (KN600,604) ismore than the household’s total weekly consumption for 87.5%of the people of the Lao PDR. Overall travel costs are relativelysmall, suggesting that most of the people avail themselves of medical care only if it is easily accessible.

Figure 8: Hospital Admission Costs in the Lao People’s DemocraticRepublic, by Healthcare Provider, 2007–2008

A v e r a g e c o s t a s s o c i a t e d w i t h v i s i t t o

p r o v i d e r ( K N ‘ 0

0 0 )

Treatment Transport

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

0

Hospitalor clinicabroad

Centralhospital

Regionalhospital

Provincialor districthospital

Publichealthcenter

Privatehealthclinic

A l l

A l l

A l l

A l l

A l l

A l l

C

h i l d r e n

C

h i l d r e n

C

h i l d r e n

C

h i l d r e n

C

h i l d r e n

C

h i l d r e n



Q = quintileSource: Authors’ analysis of LECS4 data set.

Lao PDR = Lao People’s Democratic Republic, PRC = People’s Republic of China

Sources: Authors’ analysis of LECS4 data set, analyses of Asian Development Bank technicalassistance project, van Doorslaer et al. 2007 and forthcoming estimates by Equitap researchnetwork for Fiji and Maldives.

Average costs of admission are higher for the nonpoor than for the poor, but are only 28% more for the richest than the poorestquintile. As incomes vary much more between them, these costsare a greater burden for the poor than the nonpoor, consistentwith the finding that the poor are more likely to report cost asa factor behind their nonuse of medical treatment. This indicatesthat government spending on hospitals and other social protectionschemes has been ineffective or insufficient to make inpatienttreatment more affordable to the poor, mothers and children.

Out-of-Pocket Spending on Healthcare

The LECS4 health module cannot be used to analyze thedistribution of healthcare spending, as it asks only about inpatientcosts. To analyze the levels of household health expenditures, thehousehold expenditure section of the survey, which asks about all

household spending, is used. Unfortunately, because expendituresare not disaggregated by household member, healthcarespending by specific individual characteristics or for mothers andchildren cannot be analyzed. According to LECS4, annual out-of-pocketspendingonmedicalcarein2007−2008amountedtoKN81,953 per capita, equivalent to a low (by regional standards)1.7% of total household expenditures (Figure 9).

However, there are large disparities between income groups inspending. Overall, the richest quintile spends 31 times more per capita than the poorest quintile (Figure 10). Spending also increaseswith income as a share of total household budgets and as a shareof nonfood spending (Figure 11). Overall spending on healthcare

1 Exchange rate at the end of 2007: $1 = KN9,632.



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Figure 14: Incidence of Catastrophic Out-of-Pocket MedicalSpending in Regional Countries, Recent Years

% of population spending more than 10% of householdbudget on health

0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0

Cambodia Viet Nam

PRCIndia

PakistanNepal

Kyrgyz RepublicPhilippinesIndonesia

BangladeshLao PDRThailand

Sri LankaMalaysiaMaldives

FijiPNG

Timor-Leste

Poorest

Q2

Q3

Q4

Richest

6%

9%

16%

67%

2%

Figure 12: Out-of-Pocket Health Spending in the Lao People’sDemocratic Republic, by Socioeconomic Status, 2007–2008

Q = quintileSource: Authors’ analysis of LECS4 data set.

is so concentrated in nonpoor households that the poorest quintileaccounts for only 2% of such medical expenditure, reflecting lower incomes and ability to pay. In contrast, the richest quintile accountsfor two thirds of overall healthcare spending (Figure 12).

HHE = household expenditure, Q = quintileSource: Authors’ analysis of LECS4 data set.

Figure 11: Share of Out-of-Pocket Medical Spendingin Household Budgets and Nonfood Expenditure bySocioeconomic Status in the Lao PDR, 2007–2008

