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GAVI HSS Application Form 2007
Application Form for: Lao PDR
GAVI Alliance Health System Strengthening (HSS) Applications
September 2008
An electronic version of this document is available on the GAVI Alliance website (www.gavialliance.org) and
provided on CD. Email submissions are highly recommended, including scanned documents containing the
required signatures. Please send the completed application to:
Dr Craig Burgess
Senior Programme Officer, HSS
GAVI Alliance Secretariat
c/o UNICEF, Palais des Nations
1211 Geneva 10, Switzerland
Email: cburgess@gavialliance.org
Please ensure that the application has been received by the GAVI Secretariat on or before the day of the
deadline. Proposals received after that date will not be taken into consideration for that review round. GAVI
will not be responsible for delays or non-delivery of proposals by courier services.
All documents and attachments should be in English or French. All required information should be included
in this application form. No separate proposal documents will be accepted by the GAVI Secretariat. The
GAVI Secretariat is unable to return submitted documents and attachments to countries. Unless otherwise
specified, documents may be shared with the GAVI Alliance partners, collaborators and the general public.
Please direct all enquiries to:
Dr Craig Burgess (cburgess@gavialliance.org) or representatives of a GAVI partner agency.
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GAVI HSS Application Form 2007
Table of Contents
Page
ABBREVIATIONS AND ACRONYMS ......................................................................................................................... 3
EXECUTIVE SUMMARY .............................................................................................................................................. 6
SECTION 1: APPLICATION DEVELOPMENT PROCESS .................................................................................... 10
1.1: THE HSCC (OR COUNTRY EQUIVALENT) ................................................................................................................ 10
1.2: OVERVIEW OF APPLICATION DEVELOPMENT PROCESS ............................................................................................ 12
1.3: ROLES AND RESPONSIBILITIES OF KEY PARTNERS (HSCC MEMBERS AND OTHERS) ................................................ 14
1.4: ADDITIONAL COMMENTS ON THE GAVI HSS APPLICATION DEVELOPMENT PROCESS ............................................ 17
CIVIL SOCIETY AND PRIVATE SECTOR CONSULTATIONS........................................................................... 17
SECTION 2: COUNTRY BACKGROUND INFORMATION .................................................................................. 18
2.1: CURRENT SOCIO-DEMOGRAPHIC AND ECONOMIC COUNTRY INFORMATION ............................................................ 18
2.2: OVERVIEW OF THE NATIONAL HEALTH SECTOR STRATEGIC PLAN ........................................................................ 24
SECTION 3: SITUATION ANALYSIS / NEEDS ASSESSMENT ............................................................................ 34
3.1: RECENT HEALTH SYSTEM ASSESSMENTS ................................................................................................................ 34
3.2: MAJOR BARRIERS TO IMPROVING IMMUNISATION COVERAGE IDENTIFIED IN RECENT ASSESSMENTS ...................... 36
3.3: BARRIERS THAT ARE BEING “ADEQUATELY” ADDRESSED WITH EXISTING RESOURCES ........................................... 43
3.4: BARRIERS NOT BEING ADEQUATELY ADDRESSED THAT REQUIRE ADDITIONAL SUPPORT FROM GAVI HSS............ 49
SECTION 4: GOALS AND OBJECTIVES OF GAVI HSS SUPPORT ................................................................... 53
4.1: GOALS OF GAVI HSS SUPPORT ............................................................................................................................. 53
4.2: OBJECTIVES OF GAVI HSS SUPPORT ..................................................................................................................... 53
SECTION 5: GAVI HSS ACTIVITIES AND IMPLEMENTATION SCHEDULE ................................................ 53
SECTION 5: GAVI HSS ACTIVITIES AND IMPLEMENTATION SCHEDULE ................................................ 59
5.1: SUSTAINABILITY OF GAVI HSS SUPPORT .............................................................................................................. 59
5.2: MAJOR ACTIVITIES AND IMPLEMENTATION SCHEDULE.......................................................................................... 62
SECTION 6: MONITORING, EVALUATION AND OPERATIONAL RESEARCH ........................................... 63
6.1: IMPACT AND OUTCOME INDICATORS...................................................................................................................... 65
6.2: OUTPUT INDICATORS ............................................................................................................................................. 66
6.4: STRENGTHENING M&E SYSTEM ............................................................................................................................. 70
6.5: OPERATIONAL RESEARCH ...................................................................................................................................... 70
SECTION 7: IMPLEMENTATION ARRANGEMENTS .......................................................................................... 71
7.1: MANAGEMENT OF GAVI HSS SUPPORT ................................................................................................................. 71
7.2: ROLES AND RESPONSIBILITIES OF KEY PARTNERS (HSCC MEMBERS AND OTHERS) ................................................ 72
7.3: FINANCIAL MANAGEMENT OF GAVI HSS SUPPORT ............................................................................................... 73
7.4: PROCUREMENT MECHANISMS ................................................................................................................................. 74
7.5: REPORTING ARRANGEMENTS.................................................................................................................................. 74
7.6: TECHNICAL ASSISTANCE REQUIREMENTS ............................................................................................................... 76
SECTION 8: COSTS AND FUNDING FOR GAVI HSS ............................................................................................ 77
8.1: COST OF IMPLEMENTING GAVI HSS ACTIVITIES ................................................................................................... 77
8.2: CALCULATION OF GAVI HSS COUNTRY ALLOCATION ........................................................................................... 77
8.3: SOURCES OF ALL EXPECTED FUNDING FOR HEALTH SYSTEMS STRENGTHENING ACTIVITIES ................................... 78
SECTION 9: ENDORSEMENT OF THE APPLICATION ....................................................................................... 79
9.1: GOVERNMENT ENDORSEMENT................................................................................................................................ 79
9.2: ENDORSEMENT BY HEALTH SECTOR COORDINATION COMMITTEE (HSCC) OR COUNTRY EQUIVALENT ................ 79
ANNEX 1 DOCUMENTS SUBMITTED IN SUPPORT OF THE GAVI HSS APPLICATION ............................ 80
ANNEX 2 BANKING FORM ........................................................................................................................................ 82
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GAVI HSS Application Form 2007
Abbreviations and Acronyms
To the applicant
Please ensure that all abbreviations and acronyms presented in the application and supporting
documents are included here.
ADB Asian Development Bank
AFD French Development Agency
ASEAN Association of South East Asian Nations
BCG Bacille Calmette Guerin
BTC Belgium Technical Corporation
CBHI Community Based Health Insurance
cMYP comprehensive Multi Year Plan
CPI Committee of Planning and Investment
(Now Ministry of Planning and Investment)
CSS Civil Service Scheme
CU Coordination Unit
DHO District Health Office
DOP Department of Personnel and Organisation
DOTS Direct Observed Treatments
DP Development Partner
DPB Department of Planning and Budgeting
DDG Deputy Director General
DRF Drug Revolving Fund
DTP Diphtheria, Tetanus, Pertussis
EPI Expanded program for Immunization
FP Family Planning
GAVI Global Alliance for Vaccines and Immunization
GNI Gross National Income
GOL Government of Laos
HC Health Centre
HEF Health Equity Funds
Hep Hepatitis
Hib Human Influenza B
HIV/Aids Human Immunodeficiency Virus/ Acquired Immune Deficiency Virus
HMIS Health Management Information System
HRD Human Resource Development
HRH Human Resources for Health
HSCC Health Sector Coordinating Committee
HSDP Health Sector Development Project
HSIP Health Sector Improvement Project
HSS Health System Strengthening
IEC Information, Education and Communication
IBN Bed Net Impregnation
IDA International Donor Assistance
ILO International Labor Organization
IMCI Integrated Management of Sick Children
ITN Impregnated Treated Bed Net
JICA Japan International Cooperation Agency
LAO/010 Nurse In Training Project
LAO/015 Health In Vientiane Project
LAO/017 Lao- Luxembourg Health Initiatives Support Programme
Lao PDR Lao People‘s Democratic Republic
LPRP Lao People‘s Revolutionary Party
Lux- Development Luxembourg Development
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GAVI HSS Application Form 2007
M&E Monitoring and Evaluation
MCH Maternal and Child Health
MDGs Millennium Development Goals
MICS Multiple Indicator Cluster Survey
MLM Mid level Management
MMR Maternal Mortality Rate
MNCH Maternal, Newborn and Child Care
MNT Maternal Neonatal Tetanus
MoF Ministry of Finance
MOH Ministry of Health
MOLSW Ministry of Labour and Social Welfare
MPPHC minimum package of primary health care
MR Minimum Requirements
MSc Master of Sciences
MTEF Medium Term Expenditure Framework
NA National Assembly
NGOs Non Government Organizations
NGPES National Growth and Poverty Eradication Strategy
NIP National Immunization Program
NSEDP National Socio- Economic Development Plan
(O) Operational
OTJ On the job training
(P) Policy
PACSA Public Administration and Civil Service Authority
PHC Primary Health Care
PhD Doctor of Philosophy
PHO Provincial Health Office
PMTCT Prevention of Mother to Child Transmission
PMUs Project Management Unit
PRSO Poverty Reduction Support Operation
PRSP Poverty Reduction Strategy Paper
Q Quarter
RDF Revolving Drug Fund
SARS Severe Acute Respiratory Syndrome
SCA Save the Children Australia
SSO Social Security Office
STD Sexually Transmitted Disease
SWAp Sector Wide Approach (for funding)
SWC Sector Wide Coordination Mechanism for Health
SWG Sector Working Group
TB Tuberculosis
ToR Terms of Reference
TT+2 Two doses of Tetanus Vaccination
TWG Technical Working Group
UN United Nations
UNDAF UN Development Assistance Framework
UNDP United Nations Development Program
UNESCAP United Nations Economic and Social Commission for Asia and the Pacific
UNFPA United Nations Population Fund
UNICEF United Nations Children's Fund
VHV Village Health Volunteer
VHW Volunteer Health Worker
VPD Vaccine Preventable Diseases
WHO World Health Organization
WHO Lao PDR World Health Organization Lao PDR Country Office
WHO WPRO World Health Organization Western Pacific Regional Office
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GAVI HSS Application Form 2007
WTO World Trade Organization
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GAVI HSS Application Form 2007
Executive Summary
To the applicant
Please provide a summary of the proposal, including the goal and objectives of the GAVI HSS
application, the main strategies/activities to be undertaken, the expected results, the duration of
support and total amount of funds requested and the baseline figures and targets for the
priority indicators selected.
Please identify who took overall responsibility for preparing the GAVI HSS application, the role
and nature of the HSCC (or equivalent), and the stakeholders participating in developing the
application.
Goal of the GAVI HSS Initiative
The Goal of the GAVI HSS Support Initiative is to contribute to the achievement of MDGs 4 and 5
in Lao PDR by strengthening the capacity of the health sector to deliver an integrated package of
MNCH services (including EPI) at the district, health centre and village level.
Objectives of the GAVI HSS Initiative
The objectives of this GAVI HSS support initiative focus on resolution of issues in the six building
blocks. These include:
Health Services: Vaccine and medical products inventory control; distribution logistics; lack of
facilities or diagnostic support; infection control etc.
Human Resources: lack of or ambiguous protocols or guidelines or job descriptions; lack of
clinical or management skills; lack of motivation; lack of non-financial incentives etc.
Health Information Systems: lack of basic demographic, needs and/or activity data; duplication
and non-standard reporting requirements
Medical Products and Technology: lack of electricity; telephones; transport; lack of imaging or
surgical equipment and associated consumables; lack of pharmaceuticals; etc
Health Financing: lack of financial resources; inability to afford services; perverse incentives; low
salaries; lack of financial incentives or inability to pay for out-of-pocket expenses; escalating cost of
consumables such as petrol etc
Health Governance and Management: lack of or ambiguous or conflicting policies or guidelines;
lack of supervision and guidance; inadequate reporting mechanisms; lack of monitoring and
feedback mechanisms etc.
Objective No. 1. is to facilitate MNCH and EPI development and delivery of services within
and between districts in selected provinces.
This objective will help improve deployment and availability of health and immunization services by
coordinating and linking local resources, minimising undesirable duplication and increasing
cooperation between service providers and donors in the target districts. It will build on and link
with the Minimum Requirements service coordination framework which provides a mechanism to
facilitate the improvement of the quality of acute hospital care at Provincial and District levels.
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GAVI HSS Application Form 2007
Objective No. 2. To enhance MNCH and EPI services problem recognition skills and then to
take action for selected priority issues at the village, health centre and district levels.
This objective will help improve utilization of health services and immunization coverage by
improving community understanding of health care needs, mobilizing communities ability to identify
health care need and facilitating community support for the use of life saving essential MNCH
services in appropriate settings. This objective will achieve two key results: it will mobilise
individuals in the village, health centres and district levels to take some type action when they
observe MNCH/EPI problems instead of waiting for the problem to resolve itself; and it promotes
information sharing and mutual assistance within and between service levels.
Effective delivery of health services at the local level requires the support from all levels of the
health sector, from the village level to the national level. Because resources are limited, the
primary focus of this initiative is from the village level to the district level. However, Provincial and
National mechanisms for monitoring and support supervision as well as response to problems in
MNCH and EPI services will also be considered and, where necessary, strengthened with
additional MOH and Development Partner support responses.
Expected Results
This GAVI HSS Support Initiative will prepare for the roll-out of the integrated package of MNCH by
supporting coordination and integration of MNCH service development and delivery activities and
strengthening MNCH service problem solving capacity within and between districts and between
districts, provinces and national levels. This focus supports the strengthening of health service
delivery in rural areas and complements ongoing efforts of GoL and support of development
partners. The limited scope of the objective makes it achievable given the low skills base and the
limited time-frame and budget.
The GAVI HSS Support Initiative will directly address the second of GAVI‘s HSS priority areas, viz.
organization and management of health services [delivery] at the district level and below. The first
and third of GAVI‘s HSS priority areas are indirectly supported by these activities.
Although immunization is represented only by a single line in the MNCH package, it is a core
component of primary health care and is given high priority in Government policies. And the single
line is separately expanded in the Comprehensive Multi-Year Plan - National Immunization
Program. Activities in the GAVI HSS Support Initiative directly target immunization barriers to
improve coverage at the local level.
Strengthening coordination and enhanced MNCH problem solving capacity supports
implementation of the GOL/MOH model healthy village policy and delivery of PHC. It does this in
a practical, staged approach starting with a basic, well defined set of services that can be
expanded when circumstances allow.
This GAVI HSS Support Initiative will deliver:
6. Coordination of MNCH and EPI service development and delivery activities within and
between districts
7. A tool for measuring skills in recognizing and acting on MNCH and EPI service
problems at village, health centre and district levels;
8. Improved and sustained MNCH and EPI problem recognition and action at village,
health centre and district levels;
9. Improved communication of needs for and barriers to service provision between the
communities and higher levels of the health sector;
10. Improvement in Maternal and Child Health and Immunization outcomes to help
achieve the MDG 4 & 5;
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GAVI HSS Application Form 2007
Duration Of Support and Funds Requested
Lao PDR MOH is seeking 2 years support for the remainder of the 2006-2010 NSEPD and
corresponding Health system plan.
The funds requested is $US 1.08 for 2 years.
2009 2010 Total
$534,649 $547,358 $1,082,007
Baseline Figures And Targets For Priority Indicators
Outcome Indicators Baseline Value Date of Baseline Target Date for Target
1. National DTP3 coverage (%) 81 2006 85 2010
2. Number / % of districts achieving
≥80% DTP3 coverage 63 2006 80 2010
3. Under five mortality rate (per
1000) 98 2005 70 2015
4. Infant (< 1 year) mortality rate (per
1000 live births) 70 2005 45 2015
5. Maternal Mortality Rate (per
100,000 live births) 405 2005 260 2015
Output Indicator Baseline Value Date of Baseline Target Date for Target
District Administration Units with
staff formally engaged on PHC 0 2008 100% 2011
Coordination Activities
Health Centres receiving at least 3
rounds of clinical supervision per 0 2008 50%; 80% 2011; 2015
year from Districts
Villages receiving at least 2 round of
clinical supervision per year from 0 2008 45%; 70% 2011; 2015
Health Centres
Overall Responsibility For Preparation of the GAVI HSS Application
Dr. Prasongsidh BOUPHA, Deputy Director General of the Department of Planning and Budgeting,
MOH. (overall responsibility) with day-to-day activities assigned to Dr. Soulivanh Pholsena,
Planning Medical Officer, Department of Planning & Budgeting.
Role and nature of HSCC
The Sector Wide Coordination Mechanisms for Health (SWC) has political (P), operational (O) and
technical levels.
Policy dialogue in the SWC is facilitated in the Sector Government - Donor Coordination Meeting
on Health, which is called ―Sector Working Group in Policy Level/SWG (P)‖ (Minister of Health,
Representatives of Development Partners, Ambassadors and Representatives and Advisors). The
MOH steering committee includes the Minister and vice-ministers of Health, Directors and Deputy
Directors of the MOH, and it is the decision making body of the sector coordination mechanism.
For inter-sector policy dialogue, the Donor‘s Round Table meeting, including Ambassadors,
representatives and advisors, is held annually (formally or informally).
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GAVI HSS Application Form 2007
At the operational level the ―Sector Working Group for Health/SWG (O)‖ (Vice Minister/ Director of
the Cabinet/ Director Planning and Budget, Deputy Directors of MoH, Representatives of
Development Partners and other stakeholders such as the Ministry of Labour and Social Welfare,
the Ministry of Finance and the Ministry of Planning and Investment and others) is responsible for
strategic implementation and practical coordination towards health system strengthening in Lao
PDR.
Technical Working Groups (TWG) for Health Financing, Human Resources and Programs, which
includes MNCH/EPI conduct research and provide technical advice for sector coordination and
decision making at higher levels. The TWGs have permanent members selected from related
areas. The chair of the TWGs can convene a taskforce (with specialist input or representation) as
required. Within the TWG on MNCH two task forces have been set up (one to define the package
of MNCH interventions, the strategy for its implementation and scaling up and the pilot in 10
districts, a second on issues of training , supervision and monitoring and evaluation, including desk
review of ongoing projects). The two taskforces have been created to develop the SBA
development plan.
The SWC has a Secretariat to facilitate and provide logistics support on a day-to-day basis.
(Chair: Dep. Dir. of Cabinet/ Director Planning and Budget, Members from the MOH Cabinet,
Departments and nominated representatives of external partners and agencies.)
Stakeholders were initially consulted in informal meetings with the team drafting the application
and subsequently in formal SWC committee meetings. Drafts of the application were circulated for
comment to all stakeholders (including the organizations listed above) and reviewed in formal
SWG (O) committee meetings where the listed organizations are formally represented.
This GAVI HSS proposal is part of an extensive and on-going process of Health Sector
Development in Lao PDR in which Government Authorities and Development Partners have
undertaken extensive consultations. For example, The Minister of Health has been promoting the
need for Primary Health Care Capacity building within the Government, within the Health Sector,
with Provincial Governors and at the District level for several years. Further, in Lao PDR, there is
extensive political discussion in National Planning Processes. The 6th National Conference for
Health in November 2007 endorsed the strengthening of Primary Health Care (PHC) at the village
level with strong Civil Society and Private Sector Involvement. In January, 2008 there were
consultations on priority implementation of the Healthy Village Model between the Provincial
Health Offices and the Provincial Governors under the direction of the President of the GOL. The
14 poorest Districts in 5 Provinces in which this GAVI HSS will be implemented were selected
through in this consultative process and with the written agreement of the Provincial Governors
concerned.
This GAVI HSS Initiative supports ongoing consultations. It has been compiled with the support of
the Minister of Health, the Directors General of all MOH Departments and the major international
Development partners, including representatives of NGOs in Lao PDR. (MOH and Development
Partners directly consulted and involved in development of the proposal are listed in other sections
below.) The Private Sector was not formally involved in the development of this proposal. National
plans anticipate that this sector will play an increasing role in the delivery of health care in Laos.
Stakeholders participating
Stakeholders participating include:
World Bank (WB) ; Asian Development Bank (ADB) ; Luxembourg Development (Lux-
Development) ; United Nations Children's Fund (UNICEF) ; United Nations Population Fund
(UNFPA); Japan International Cooperation Agency (JICA) ; World Health Organization Lao PDR
Office (WHO Lao PDR including MCH and EPI sections) ; World Health Organization Western
Pacific Regional Office (WHO WPRO); International NGO Network; MOH Department of Planning
and Finance; Department of Hygiene; Treatment Department; Department of Personnel; MNCH
Centre including EPI.
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GAVI HSS Application Form 2007
Section 1: Application Development Process
To the applicant
In this section, please describe the process for developing the GAVI HSS application.
1. Please begin with a description of your Health Sector Coordinating Committee or equivalent
(Table 1.1).
1.1: The HSCC (or country equivalent)
Name of HSCC (or equivalent):
Sector-Wide Coordination Mechanism for Health (SWC)
HSCC operational since:
Formulation of the SWC commenced in December 2005 with support and funding from the Japan
International Cooperation Agency (JICA). It was further accelerated since August 2006 when the
JICA formalized its support for the SWC with its technical cooperation scheme and strengthened
its partnership with WHO and other UN agencies as well as the World Bank and Asian
Development Bank (ADB). Following such efforts the Coordination Unit (CU) was established in
the MOH, so that both internal and external coordination in sector-wide would be facilitated.
The 1st Health Sector-wide Coordination meeting was held in April 2007, and the concepts of the
SWC mechanism and the integration strategy between MCH and EPI were shared widely among
stakeholders. The first formal meeting of the Maternal Neonatal and Child Health (MNCH)
Technical Working Group (TWG) was held in May, 2007. Since then there have been 6 meetings
of the MNCH TWG, the last on 20th August, 2008. There have been 3 meetings of the SWC with
the last held on 10th September, 2008 .