O u t - o f - p o c k e t h e a l t h s p e n d i n g a s a % o

f t o t a l H H E

a n d a % o

f n o n f o o d e x p e n d i t u r e

7

6

5

4

3

2

1

0Poorest RichestQ2 Q3 Q4

OOP expenditure as % of total household expenditure

OOP as % of household nonfood expenditure

Quintile

Financial Impact of Out-of-PocketSpending on HealthcareOut-of-pocket financing of healthcare can cause considerablefinancial hardship to families. This impact can be assessed in twoways: by the number of households pushed below the poverty lineby such spending (impoverishing impact), and by the number of households that must devote a large share of their resources tomedical treatment (catastrophic impact). Studies show that heavyreliance on out-of-pocket spending in health systems usuallyresults in medical impoverishment and catastrophic spending (vanDoorslaer et al 2006; van Doorslaer et al. 2007). The LECS4reveals levels of impoverishing and catastrophic expenditures thatare much lower than those in other countries in the region suchas Bangladesh, the People’s Republic of China, and Viet Nam. In

anygivenmonthin2007−08,0.5%ofpeopleintheLaoPDRwere pushed below the $1 international poverty line2 as a resultof household medical spending (Figure 13).

The frequency of catastrophic health expenditures is also relativelylow, whichever definition is used (Figure 14). In any given month in2007–2008, 3.8% of the people of the Lao PDR had to allocatemore than 10% of their total household budget, and 3.6% had toallocate more than 40% of their monthly nonfood expenditures,to medical treatment costs. The relatively low financial impact

Figure 13: Incidence of Impoverishment Resulting fromOut-of-Pocket Medical Spending by Households inRegional Countries, Recent Years

0.0 1.0 2.0 3.0 4.0 5.0

% of population falling below the international povery line of $1.08 (1993 PPP) per day

PakistanIndia

BangladeshPRC

Nepal Viet NamIndonesiaMaldives

PhilippinesLao PDRSri Lanka

PNGThailand

Timor-LesteMalaysia

Kyrgyz RepublicFiji

Lao PDR = Lao People’s Democratic Republic, PNG = Papua New Guinea,PRC = People’s Republic of China

Sources: Authors’ analysis of LECS4 data set, analyses of Asian Development Bank technical

assistance project, and forthcoming estimates by Equitap research network.

Lao PDR = Lao People’s Democratic Republic, PNG = Papua New Guinea,PRC = People’s Republic of China

Sources: Authors’ analysis of LECS4 data set, analyses of Asian Development Bank technicalassistance project, and forthcoming estimates by Equitap research network.

2 Equivalent to a consumption level of $1.08 (1993 PPP) per day, or KN3,973per day, in 2007.




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ConclusionsThis analysis of the Lao Expenditure and Consumption Survey2007−2008revealssignificantinequalitiesintheuseof,andaccessto,basic healthcare services, with travel and cost being the most significantbarriers. Overall, out-of- pocket spending on healthcare is low, and sodoes not lead to a high incidence of financial impoverishment. This isnot a positive finding, however, as the low spending is associated withvery low use of healthcare services in the Lao PDR.

The high costs of obtaining medical treatment discourage poor families from taking their sick children for medical care. Despitegovernment programs, visits to public healthcare facilitiestypically cost as much as or more than visits to private clinics.To improve access to maternal and child health services andthe outcomes of such services, the Lao PDR should focus onexpanding the service delivery network in rural areas to givemore families ready access to healthcare facilities, and onreducing the costs of obtaining treatment at public facilities.

ReferencesDepartment of Statistics, Lao People’s Democratic Republic (The Lao PDR), and

United Nations Children’s Fund (UNICEF). 2000. Multiple Indicator Cluster Survey 2000: Preliminary Report. Vientiane: National Statistical Center.

———. 2008. Lao PDR Multiple Indicator Cluster Survey 2006: Final Report. Vientiane, Lao PDR: Department of Statistics and UNICEF.

Lao Statistics Bureau, Ministry of Planning and Investment. 2008. LaoExpenditure and Consumption Survey 2007−2008. Vientiane.

Organisation for Economic Co-operation and Development (OECD).2010. Health at a Glance: Asia/Pacific 2010. Paris.

State Planning Committee and National Statistical Center, Lao People’sDemocratic Republic (Lao PDR). 2000. Lao National Health Survey. Vien-tiane, Lao PDR: State Planning Committee and National Statistical Center.

Svhakhang L., S. Sengaloundeth, S. Freudenthal, and R. Walhstrom. 2008. Availability of Essential Drugs and Sustainability of Village Revolving Drug Fundsin Remote Areas of Lao PDR. In Health and Social Protection: Experiences fromCambodia, [People's Republic of] China and Lao PDR, edited by B. Meessen,

X. Pei, B. Criel, and G. Bloom. 23 ed. Antwerp: ITG Press, pp. 519–543.Thome Jean-Marc, and Soulivanh Pholsena. 2009. Lao People’s

Democratic Republic: Health Financing Reform and Challenges inExpanding the Current Social Protection Schemes. In United NationsEconomic and Social Commission for Asia and the Pacific (UNESCAP),Promoting Sustainable Strategies to Improve Access to Health Care inthe Asian and Pacific Region, pp. 71–102.