Organisational structure (e.g., sub-committee, stand-alone):
The SWC has policy (P), operational (O) and technical levels (See Figure 1)
Policy dialogue in the SWC is facilitated in the Sector Government - Donor Coordination Meeting
on Health, which is called ―Sector Working Group in Policy Level/SWG (P)‖ (Minister of Health,
Representatives of Development Partners, Ambassadors and Representatives and Advisors). The
MOH steering committee includes the Minister and vice-ministers of Health, Directors and Deputy
Directors of the MOH, and it is the only decision making body of the sector coordination
mechanism. For inter-sector policy dialogue, the Donor‘s Round Table meeting, including
Ambassadors, representatives and advisors, is held annually (formally or informally).
At the operational level the ―Sector Working Group for Health/SWG (O)‖ (Vice Minister/ Director of
the Cabinet/ Director Planning and Budget, Deputy Directors of MoH, Representatives of
Development Partners and other stakeholders such as the Ministry of Labour and Social Welfare,
the Ministry of Finance and the Ministry of Planning and Investment and others) is responsible for
strategic implementation and practical coordination towards health system strengthening in Lao
PDR.
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GAVI HSS Application Form 2007
Figure 1: Lao Sector-Wide Coordination Mechanism for Health
OTHER
SECTORS HEALTH SECTOR
MOH Steering Committee
> Minister
> Vice Ministers Round Table Meeting
> Directors and Deputy Directors
DECISION-MAKING
POLITICAL - LEVEL
Sector Coordination Mechanism for Health
Political
Sector policy
Consensus building
Sector Working Groups on Health and HIV/AIDS
Chair: MoH dialogue
Co-Chair: WHO and Japan
(Sector) Government - Donor Coordination Meeting on
Health
> Minister of Health
> Representatives of Development Partners
> Ambassadors and Representatives
> Advisors
2 times/year
POLICY DIALOGUE & OVERSIGHT
OPERATIONAL - LEVEL Strategy/
Technical Consultation & Discussion, Recommendation and Advise
Sector Working Group on Health Technical
health systems strengthening
Integration of policies and
>Vice Minister/ Director of the Cabinet/ DPB Secretariat for SWG*
Health policy and
Inter-sectorial
Coordination Unit at MoH health systems
> Deputy Directors of MoH
(multi-sectorial) > Chair: Dep. Dir. of Cabinet/DPB review
technical coordination > Representatives of Development Partners
> Members from the Cabinet, Depts and dialogue
and dialogue > and other stakeholders like MOLSW, MoF, CPI, ...
> Focal Points of TWGs
4 times/year PRACTICAL-COORDINATION Development
Partners
FACILITATION & LOGISTICS
TECHNICAL LEVEL Technical
Financial TWG Specific technical
HRD TWG Program TWG**
>Chair: Deputy Director of DPB >Chair: Deputy Director of DOP >Chair: Deputy Director of related Dpt. dialogue
>Members: MoH & DPs & other technical >Related Depts
>Members: MoH & DPs & other technical
>stakeholders like MoF/Dept of Bud., etc. >Members: MoH & DPs
>stakeholders like PACSA
monthly
Technical
TASK FORCES TASK FORCES TASK FORCES Specific
Ad hoc Activities/Tasks
* Provides secretariat support to all TWGs, ToR and composition still to be developed, including information on general and specific level support.
** Detailed ToR under development
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GAVI HSS Application Form 2007
Technical Working Groups (TWG) for Health Financing, Human Resources and Programs, which
includes MNCH/EPI conduct research and provide technical advice for sector coordination and
decision making at higher levels. The TWGs have permanent members selected from related
areas. The chair of the TWGs can convene a taskforce (with specialist input or representation) as
required. Within the TWG on MNCH two task forces have been set up (one to define the package
of MNCH interventions, the strategy for its implementation and scaling up and the pilot in 10
districts, a second on issues of training , supervision and monitoring and evaluation, including desk
review of ongoing projects). The two taskforces have been created to develop the SBA
development plan.
The SWC has a Secretariat to facilitate and provide logistics support on a day-to-day basis.
(Chair: Dep. Dir. of Cabinet/ Director Planning and Budget, Members from the MOH Cabinet,
Departments and nominated representatives of external partners and agencies.)
Frequency of meetings (Annexes 1.25 & 1.26):1
Sector Working Group for Health (Policy Level) 2 times per year
Sector Working Group for Health (Operational Level) 4 times per year
Technical Working Groups Monthly
SWC Taskforces As required
Secretariat As required
Overall role and function:
The overall goal is to ―free the health care service in Lao PDR from the state of underdevelopment,
ensure full health care service coverage, justice and equity in order to increase the quality of life of
all Lao ethnic groups.‖ (Health Strategy up to the Year 2020)
Within this goal the purpose of the Health Sector Coordination Mechanism (HSCM) is to ―promote
the achievement of the Goal and the Objectives of Five-Year Health Sector Development Plans
under Health Strategy up to the Year 2020 through effective utilization of the Sector Coordination
Mechanism‖ (Terms of Reference, SWG-O)
Members of the SWG and TWG were consulted in the course of this application and endorsed the
application. Members of the SWG and TWG also participated in the development and agree to
support implementation of the strategy and planning framework for the integrated package of
MNCH services 2008-2015 and the skilled birth attendance development plan for Lao PDR on
which this application is based.
To the applicant
2. Next, please describe the process your country followed to develop the GAVI HSS application
(Table 1.2)
1.2: Overview of application development process
Who coordinated and provided oversight to the application development process?
1
Minutes from HSCC meetings related to HSS should be attached as supporting documentation, together with the minutes of the HSCC
meeting when the application was endorsed. The minutes should be signed by the HSCC Chair. The minutes of the meeting endorsing
this GAVI HSS application should be signed by all members of the HSCC.
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GAVI HSS Application Form 2007
Dr. Prasongsidh BOUPHA, Deputy Director General of the Department of Planning and
Budgeting, MOH. (overall responsibility) with day-to-day activities assigned to Dr. Soulivanh
Pholsena, Planning Medical Officer, Department of Planning & Budgeting.
Who led the drafting of the application and was any technical assistance provided?
Dr. Soulivanh Pholsena, Planning Medical Officer, Department of Planning & Budgeting with
technical support provided by Dr Ron van Konkelenberg contracted for the purpose by the World
Health Organization, Lao PDR.
Give a brief time line of activities, meetings and reviews that led to the proposal
submission.
MOH hosts Conference on Skilled Birth Attendance to advise on MCH
strengthening options
Jul-07
MOH hosts High Level National Human Resources for Health Conference to
advise on HRH strengthening policy development
6th National Health Conference Endorses Primary Health Care and Model Healthy
Aug-07
Village Priorities
Draft HRH Strategic Framework documents essential PHC functions and tasks at
Sep-07
Village, Health Centre and District Levels
Nov-07 Minister briefs Development Partners on National Priorities
WHO Commissions second technical support project for GAVI HSS Application;
GAVI HSS Application consultations continued
Dec-07
Minister formally assigns responsibility for drafting the GAVI HSS Application to
SWC Secretariat and appoints a working party members to draft the Application
President of Lao PDR initiates consultations between Provincial Health Offices and
the Provincial Governors and determines priority districts in which to implement
Jan-08
Healthy Village Model.
Policy and Planning Documents and Situation Reports collated and analysed;
Mar-08 SBA Assessment Completed
Jun-08 MOH requests support for resubmission of GAVI HSS proposal
Strategy and Planning Framework for the Integrated Package of MNCH Services
Jul-08 2008-2015 based on extensive consultation with stakeholders circulated
Development Partners to initiate Pilot of MNCH Package
SBA Development Plan Completed based on extensive consultations with
stakeholders
Aug-08 Consultations focuses GAVI HSS resubmissions on agreed MNCH/EPI package
Drafting Committee commences drafting of GAVI HSS resubmission
TWG MNCH/EPI meets to review first draft of resubmission
Second draft of GAVI HSS Application Completed
Steering Committee endorses second draft and approves submission to GAVI
Meeting of SWC (O) endorse second draft subject to meeting comments included
Sep-08 in draft;
Minister of Health Signs GAVI HSS Application
MOH obtains endorsement and signatures from Finance Department (after
submission to GAVI)
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GAVI HSS Application Form 2007
Who was involved in reviewing the application, and what was the process that was
adopted?
World Bank (WB) ; Asian Development Bank (ADB) ; Luxembourg Development (Lux-
Development) ; United Nations Children's Fund (UNICEF) ; United Nations Population Fund
(UNFPA); Japan International Cooperation Agency (JICA) ; World Health Organization Lao PDR
Office (WHO Lao PDR including MCH and EPI sections) ; World Health Organization Western
Pacific Regional Office (WHO WPRO); International NGO Network; MOH Department of Planning
and Finance; Department of Hygiene; Treatment Department; Department of Personnel; MNCH
Centre including EPI.
These Organizations were initially consulted in informal meetings with the team drafting the
application and subsequently in formal SWC committee meetings.
Drafts of the application were circulated for comment to stakeholders (including the organizations
listed above) and reviewed in a formal SWG (O) committee meeting where the listed
organizations are formally represented. Organisations not able to attend the formal endorsement
meeting participated in earlier discussions.
Who approved and endorsed the application before submission to the GAVI Secretariat?
Minister of Health; MOH Drafting Committee; MOH Steering Committee; SWG (O)
Governors of the provinces in which the health system strengthening activities will be
implemented have endorsed this proposal.
To the applicant
3. Please describe overleaf the roles and responsibilities of key partners in the development of
the GAVI HSS application (Table 1.3).
Note: Please ensure that all key partners are included; the Ministry of Health; Ministry of Finance;
Immunisation Program; bilateral and multilateral partners; relevant coordinating committees; NGOs
and civil society; and private sector contributors. If there has been no involvement of civil society or
the private sector in the development of the GAVI HSS application, please explain this below (1.4).
1.3: Roles and responsibilities of key partners (HSCC members and others)
Title / Post Organisation HSCC Roles and responsibilities of this partner in
member the GAVI HSS application development
yes/no
Dr. Prasongsidh MOH Yes Chair of GAVI HSS application development
BOUPHA committee delegated overall responsibility for
DDG of Planning & preparation of the draft.
Budgeting Dept.
Dr. Bounfeng MOH Yes Director of MOH Cabinet and Vice Chair of
PHOUMMALASITH GAVI HSS application development
DDG of Cabinet committee supporting development of the
proposal
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GAVI HSS Application Form 2007
Dr. Somchit MOH Yes Vice Chair of GAVI HSS application
ACKHAVONG development committee reviewing
DDG of Hygiene & development of the proposal
Prevention Dept. Participated in TWG MNCH/EPI SBA plan
and MNCH Package Development
Dr. Phouthone MOH Yes The Committee member reviewing
VANGKONEVILAY development of the proposal Participated in
DDG of Personnel TWG MNCH/EPI SBA plan and MNCH
Dept Package Development
Dr. Savengvong MOH Yes The Committee member reviewing orting
DOUANGSAVANH development of the proposal Participated in
DDG of Food & TWG MNCH/EPI SBA plan and MNCH
Drug Dept Package Development
Assoc. Prof. Dr. MOH Yes The Committee member reviewing
Chanphomma development of the proposal Participated in
VONGSAMPHANH TWG MNCH/EPI SBA plan and MNCH
DDG of Curative Package Development
Dept.
Dr. Soulivanh MOH Yes Secretariat member; assigned responsibility
PHOLSENA for drafting the proposal for the MOH; passing
Senior Health proposal through approval stages; general
Planner consultations. Participated in TWG
MNCH/EPI SBA plan and MNCH Package
Development; Participated in drafting of GAVI
HSS Application
Dr. Kaisone MCH Yes Chief of Secretariat supporting development
Chounlamany of the proposal Participated in TWG
Director of MCH MNCH/EPI SBA plan and MNCH Package
Center Development
Dr. Khampiew MCH No Secretariat member supporting development
SIHAKHANG of the proposal Participated in TWG
Deputy Dir. Of MCH MNCH/EPI SBA plan and MNCH Package
Center Development
Dr. Anonh EPI Yes Secretariat member supporting development
Xeuathvongsa of the proposal Participated in TWG
Director of EPI MNCH/EPI SBA plan and MNCH Package
program Development
Dr. Khaenchan EPI No Secretariat member supporting development
XAYSANAPHAISAN of the proposal Participated in TWG
Chief of EPI MNCH/EPI SBA plan and MNCH Package
Planning Unit Development
Dr. Dong Il ANH WHO Yes Consultation and review the application
WHO
Representative
Dr.Asmus WHO Yes Consultation and review the application
HAMMERICH Participated in TWG MNCH/EPI SBA plan
Programme and MNCH Package Development
Management Officer Participated in drafting of GAVI HSS
(Health Systems)
Application
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GAVI HSS Application Form 2007
Dr. Shin-ichiro JICA Yes Consultation and review the application
NODA Coordinate with other development partners
Chief Advisor
Mr. Kenichi JICA Yes Consultation and review the application
TSUNODA Coordinate with other development partners
Project Coordinator
of Sector wide
Coordination Project
Dr. Aboudou UNICEF Yes Consultation and review the application
Karimou ANDELE Participated in TWG MNCH/EPI SBA plan
Health and Nutrition and MNCH Package Development
Head
Mieko Yabuta UNFPA Yes Consultation and review the application
Representative Participated in TWG MNCH/EPI SBA plan
and MNCH Package Development
Magnus LINDELOW WB Mission and Yes Consultation and review the application
Senior Economist Project Participated in TWG MNCH/EPI SBA plan
and MNCH Package Development
Michiko SUGA ADB Mission Yes Consultation and review the application
Social Sector and Project Participated in TWG MNCH/EPI SBA plan
Specialist and MNCH Package Development
Odile Pham-Tan Lux No Consultation and review the application
International Team Development Participated in TWG MNCH/EPI SBA plan
Leader and MNCH Package Development
Dr. Frank Belgium –Lao No Consultation and review the application
Haegeman Participated in TWG MNCH/EPI SBA plan
Project Coordinator and MNCH Package Development
Ms. Yvonne Taylor Concern No Consultation and review the application
Chair of Lao NGO Worldwide Participated in TWG MNCH/EPI SBA plan
Association and MNCH Package Development
Mr Mathew Pickhard SCA Yes Participated in TWG MNCH/EPI SBA plan
Country Director and MNCH Package Development
Ornella Linchetto WHO No Participated in TWG MNCH/EPI SBA plan
MCH Officer and MNCH Package Development;
Participated in drafting of GAVI HSS
Application
Keith Feldon WHO No Participated in TWG MNCH/EPI SBA plan
Immunization Officer and MNCH Package Development
Participated in drafting of GAVI HSS
Application
To the applicant
If the HSCC wishes to make any additional comments or recommendations on the GAVI HSS
application to the GAVI Secretariat and Independent Review Committee, please do so below.
Please explain if there has been no involvement of civil society or the private sector, and state
if they are expected to have a service provision or advocacy role in GAVI HSS implementation.
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GAVI HSS Application Form 2007
1.4: Additional comments on the GAVI HSS application development process
Civil Society and Private Sector Consultations
This GAVI HSS proposal is part of an extensive and on-going process of Health Sector
Development in Lao PDR in which Government Authorities and Development Partners have
undertaken extensive consultations. For example, The Minister of Health has been promoting the
need for Primary Health Care Capacity building with a focus on MNCH and immunization within the
Government, within the Health Sector, with Provincial Governors and at the District level for
several years. Further, in Lao PDR, there is extensive political discussion in National Planning
Processes. In the Health Sector the 6th National Conference for Health in November 2007
endorsed the strengthening of Primary Health Care (PHC) at the village level with strong Civil
Society and Private Sector Involvement. In January, 2008 there were consultations on priority
implementation of the Healthy Village Model between the PHO and the Provincial Governors under
the direction of the President of the GOL. In the meantime, the Government's focus on an
integrated MNCH package and skilled birther attendance has sharpened and necessary
interventions have been further defined in close consultation with a wide range of national and
international health partners (see annexes). The 14 poorest Districts in 5 Provinces in which this
GAVI HSS will be implemented were selected through in this consultative process and with the
written agreement of the Provincial Governors concerned.
The major Development Partners have also consulted with civil society and the private sector at all
levels, from the National Level through the Provinces, the Districts the Health Centres and the
Villages.
This GAVI HSS Initiative supports ongoing consultations. It has been compiled with the support of
the Minister of Health, the Directors General of all MOH Departments and the major international
Development partners, including representatives of NGOs in Lao PDR. (MOH and Development
Partners directly consulted and involved in development of the proposal are listed in other sections
below.) The Private Sector was not formally involved in the development of this proposal. National
plans anticipate that this sector will play an increasing role in the delivery of health care in Laos.
Village leaders and mass organisations such as the Lao Edification Front, the Lao Women‘s Union
and the Lao Youth Union will be involved in the implementation of the GAVI HSS Initiative. These
mass organizations are grass root and closely aligned with the political system. In the Lao context
they are the closest thing to grassroots, community based organizations possible. The
involvement of these mass organizations is anticipated and mandated by the resolutions of the 6th
National Conference for Health which calls for the establishment of Village Health Committees in
Model Healthy Villages.
For the purposes of the GAVI HSS activities, the Village Health Committees and the village health
volunteers will assist in the delivery of the integrated package of MNCH; coordinate activities of
outreach teams; and raise awareness of need for and availability of services in the local
community. The involvement of Provincial Governors and District Leaders WILL facilitate
coordination of activities within respective jurisdictions. Many of the village health volunteers are
also members of the Lao women‘s union or other mass movements. This linkage will strengthen
delivery of the MNCH package at village levels.
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GAVI HSS Application Form 2007
Section 2: Country Background Information
To the applicant
Please provide the most recent socio-economic and demographic information available for your
country. Please specify dates and data sources. (Table 2.1).
2.1: Current socio-demographic and economic country information2
Country Information (Population Census 2005)
Information Value Information Value
A
Population GNI per capita $US 490
5,621,982
34.7/1,000
Annual Birth Cohort Under five mortality rate 98/ 1000
193,753
Surviving Infants* Infant mortality rate 70/ 1000
Percentage of GNI A
Maternal Mortality Rate 405/100,000 1.1%
allocated to Health
A
Percentage of Government 5.7%
expenditure on Health
A
Sixth National Socio-Economic Development Plan (NSEDP) 2006-2010
* Surviving infants = Infants surviving the first 12 months of life
GAVI HSS Initiative Target Provinces
Xieng Khoang Province 2005 (Census)
Information Value Information Value
Population 239,523 GNI per capita
Annual Birth Cohort 40/1000 Under five mortality rate
Surviving Infants* 5,450 Infant mortality rate 68/1000
Maternal Mortality Rate 469/100,000 Population in the selected district 147,528
Number of Household in the selected Number of HC in the selected
23,735 20
district district
Number of Villages in the selected Number of Villages in the selected
423 224
district districts with road access
Number of Villages in the selected Number of Villages in the selected
56 18
district access to electricity districts access to pipe water
Selected Districts: 1. Pek, 2. Kham, 3. Khoune
2
If the application identifies activities that are to be undertaken at a sub-national level, sub-national data will need to be provided where
it is available. This will be in addition to the national data requested.
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GAVI HSS Application Form 2007
Phongsaly Province 2005 (Census)
Information Value Information Value
Population 162,683 GNI per capita
Annual Birth Cohort 33.4/1000 Under five mortality rate
Surviving Infants* 3,289 Infant mortality rate 68/1000
Maternal Mortality Rate 690/100,000 Population in the selected district 78,940
Number of Household in the selected Number of HC in the selected
12,568 4
district district
Number of Villages in the selected Number of Villages in the selected
275 46
district districts with road access
Number of Villages in the selected Number of Villages in the selected
4 4
district access to electricity districts access to pipe water
Selected Districts: 1. Mai, 2. Samphanh, 3. Nhotou
Houa Phane Province 2005 (Census)
Information Value Information Value
Population 280,938 GNI per capita
Annual Birth Cohort 37.7/1000 Under five mortality rate
Surviving Infants* 5,782 Infant mortality rate 68/1000
Maternal Mortality Rate 489/100,000 Population in the selected district 110,925
Number of Household in the selected Number of HC in the selected
16,575 9
district district
Number of Villages in the selected Number of Villages in the selected
335 133
district districts with road access
Number of Villages in the selected Number of Villages in the selected
38 0
district access to electricity districts access to pipe water
Selected Districts: 1. Viengthong, 2. Huameuang, 3. Xamtay
Xekong Province 2005 (Census)
Information Value Information Value
Population 84,995 GNI per capita
Annual Birth Cohort 56/1000 Under five mortality rate
Surviving Infants* 2,866 Infant mortality rate 129/1000
Maternal Mortality Rate 433/100,000 Population in the selected district 84,995
Number of Household in the selected Number of HC in the selected
12,640 13
district district
Number of Villages in the selected Number of Villages in the selected
253 134
district districts with road access
Number of Villages in the selected Number of Villages in the selected
27 7
district access to electricity districts access to pipe water
Selected Districst: 1. Lamam, 2. Khaleum, 3. Dakcheung, 4. Thateng
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GAVI HSS Application Form 2007
Vientiane Capital Province 2005 (Census)
Information Value Information Value
Population 698,318 GNI per capita
Annual Birth Cohort 26.3/1000 Under five mortality rate
Surviving Infants* 10,313 Infant mortality rate 19 / 1000
Maternal Mortality Rate 228/100,000 Population in the selected district 24,215
Number of Household in the selected Number of HC in the selected
4,947 5
district district
Number of Villages in the selected Number of Villages in the selected
37 33
district districts with road access
Number of Villages in the selected Number of Villages in the selected
29 1
district access to electricity district access to pipe water
Selected District: 1. Sangthong
Additional background information:
Demographics
The Lao Peoples‘ Democratic Republic has a population of 5.6 million (2005), a population growth
rate of 2.1%, a sparse population density (23.7/km2) with large interprovincial variations, and an
average household size of 5.9. The topography breaks into lowland areas along the Mekong River,
which depend predominantly on paddy rice, and highland areas that depend on upland rice and
the gathering of non-timber forest products for their livelihoods. The population is young, but there
are signs of changes in its demographic structure; the percentage under 15 years of age fell from
43.6% to 39% between 1995 and 2005. The nation is predominately rural, with the beginnings of a
rural-to-urban shift, as indicated by the increase in urban areas; the percentage of the population
living in rural areas fell from 83% to 73% from 1995 to 2005.