United Nations Children’s Fund (UNICEF). 2012. The State of theWorld’s Children: Children in an Urban World. New York City.

van Doorslaer, E. et al. 2006. Effect of Payments for Health Care on PovertyEstimates in 11 Countries in Asia: An Analysis of Household Survey Data.Lancet. 368 (9544). pp. 1357–1364.

van Doorslaer, E. et al. 2007. Catastrophic Payments for Health Care in Asia.Health Economics. 16 (11). pp. 1159–1184.

World Health Organization (WHO). 2011. Country Cooperation Strategyfor the Lao People’s Democratic Republic 2012–2015. Geneva.

———. 2012. Estimates for NHA Data. http://apps.who.int/nha/data-base/ DataExplorerRegime.aspx.

World Health Organization (WHO) et al. 2010. Trends in Maternal Mortality:1990 to 2008. Geneva: WHO, UNICEF, UNFPA, and World Bank.

Suggested citation Anuranga, C., J. Chandrasi ri, R. Wickramasinghe, and R.P. Rannan-Eliya. 2012. The Impact of Out-of-Pocket Expenditures on Familiesand Barriers to Use of Maternal and Child Health Services in the LaoPeople’s Democratic Republic: Evidence from the Lao Expenditure and

Consumption Survey 2007–2008 RETA–6515 Country Brief. Manila: Asian Development Bank.

of healthcare in the Lao PDR does not imply that the healthcaresystem provides good protection against financial risk. Given thelow overall rates of use of medical care in the Lao PDR, this lowlevel of impoverishing expenditures is due more to nonuse of services, the inability of households to pay, and the lack of effectiveaccess to non-free alternatives, especially in the rural areas.

© Asian Development Bank. Publication Stock No. ARM125146-3 December 2012

ADB RETA 6515 Country Brief SeriesPoor maternal, neonatal, and child health adversely affects women, families, and economies across the Asia and Pacific region. This burden of illnessmust be reduced if the Millennium Development Goals (particularly 4 [reduce child mortality] and 5 [improve maternal health]) are to be achievedand improvements made in the health and economic well-being of households and nations. Progress in this regard will require an increased supplyof effective healthcare services, as well as demand for such services. This series of country briefs provides evidence from national household surveyson the financial burdens imposed on the poor by private expenditures on public and private healthcare services. Countries can use this informationin building awareness within health systems and policy bodies of financial constraints on healthcare, and in designing demand-side interventions toincrease the use of maternal, neonatal, and child health services. Summaries of the analysis of household data from Bangladesh, Cambodia, the LaoPeople’s Democratic Republic, Pakistan, Papua New Guinea, and Timor-Leste, and a summary overview, are included in the series.

This country brief was prepared by the Institute for Health Policy in Sri Lanka under an Asian Development Bank (ADB) technical assistanceproject, Impact of Maternal and Child Health Private Expenditure on Poverty and Inequity (TA–6515 REG). The Institute for Health Policy andauthors gratefully acknowledge the funding made possible by ADB that was financed principally by the Government of Australia.

Australia is taking a leading role in global and regional action to address maternal and child health. A key part of this is to strengthen theevidence for increased financial support and the most effective investments that governments and donors can make to meet MillenniumDevelopment Goals 4 and 5. Australia supported this technical assistance project as a part of this commitment.

About the Asian Development Bank ADB’s vision is an Asia and Pacific region free of poverty. Its mission is to help its developing member countries reduce poverty and improvethe quality of life of their people. Despite the region’s many successes, it remains home to two-thirds of the world’s poor: 1.7 billion peoplewho live on less than $2 a day, with 828 million struggling on less than $1.25 a day. ADB is committed to reducing poverty through inclusiveeconomic growth, environmentally sustainable growth, and regional integration.

Based in Manila, ADB is owned by 67 members, including 48 from the region. Its main instruments for helping its developing member countries are policy dialogue, loans, equity investments, guarantees, grants, and technical assistance.

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impact of out-of-pocket expenditures on families and barriers to use of maternal and child health...

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