The last census identified 47 distinct ethnic groups. The ethnic Lao comprise 52.5% and
predominate in the lowlands, while ethnic minorities predominate in the highlands, although mixing
is common. The highlands have more poverty, worse health indicators, and fewer services
available for multiple reasons, including remoteness, lower education levels, land that is less
agriculturally productive, increasing land pressure and limited rural health care services. Ethnic
diversity presents a major challenge in health care delivery and education, due to cultural and
linguistic barriers. Women have lower literacy rates and girls have lower school completion rates.
These gaps are accentuated in the rural and highland areas, where poverty is highest. There is
some evidence of decreased treatment-seeking behaviour among women when ill.
Between 1995 and 2005 the number of villages reduced in number from 11,640 to 10,553 at an
average annual loss of nearly 1%. The Government‘s policy of discouraging transient agriculture
(slash & burn) will perpetuate the village loss rate. This will substantially reduce the type and
number of Health workers required at the lower levels.
Transport and communication networks in Lao PDR are poorly developed. Approximately 20% of
villages have no road access and most of these also have no telephone communication. Most of
these villages have populations less than 1000 population. These factors make it difficult to
maintain a base skilled health workers in the villages and to deliver essential services with
outreach programs.
The populations in many villages have unique cultures and languages. This makes it difficult to
standardise prevention and treatment protocols and to train Health workers in appropriate
recognition and treatment of common conditions and diseases.
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GAVI HSS Application Form 2007
Transition of Health Care Needs Lao PDR health needs are in transition: The country‘s ―Old‖
needs include high maternal and infant mortality rates, infectious and vector diseases are not yet
effectively addressed. At the same time, there are ―New‖ needs are such as diabetes,
hypertension, renal disease, renal failure, cancer, stroke and asthma are growing. These are
compounded by increasing lifestyle and behaviour needs such as road accidents and the impacts
of smoking and alcohol and drug abuse and the threat of emerging diseases SARS, Avian
Influenza, HIV/Aids and Hepatitis C. The lack of effective control of infectious diseases, the growth
of non-communicable diseases and the emerging diseases compound the problems of service
delivery in a system that is already chronically under-resourced.
Political situation
The Lao People‘s Democratic Republic was founded in 1975. The organs of government are the
President, the Prime Minister and the National Assembly. The Government operates under the
guidance of the Lao People‘s Revolutionary Party (LPRP) through five-yearly Party Congresses,
the Politburo and the Central Committee. The VIIIth Party Congress was held in early 2006. A
National Assembly (NA) election was held in April 2006, with competition among a group of LPRP-
approved candidates and outstanding participation by the population. The National Assembly, the
main legislative organ, is composed of 115 members, of which 29 are women; 113 are LPRP
members. The NA elected a new President, Lt. Gen. Choummaly Sayasone, in June 2006. At the
same time, a new Prime Minister, Mr Bouasone Bouphavanh, was appointed by the President for a
five-year term, with the approval of the NA. The rule of law has continuously been strengthened by
new laws, including several health sector laws in respect of public health, curative services, food
safety, drugs and medical devices.
Until January 2006, the country was composed of 16 provinces and one special administrative
zone under military administration. In early 2006, the special administration status of
Xaysomboune region was removed and the concerned districts allocated to Xiengkhouang and
Vientiane provinces.
Organization of Health Services
Public Sector Health and Health Care services in Lao PDR are provided in 8 administrative levels
from entry levels in the villages up through central service and policy levels. The arrangement and
functions of these administrative levels is illustrated in the following table:
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GAVI HSS Application Form 2007
Administration of Health Public Sector Health Services in Lao PDR
Administrative Health and Health Care Functions
Level
o Policy development and implementation;
Ministry of Health and o Resource allocation;
Central Health Agencies Monitoring;
o Quality Control
o Tertiary and Specialist Services;
7 Central Hospitals
o Central Health Education and Training
3 Regional Hospitals o Regional administration;
(Not currently o Regional acute referral services Regional Public Health Service;
commissioned)
o Regional Health Education and Training
o Provincial Administration;
o Secondary Acute Care;
16 Provincial Hospitals
(3 to become Regional) o Provincial Public Health Services;
o Provincial Health Education and Training.
o District Administration;
o Acute Surgery (in urban areas delivered in provincial hospitals);
District A o Acute Medical Care (in urban areas delivered in provincial hospitals);
o Comprehensive Primary Health Care;
o District Level Public Health Services
o District Administration;
o Acute Medical Care (in urban areas delivered in provincial hospitals);
District B o Comprehensive Primary Health Care;
o District Level Public Health Services
Health Centre A o Primary Health Care Clinic and Outreach service;
standard 5 workers o Health Centre Public Health Service
Health Centre B o Primary Health Care Clinic and Outreach service;
standard 3 workers o Health Centre Public Health Services
o Basic Primary Health Care;
Village o Basic Public Health Services
Source: MOH Planning and Financing Department
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GAVI HSS Application Form 2007
Number of Health Workers by Setting
Lao PDR HRH 2005
Health
MOH MOH Not Defense Total Public
Education
HR Category Health in Villages & Public Health
and
Facilities Facilities Security Sector
Training
High level 1,062 893 - 181 363 2,499
Physicians (medical doctors) 690 484 69 288 1,531
Specialists (PhD, MSc, etc.) 203 162 50 16 431
Pharmacists 71 216 23 43 353
Dentists 82 30 34 10 156
Imaging Specialists
Laboratory specialists 16 1 5 6 28
Middle level 2,190 1,329 - 119 1,401 5,039
Medical Assistants 796 710 26 1,060 2,592
Nurses (hi + mid level) 666 119 63 39 887
Imaging Assistants 23 - - 23
Laboratory assistants 226 94 5 52 377
Pharmacist assistants 172 111 8 144 435
Hygienists 115 206 8 63 392
Kinesiotherapists 107 59 6 29 201
Dentist Assistants 85 30 3 14 132
Low level 3,203 1,480 - 14 3,612 8,309
Auxiliary nurses 2,910 1,358 13 3,421 7,702
Pharmacist technicians 126 95 - 189 410
Laboratory technicians 79 27 1 2 109
Primary Health Workers 88 - - - 88
Village Workers - - 20,170 - - 20,170
Village Health Workers - 537 - 537
Village Health Volunteers - 13,821 - 13,821
Traditional Healers - 576 - 576
Traditional Birth Attendants - 5,236 - 5,236
Non Medical Staff 218 380 - 58 3 659
Non medical low level 109 183 18 - 310
Non medical mid level 73 115 17 - 205
Non medical hi level 36 82 23 3 144
No class 102 54 10 - 166
Totals 6,775 4,136 20,170 382 5,379 36,842
Source: Compiled from statistics in WHO, Lao PDR Human Resource Analysis, January 2007
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GAVI HSS Application Form 2007
To the applicant
Please provide a brief summary of your country‟s Health Sector Plan (or equivalent), including
the key objectives of the plan, the key strengths and weaknesses that have been identified
through health sector analyses, and the priority areas for future development (Table 2.2).
2.2: Overview of the National Health Sector Strategic Plan
Health Sector Planning in the Lao PDR is informed by a number of overarching policy documents.
These include:
6th National Socio Economic Development Plan 2006-10
MoH Health towards the Year 2020 Plan (2000)
5 Year Health Development Plan 2006-10
Lao Health Master Plan Study (2002)
Comprehensive Multi-Year Plan for the National Immunization Program
Maternal and Child Health Policy/Strategies/Plan of Action
Directive of the President Lao PDR to the Ministry of Health on Model Healthy Villages.
Health is one of the four priority sectors for development in Lao PDR and within Health Primary
Health Care (PHC), which includes EPI, MCH and Nutrition, is a major focus. The 6th National
Socio Economic Development Plan outlines key objectives for the Health. The MOH 5 year
Development Plan is part of the MoH Health towards the Year 2020 Plan (2000) and the sector
response to implementation of NSEDP6. A Lao version of the plan was recently released to
development partners through the SWG and it is currently being officially translated for use by
Development Partners. Although not official policy, the 2002 Health Master Plan Study is a key
reference document for the MOH. The comprehensive Multi Year Plan (cMYP) for the period of
2007-2011 deals specifically with the immunization service. Draft MCH policies and strategies
integrate EPI at the point of service delivery. In January, 2008 the President of GOL decreed that
the MOH should implement Primary Health Care as a matter of priority in ―Model Healthy Villages‖.
A Skilled Birth Attendances (SBA) Review was completed in March 2008 and a revised Strategy
and Planning Framework for the Integrated Package of MNCH services 2008-2015, the core of the
Model Healthy Villages, was circulated in July 2008, with a draft plan for the development of SBAs,
a key element of the MNCH strategy, completed in August, 2008.
6th National Socio-Economic Development Plan (NSEDP6) 2006–2010 (Annex 1.1)
The NSEDP6, drafted in 2006, is an overarching planning document outlining the Lao PDR
Government‘s priority goals and strategies. It builds on and incorporates much of the National
Growth and Poverty Eradication Strategy (NGPES), the Lao PDR equivalent of a Poverty
Reduction Strategy Paper (PRSP). Party Congress and more recently the National Assembly
approves the NSEDP on a five-yearly basis. In Lao PDR, this is the reference document that
authorizes expenditures by Government Departments.
The main focus areas of the NSEDP6 are:
o promoting economic development, with human development as a key vehicle;
o increasing competitiveness and utilizing comparative advantages to implement effectively
international economic commitments in the framework of the ASEAN and other bilateral
and multilateral commitments, including WTO; and
o strengthening the positive linkages between economic growth and social development, in
addressing social issues such as poverty and other social evils, and help keep the socio-
political situation stable.
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GAVI HSS Application Form 2007
The indicators and targets for the Plan coincide with most of those for the Millennium Development
Goals (MDGs) and the Brussels Programme of Action for the Least Developed Countries (2001-
2010).
NSEDP6 nominates health as one of four priority sectors for development. Poverty reduction is a
major cross-cutting theme and the long-term objective is to free the country from the status of least
development by 2020. The health sector is expected to contribute to achievement of this National
objective.
Health Sector Objectives The overarching goals for the health sector are to
o develop a nation-wide health delivery service that is fair and equal according to gender,
age, social rank, tradition, religion, ethnicity, and geographic location;
o provide basic health services that respond to the peoples‘ needs and expectations and
that gain peoples‘ trust; and
o achieve substantial improvement in peoples‘ health status, especially of the poor
people.
Within these goals the objectives are to:
o reduce the incidence of diseases including communicable diseases such as diarrhoea,
malaria, dengue fever, tuberculosis, leprosy ;
o reduce maternal and child mortality rates; and
o provide health care services and enable people to access high quality medical services.
Strengths The health system has improved and gradually expanded to form a complete network
from the central level to the districts and villages. This is an important basis for extending improved
health services including primary health care to the population.
In the areas of prevention, priority is given to primary health care with emphasis on high risk
groups; child immunization; recommendations on the use of safe and sanitized water;
management and the control of transmittable diseases, such as diarrhoea, malaria, dengue fever,
tuberculosis, leprosy; and the close monitoring of other diseases caused by drug addiction.
Centres for disease prevention and health care are established in eight areas throughout the
country.
Child polio was eradicated in 2000. Immunization was expanded to children less than one year old
for various diseases such as coughs, measles, tetanus, tuberculosis and others. Efforts made in
the prevention of transmittable diseases such as malaria, dengue fever have shown positive
results.
There have been investments to upgrade treatment in the central and regional hospitals and
expand access to medical services. At the same time, in cooperation with Vietnam, traditional
treatment systems have been improved and developed.
The private health network is developing. There are nearly 500 private clinics, half of which are
located in Vientiane. These contribute to the diversification of health care services.
Provinces and Districts in Lao PDR are classified according to socio-economic status. NSEDP6
aims to special assistance to the 72 poorest Districts in the country. In the last five years, the
country has provided health kits to 94% of the villages in the 72 poor Districts identified in the
NGPES.
Health indicators have been improving steadily over the past three decades, but despite the efforts
of the national authorities, they remain below international standards, being some of the lowest in
the Region. The infant mortality rate (deaths per 1000 live births) declined from 137 to 70 from
1990 to 2005. Over the same period, the maternal mortality ratio (deaths per 100 000 live births)
fell from 750 to 400. The crude death rate (deaths per 1000 inhabitants) also declined, from 15.1 to
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GAVI HSS Application Form 2007
9.8, the total fertility rate (average number of children per women) from 5.0 to 4.5, and the crude
birth rate (number of births per 1000 inhabitants) from 36.6 to 34.3. Meanwhile, life expectancy at
birth rose by 10 years in a decade, from 51 years in 1995 to 61 in 2005. Female life expectancy is
slightly higher than that of males.
Weaknesses The health sector and the health care services delivery do not fully meet the
requirements of the population, either in quantitative or qualitative terms. The health system does
not yet meet the health requirements of isolated areas, particularly poor areas with difficult access.
The level of competence of health personnel is not consistent with the actual needs. Dispensaries
still need the presence of medical doctors. The deployment of health personnel is not in
accordance with their training and the pharmaceutical sub-sector is developing very slowly.
Cultural factors including beliefs and local health care practices have negative impacts reinforce
negative health seeking behaviour by Ethnic groups.
Priority for Future Development NSEDP6 has 12 priority programmes to increase the standard and
availability of health care in the country:
Information, Education and Communication (IEC)
Expansion of the Rural Health Service Network
Upgrading the Capacity of Health Workers
Maternal and Child Health Promotion
Immunisation
Water Supply and Environmental Health
Communicable Disease Control
HIV/AIDS/STD Control
Village Drug Revolving Fund Development
Food and Drug Safety
Promotion of Collaboration/Complimentarity between Traditional and Modern Medicine
Strengthen Financial Sustainability of the Health Sector
Five Year Health Development Plan 2006–2010
The MOH 5 year Development Plan is the sector response to implementation of NSEDP6. The
plan is only available in Lao language and it is currently being translated. Key elements of the plan
have been described in presentations by the Minister in presentations to the 6 th National
Conference for Health August, 2007 (Annex 1.2A) and to the Development Partners November,
2007 (Annex 1.2B). The 5 year health plan typically comes out one year after the NSEDP and
implementation of the plan is for the period 2007-2011. The 6th National Conference for Health
endorsed the 2006-2010 Development Plan.
Health Sector Objectives The key objectives are to:
o Support the NSEDP6 by 2010 paying specific attention to reduction of poverty in 47
poor districts and to move Lao PDR from Least Developed Country status by 2020;
o Achieve Millennium Development Goals by 2015 with particular emphasis on
reduction of maternal and infant mortality rates (MDG 4 and 5)
o Expand Primary Health Care
o Undertake health system reform and strengthening and
o Contribute to achievement of the objectives of the 2020 Health Master Plan.
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GAVI HSS Application Form 2007
Strengths Key strengths include
o community focus in village committee for health: availability of village drugs kits with
96% coverage;
o hygiene, prevention, health promotion campaigns with 8 elements of PHC as contents;
o Initiating healthy village model building following the 8 elements of PHC for providing
health for all;
o District Mobile teams formed to provide outreach services;
o more effective services at the Provincial Level;
o The national commission for mother and child;
o faculty of medical sciences transferred to MOH and upgraded to University of Health
Sciences integrating all health related disciplines;
o upgraded central hospital system;
o Health sector policies are basically correct and based on local realities, on general
policies of the government, on the real capacities, on the general and on the policies of
WHO, UNICEF, UNFPA,UNDP and other bilateral partners; and
o implementation arrangements are significantly progressing.
Weaknesses Compared to the past, initial results are significant, positive and meaningful.
However, compared to the overall, fast increasing demands what has been achieved is not enough
and the health system faces severe human resources limitations, health financing constraints.
Specific weaknesses include:
o Supply not yet meeting the fast and increasing demands;
o While old challenges not yet solved with satisfaction: high maternal and infant
morbidities and mortalities, new challenges are added linked with environment changes
in particular climate warming and emerging and reemerging diseases such as Avian
Influenza and SARS, and non communicable diseases associated with lifestyle changes
including: diabetes, hypertension, cardio vascular diseases, strokes and mental health
as well as over consumption of tobacco, alcohol, traffic injuries.
o Human Resources for Health (HRH) challenges including not enough in quantity; Not
appropriate in structure; Not standardized in qualification (virtues and ethics,
professional practical clinical skills, knowledge: languages, computer, financial
management skills) and inappropriate structure; Incorrect quota determination,
incorrect quota requests, incorrect quota utilization; Not enough and inefficient
mobilization for decentralization and working at the health centers and district levels; not
enough incentives;
o Financial challenges including: Too small budget at all level; High level out of pocket
payments by the patients; Only initial and partial health insurance schemes: civil
servants, enterprises, CBHI, equity funds; and Operating hardships.
o Lack of an integration focus in health system development and delivery of care.
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Priority for Future Development The priorities for health sector development are:
o Up-grading health care at the village level a Healthy Model Village concept based on
delivery of priority Primary Health Care (with functions, services and priorities yet to be
defined)
o integration of the delivery of health services and programs as a core activity, in space, in
time and in terms of effectiveness;
o Immunization (EPI), the core and central activity;
o MCH activities as a top priority including safe motherhood package and child survival
package;
o other PHC developments including: Water and Sanitation, drug revolving funds and
traditional medicine
o Reorganization of services: Central level normative centralization and executive
decentralization; Province level strategic unit; District level planning and financing unit ;
Health center or village implementing unit; Village action focal point Family, schools and
High risk group in family: mother and child.
o continuous provision of fixed site preventive and curative care at health centers, district,
provincial, central hospitals;
o At least 4 rounds of outreach integrated activities during the dry season
o Improve Efficiency: Avoid duplication; Increase strong impacts of health; Diminish
personnel and financial needs; increase productivity; Increase team spirit; Allow more
participation, more control; results focus.
Health Master Plan Study (Annex 1.3)
Prepared in 2002 with the support of JICA, the Health Master Plan Study is a key reference
document for the MOH but it is not official Government policy. The current 5 year Health
Development Plan is designed in part to achieve the Master Plan objectives.
Health Sector Objectives The Goals of the Master Plan are to:
o To strengthen the ability of the health care system to provide access to regularly
available, appropriate, affordable, and good quality essential health services that are
responsive to people‘s needs and expectations, especially for those who are currently
underserved or unserved and
o To empower communities, families and individuals to make their own health-related
decisions and become self-reliant.
Within these goals, the objectives are to:
o broaden the coverage of essential health services for people in remote areas, ethnic
minority groups and the urban poor
o To enhance the quality of basic facility-based and community-based health services
while striving for more efficiency in the management of resources
o To protect people from the financial burden of ill-health and other health events
o To heighten people‘s awareness of practical, scientifically sound, socially acceptable,
and affordable methods and technologies for maintaining, restoring and improving
health.
Strengths In Lao PDR various actors, such as MOH, provincial and district health offices,
international donors and NGOs, have made efforts at health sector development in many different
ways and in various sub-sectors. Some of these efforts were successful in improving people‘s
health and health service delivery. Despite these efforts, the health care sector remains fragile.
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Weaknesses The weaknesses, documented in 2002 are still evident today. They are:
o Low level of health services;
o Low input of recurrent expenditure and wasteful resource utilisation;
o Unsustainable development and operation of health infrastructure;
o Weakness of health finance and dependency on foreign assistance;
o Inadequate health finance system;
o Uneven geographical distribution of health personnel;
o Shortage and maldistribution of well trained hospital nurses and community nurses;
o Budget allocation skewed in favour of hospitals and medical doctor training;
o Lack of motivation system for government health staff;
o Poor development of job descriptions of health staff;
o Undifferentiated strategies of health sector development for remote areas;
o Budget shortage and disparities among district health offices due to excessive;
decentralization to the district level;
o Low capacity of provincial and district health offices;
o Unclear and non-transparent decision-making system in health management;
o Shortage of human resources and recurrent budget at the district level;
o Weak people‘s participation in the health sector;
o Weak health service delivery in MCH, nutrition and health education;
o Insufficient infectious disease control activities.
Priority for Future Development The Master Plan identified Very High Priority Programmes:
Essential programmes to be initiated as initial steps within 5 years, in accordance with the overall
basic strategies, to change/improve the existing situation of the Lao health sector; High Priority
Programmes: Programmes to be undertaken after the very high programmes are started, to raise
effectiveness in achieving goals/ objectives, in parallel with the very high priority programmes; and
Priority Programmes: Programmes selected from sub-sector perspectives. It should be
reconsidered whether they should be implemented, after all the very high and high priority
programmes have been started.
The short list of very high priority areas for development (including detail not presented here) is:
o Planning and management;
o Human resources development;
o Health finance;
o Health education;
o Infectious disease control;
o Primary health care;
o Maternal and child health;
o Nutrition;
o Hospital services;
o Medical laboratory technology;
o Essential drugs.
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Comprehensive Multi-Year Plan - National Immunization Program (2007-2011) (Annex 1.4)
The Ministry of Health of Lao PDR developed the comprehensive Multi Year Plan (cMYP) for the
period of 2007-2011 for the National Immunization Program (NIP) as a guide to ensure high quality
immunization service.
Health Sector Objectives The cMYP has seven goals each with it‘s own objective:
o Maintain Polio free status and achieve Hepatitis B control and the elimination of
Measles by 2012 and eliminate Maternal Neonatal Tetanus (MNT) by 2010 through
integration of immunization services into the Primary Health Care system; Objective: To
maintain Polio free status until the time of global eradication, eliminate Measles and
control Hepatitis B by 2012 and eliminate Maternal and Neonatal Tetanus by 2010 to be
verified by National Certification Committee, JRF and WHO Certification;
o Districts and health centres will provide efficient and safe immunization services
integrated with other health intervention services to all children under one year,
pregnant women, and women aged 15-45 years; Objective: Ensure regular quality
immunization plus services are delivered to all eligible children and women as verified
by MICS survey, WHO/UNICEF JRF and National Immunization Report;
o Vaccine procurement, vaccine security, and immunization injection safety are in place
and managed effectively; Objective: Improve vaccine security, immunization injection
safety and strengthen the vaccine management system as verified by JRF and EVSM
reports;
o Community demand is revitalized for maternal child health and immunization services;
Objective: To increase understanding and change in community behavior towards
immunization and other MCH services to be verified by MICS survey and National
Routine Immunization Report;
o Sufficient and sustainable funding for National Immunization Program will be obtained;
Objective: Resources for immunization program are met by a consortium of donor and
government agencies and verified by the NIP Annual Work Plan;
o National capacity from district level upwards to develop routine immunization
monitoring, surveillance of vaccine preventable diseases, and strengthen immunization
safety shall be built. Objective: To review current high priority new vaccines including
MR, JE, Typhoid, and Rotavirus and to extend the introduction of Hepatitis B Birth Dose
as verified by study reports and WHO/UNICEF JRF;
Strengths The National Immunization Program (NIP) conducts monitoring and supervision twice a
year to provinces and districts. A task-force for immunization supervision has been established in
order to provide more frequent technical support for immunization work at local level. The task-
force team of MoH comprises of senior health officers from various departments in MoH, central
hospitals, pediatricians and professors in mother and child area, these health professionals make a
monitoring and supervision visit to province and district twice a year. The Minister of Health and
Vice Ministers have made an extensive commitment to visit local communities and provide their
leaderships in order to improve immunization practices in local level.
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Weaknesses Number of children immunized has not increased substantially during last ten years
because:
o Coverage is not uniform and varies from provinces to provinces and districts to districts
even within the same province;
o Ineffective and irregular monitoring and supervision at implementing levels (province,
district and health centres);
o Vacancy or understaffing at implementing levels (districts and health centres);
o Re-orientation of most district EPI managers and some provincial EPI managers;
o High drop-out due to poor access and poor utilization of the service;
o Absence of inventory of cold chain, no replacement plan, and poor maintenance of
equipment;
o No community-based surveillance for vaccine preventable diseases (VPDs);
o Weak vaccine supply logistics;
o Inaccurate reporting system and lack of validity of data (over-reporting and under-
reporting);
o Low performance due to insufficient training and irregular monitoring and support from
province and districts;
o Insufficient partnership between health workers and community authorities;
o Poor health education service delivered to communities, resulting in low demand for
immunization;
o Hard accessibility to the service due to geographical barrier and only 4 contacts
available for outreach and mobile villages and lack of consistency;
o Lack of data base for planning, monitoring and supervision.
Priority for Future Development Special attention will be given to strengthening routine
immunization in districts with coverage below 50% as a first priority, and below 75% as a second.
Reach Every District management strategies will be adopted and there will be regular compilation
and analysis of district data to identify problems, corrective action to solve the problems by using
existing resources as far as possible, and addition of corrective activities to the work plan as
required.
Maternal and Child Health Policy/Strategies/Plan of Action (Annex 1.5A)
Maternal and Child Health is a priority for Government and for the MOH. MCH policies and
strategies are currently under review and aim at integrating MCH and EPI at the point of service
delivery. This paper and associated drafts of MCH-EPI services package have been prepared by
the MNCH centre following extensive consultations. Although, they have not yet been adopted as
policy, there is widespread support for the integrated package of MNCH services 2008-2015 and
the related skilled birth attendances (SBA) development plan (Annex 1.5B) , within the MOH and
in the development partner community. The MNCH package is a key focus for this application and
it is discussed in detail in following sections.
Health Sector Objectives The main goal of the MCH policy is to reduce Infant and Maternal
mortality rates. The objectives to achieve this goal are to review existing policies in the MCH
centre; and to provide better services to mother and child. Strategies include:
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GAVI HSS Application Form 2007
o Every woman will have access to a skilled professional attendant during pregnancy and
delivery;
o Every woman of child bearing age will receive iron and acid folic supplements;
o Every district and provincial hospital will provide emergency obstetric care;
o Every woman of child bearing age will receive information on reproductive health;
o All pregnant women will be immunized against tetanus;
o Every infant will receive a breastfeed within 1 hour of birth and will be exclusively
breastfed for the first 6 months of life;
o All children should receive complementary food from 6 months of age;
o All children should receive full immunization according to the national immunization
schedule including vitamin A supplementation;
o All children under 5 will receive an appropriate treatment during their illness;
o Antenatal care, delivery, children and baby check-up should be free of charge;
o All children and women should sleep under insecticide treated bed-nets and receive
prophylaxis and treatment for malaria according to the National Treatment Guide for
malaria.
Strengths There is now a sector wide, shared understanding of the causes of maternal and child
mortality, key interventions and obstacles in providing interventions. Committees have been
established in the North, Central and Southern regions of the country to take responsibility for
planning and action in their respective regions.
Weaknesses Despite significant progress, children are still dying from easily prevented and
treatable diseases: pneumonia, diarrhoea and measles, and the trend in falling MMR is unlikely to
be sustained unless access and services are improved. Quality of MCH services is defined as
poor, services have no agreed standard and capacity to manage pregnancy related complications
is inadequate. Management of the MCH program is not effective and Human Resources for MCH
do not have skills or experience to provide a quality service.
Priority for Future Development The MCH Document priorities include:
o Improving quality of services;
o Promoting MCH activities; Improving management of the organization and services;
o Developing outreach activities as a regular part of MCH activities;
o Mobilizing communities for MCH;
o Developing MCH model facilities;
o Promoting of birth in facilities where there is access to Essential Obstetric Care
Directive of the President of Lao PDR to the Ministry of Health on Model Healthy Villages
(Annex 1.6)
This directive, dated 22nd January 2008, is only available in Lao language. The MOH has prepared
a Program to implement the directive in Northern and Southern Provinces (Summary of model
healthy village Program – drafts of this document are similar for Northern and Southern
Provinces except for the target areas listed). The Directive is to establish ―developed‖ villages and
groups of ―developed‖ villages following the direction and the strategy of the Party and the
Government. This is interpreted to include the Model Healthy Villages concept endorsed by the 6 th
National Conference on Health.
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Health Sector Objectives
The Program has 3 specific objectives. These are:
o To increase Primary Health Care services coverage in target zones of focal points for
development to become healthy model villages
o To strengthen District Health Systems and Health Centres in order to be able to manage
grass root level operations
o To Strengthen the community to be aware of their own health promotion
Strengths and Weaknesses
The document does not list strengths and weaknesses
Priority for Future Development
The program has 4 priorities for future development:
o Focus on villages as the implementing unit;
o Focus on disadvantaged populations in the districts, including ethnic groups and women
and children in poor remote areas;
o Strengthening of Primary Health Care ;
o Strategic Development according to the Model Healthy Village concept (The Model
Health Village concept will be clarified and defined in the GAVI HSS Initiative to enable
it to be implemented).
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GAVI HSS Application Form 2007
Section 3: Situation Analysis / Needs Assessment
To the applicant
GAVI HSS Support: GAVI HSS Initiative cannot address all health system barriers that impact on
immunisation and other child and maternal health services. GAVI HSS Initiative should
complement and not duplicate or compete with existing (or planned) efforts to strengthen the
health system. GAVI HSS Initiative should target “gaps” in current health system development
efforts.
Please provide information on the most recent assessments of the health sector that have
identified health system barriers. (Table 3.1)
Note: Assessments can include a recent health sector review (conducted in the last 3 years), a
recent report or study on sector constraints, a situation analysis (such as that conducted for the
cMYP), or any combination of these. Please attach the reports of these assessments to the
application (with executive summaries, if available). Please number them and list them in Annex 1.
Note: If there have not been any recent in-depth assessments of the health system (in the last 3
years), at the very least, a desk review identifying and analysing the key health systems
bottlenecks will need to be undertaken before applying for GAVI HSS support. This assessment
should identify the major strengths and weaknesses in the health system, and identify where
capacity needs to be strengthened to achieve and / or sustain increased immunisation coverage.
3.1: Recent health system assessments3
Title of the assessment Participating agencies Areas / themes covered Dates
Comprehensive Multi-
Immunization and health system
Year Plan - National
MOH, UNICEF, WHO barriers to immunization, 5 year 2007 - 2011
Immunization Program
cMYP
- Annex 1.4
First-line Health Care:
The Integrated MOH, Belgium Barriers and costing of PHC in
2004-2007
Community Health Government Health Centres
Centers - Annex 1.8
Barriers to accessing Health
Health Services
Care and Health System 2005 –
Improvement Project MOH, World Bank
Strengthening in 8 southern 2010??
(HSIP) – Annex 1.9
provinces
Health System Barriers to accessing Health
MOH, Asian
Development Project Care and Health System 2007 - 2011
Development Bank
(Grant) – Annex 1.10 Strengthening
Review of Ongoing
Health Financing
Reform in Lao PDR
and Challenges in MOH, UNESCAP, Situation analysis and financial
2007
Expanding the Current WHO, ILO reform for the health sector
Social Protection
Schemes – Annex
1.11
3
Within the last 3 years.
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GAVI HSS Application Form 2007
The Fundamentals of
the Sector Capacity Development for
Coordination MOH, JICA Sector-wide Coordination in 2007
Mechanism for Health Health
– Annex 1.12
Second Poverty
Reduction Support
MOH, World Bank Structural Poverty Reduction 2006
Operation – Annex
1.13
Lao-Luxembourg
Barriers to accessing Health
health Initiatives MOH, Luxembourg
Care and Health System 2008-2012
support programme – Government
Strengthening in 2 provinces
Annex 1.14
Government of Lao
Vientiane Declaration PDR and 23 Aid Effectiveness and
2006
– Annex 1.15 International Development Principles
Development Partners
Report on MR
Evaluation – Annex MOH and JICA Hospital Services Coordination 2007
1.16
Strengthening immunization
Young Child Survival
services and child survival 2007
and Development WHO, UNICEF
intervention; improving nutrition
program – Annex 1.17
of women and young children.
Handbook of Minimum Hospital Services Coordination
Requirements – MOH, JICA and Quality Improvement in 2007
Annex 1.18 Provinces and Districts
Strategic Plan
For Strengthening
WHO Health System Strengthening 2008
Health Systems -
Annex 1.19
United Nations
Development
Assistance
Health system issues and 2002-2006
Framework for the Lao GOL and UNDP
priorities for development 2007-2011
PDR – Annex 1.20A;
1.20B
Health Strategy up to
the Year 2020 – MOH Health System Strategy 2000-2020
Annex 1.27
Background paper for
the health chapter of
WHO UNICEF
the mid-term review of 7 declared priority programmes
UNFPA UNAIDS ADB 2006-2010
NSEDP6 – Annex and strategies
WB BTC JICA
1.28
Assessment of skilled
birth attendance in
MOH, UNFPA Skilled Birth Attendance 2008
Lao PDR – ANNEX
1.5C
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To the applicant
Please provide information on the major health system barriers to improving immunisation
coverage that have been identified in recent assessments listed above. (Table 3.2)
Please provide information on those barriers that are being adequately addressed with existing
resources (Table 3.3).
Please provide information on those barriers that are not being adequately addressed and that
require additional support through GAVI HSS (Table 3.4).
3.2: Major barriers to improving immunisation coverage identified in recent assessments
The barriers described in this section have direct relevance to Immunisation coverage, even
though the main purpose of the studies describing them was not necessarily analysis of
immunisation issues. Some entrenched barriers include:
o Lack of health care staff and staff with inappropriate training and skills
o Very low salaries and working conditions and lack of incentives;
o Poor facilities with insufficient equipment;
o Ineffective organisation and delivery of services;
o Chronic under-funding of health care
o Health care inaccessible (particularly too expensive) for poor and at-risk populations
o Embryonic Health Insurance and Social Protection mechanisms;
o Reliance on external sources of funding;
o Fragmentation and lack of integration of services, programs and projects
o Poor definitions of roles and responsibilities;
o Lack of management and planning capacity;
o High costs of medicines;
o Poor coordination and communications;
o Under-utilization of resources;
o Inaccurate and poor quality information systems;
o Fragmentation and poor management of commodity distributions;
o Inappropriate health seeking behaviours.
Health Services Development Barriers documented in United Nations Development
Assistance Framework for the Lao PDR 2002-2006 & 2007-2011 (Annex 1.20A & 1.20B)
United Nations Development Assistance Framework considers HSS in the context of overall
economic development. It is one of the first documents where integrated maternal and child
health is discussed with and agreed to by GOL.
Key challenges 2002-2006 Despite considerable advances in the provision and utilization of
health care services in recent years, the Lao PDR is characterized by low life expectancy, high
infant, under-five, childhood and maternal mortality, and lack of access to basic health care
services and facilities. Communicable diseases, particularly malaria, ARIs, diarrhoea, and
epidemics such as measles, are the major causes of child mortality and morbidity. The incidence
of these diseases is heavily influenced by a lack of education, inadequate nutrition, lack of clean
water, poor sanitation and housing conditions, and limited access to and untimely utilisation of
health care. The structure and administration of the public health care system is still weak; it is
also critically short of financial and human resources. The poor health conditions impede social,
human and economic development, and contribute significantly to widespread poverty. For
development targets to be met, the health status of the Lao population of all ethnic groups must
be improved, especially that of the rural poor, women and children.
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GAVI HSS Application Form 2007
Key issues for the health sector 2007 – 2011 are:
Service Delivery and Access: Improving the quality of health care services with a focus on
service delivery, and emphasis on maternal health, child/newborn health, and communicable
disease control, improving the coordination and planning of health care services, utilizing both
internal and external resources, and improving health care access and appropriate utilization of
health services for all Lao people.
Planning, Financial, and Human Resources: Improving health care financing by moving
towards financing systems that emphasize pre-payment, risk pooling and equity in financing, and
improving human resources in the areas of quality, distribution, and motivation.
Awareness and Promotion: improving health promoting behaviours at all levels.
Capacity Barriers documented in First-line Health Care: The Integrated Community Health
Centers. (Annex 1.8)
Facilities There is a large variety in size, quality and covered target population of health centers in
the project area. Most often, the infrastructure was not adequate, for lack of either water supply or
toilets, fence, staff house, access road or kitchen for patients, or other deficiencies. Most health
centers are insufficiently equipped to provide a comprehensive package of curative, preventive
and out-reach community health care.
Human Resources There is a large variety in initial professional education of health center staff,
ranging from a few months of practice in a district hospital to the 3-year ‗Medical Assistant‖
training. None however, receive a specific training for the multiple tasks and skills needed for
first-line health care. Skills required include clinical skills of diagnosis & treatment & referral, MCH
care including obstetrical care, preventive medicine, including EPI outreach plus, organizing
health committee meetings and community participation, supervision of VHW, administration,
DRF management, accounting, planning, and reporting.
Inadequate operational funds Health centers in Laos usually receive no funding for operational
cost from the government budget. They are supposed to make benefit on the sales of drugs in
order to finance routine operational costs. They receive no essential drug supply. Some budget is
periodically provided for short-lasting activities such as vaccination (EPI) and bed net
impregnation (IBN); some contraceptives are provided for subsidized sale. The salary of the staff
of health centers is much below the living wage, and staff turns to other income generating
activities (either private practice at home, pharmacy shop, farming, commerce, a.o.)
Structural barriers documented in the Health Services Improvement Project (HSIP) (Annex
1.9)
Delivery and Organization of services: limited access and poor quality of health care, especially in
rural and remote areas; weak clinical and administrative skills of health workforce as a
consequence of poor medical education; low pay and motivation of health workers. Responsibility
has been decentralised with inadequate capacity for health management at Provincial and District
levels.
Financing of services: limited public financing for health resulting in households contributing to the
bulk of health expenditures, and the effects of cost recovery contributing to low demand for
services. There is critical under funding of the health sector, and in particular the low funding of
recurrent expenditures. Health expenditure accounting is weak and not transparent.
Human Resources: While decentralization should, in theory, improve the efficiency and
effectiveness of services, lack of budgeting and administrative capacity is a major impediment,
particularly in poor and remote Districts. The weakness of human resources, as a result of poor
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GAVI HSS Application Form 2007
pre-service and in-service training, as well as low and delayed payment of salaries, is a key
constraint to quality service provision.
Facilities and Equipment: Service quality is low as a result of sub-standard facilities and
equipment.
Fragmentation and Lack of Integration: While the vertical program approach had some benefits, it
has resulted in fragmented and inefficient services, compounded by decentralization. There is an
urgent need to integrate the vertical programs in the PHC structure, implementing a preventive
health strategy through an improved PHC system, and to improve equity, both by providing basic
health services in remote rural areas and protecting the poor from user fees.
Structural Barriers Documented in the Health System Development Project (HSDP) (Annex
1.10)
Fragmentation and Lack of Integration: A major problem hampering the integration of PHC is the
vertical management of disease control through central programs, leading to fragmentation and
inefficiency at lower levels of implementation. Rather than pooling their resources and activities in
the districts and villages, health service providers are obliged to implement vertical program
activities separately. Much of this behavior is reinforced by donors who fund specific projects or
programs and restrict the use of funds, equipment, medicines, and other supplies. For example,
the maternal and child health and immunization programs, both vertical programs, have done
poorly for many years, with limited management capacity, fragmented and unstable assistance,
and, for the safe motherhood program, an inability to scale up.
Roles of provincial and district governments There is a mismatch between the responsibilities of
provincial and district health managers and their resources. Limited local stewardship and
involvement in sector performance further impede the ability of health managers to respond to
public demand. Because of the implications and risks involved, competent provincial health
managers are often reluctant to take initiatives to improve services.
Management and Planning Capacity: District managers, to varying degrees, lack capacity in such
areas as planning and budgeting, financial management, and monitoring and evaluation.
Managers are often doctors or medical assistants without appropriate management training. A
new generation of energetic managers is emerging in the districts, but most have received only
short-term management training. Almost all provincial health officers now have a master‘s degree
in public health, compared with only about half in 1999. But only a few MOH officers have non
medical training in such areas as health economics, administration, and HRD.
The current organizational structure and limited management capacity in the health system have
serious implications. National health policies and regulations are often not fully implemented by
local governments. Facility-based and outreach services are fragmented, irregular, and of poor
quality, resulting in a loss of public confidence. Also given the uncertain benefit of using public
services, associated costs of services are often unacceptable. The MOH plans to move toward
provincial results-based programs to integrate programs and services and improve ownership,
accountability, and flexibility. But management training, advocacy among stakeholders, pilot-
testing, and supporting administrative and fund flow arrangements will be needed to achieve this
goal.
Staff Performance: The performance of health facilities is affected by inappropriate staffing or
understaffing. The high ratio of doctors to other medical staff in health facilities leads to health
system inefficiencies. There is one doctor for every 1.7 mid-level staff instead of the stated MOH
goal of three to four nurses per doctor, and one to two nurses per medical assistant. At the same
time, however, surveys show that one third of the district hospitals are without a doctor.
Training: PHC services are also affected by the type of training that health professionals receive.
The past emphasis on training sufficient numbers of health staff has had implications for the
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GAVI HSS Application Form 2007
quality of the staff. Despite their participation in several in-service training programs, providers of
maternal and child health services have inadequate knowledge, skills, and attitude to provide
accurate information and appropriate services to clients. For lack of funds and opportunities for
clinical and laboratory training, many medical professionals did not receive adequate skills beyond
classroom theory before they were sent to work in health facilities. With the increase in enrollment
of self-financed students, the quality of training has deteriorated further. Also, some staff are in
positions for which they have not received pre-service training, such as nurses working as
laboratory technicians.
Management: Staff management functions, such as providing regular feedback to staff, ensuring
even distribution of workload, promoting quality, and encouraging participation, are inadequate.
Health center staff, lacking transport and an operational budget, only make a few supervisory
visits to VHVs each year. The problem of limited supervision at lower levels is compounded by a
lack of accountability. The lack of equipment, funds, and information affect staff motivation and
the quality of services.
Recurrent Cost Financing The serious under-funding of the health sector contributes directly to
low performance and presents a serious challenge to the Government, given the fiscal constraints
and poverty levels. Within these resource constraints, however, there is substantial scope for
improvement. Much of the emphasis in the past few years has been on investments in new health
facilities with the laudable purpose of improving access to health services of a higher standard.
But this development has not been matched with funding to cover the recurrent costs of the
investments. Staff salaries are relatively low (and often not paid on time) but the non-salary
recurrent budget, at about 7% of the provincial health budget, is very low as well. Health facilities
must generate an operating budget from overhead on the sale of medicines, making health
services even less affordable and encouraging over prescription.
Cost recovery Cost recovery was introduced in the early 1990s, mainly through the sale of drugs
financed from DRFs. More than half of the operating costs of central and provincial hospitals and
one third of those of district hospitals are now met through cost recovery. The Decree on Fees
and Charges (December 2005) allows public agencies to expand the types of charges and fees
for services, and to use revenue from fees to cover salaries and other recurrent costs. However,
even with expanded cost recovery, there is no net increase in health sector financing because of
a reduction in the central budget allocation, as revenue is integrated with the formal fiscal year
budget. The actual surplus from the estimated fee income will go to the Treasury, and deficits in
anticipated fee income lead to central budget subsidies only after a formal audit.
Affordability for the Poor: While user fees play an important role in health system financing, they
are not the solution to the problem of under-funding for the recurrent costs of health facilities. User
fees at public facilities, even with accompanying exemption schemes for the poor, deter the poor
from using health services. The income disparity between the poor and non poor has increased,
and the cost of health care has gone up substantially over the past several years. The introduction
of cost recovery for drugs is likely to have made health care even less affordable and the new
Decree on Fees and Charges under the Curative Law may exacerbate matters. While the poor
are unable to pay for services, there is not enough public finance to provide them with free
services.
Cost of medicines: Households obtain about 90% of their medicine needs through out-of-pocket
spending. This implies that free medicines are very limited in the health system and the poor may
not be getting the medicines they need. A market is thus created for cheap counterfeit drugs that
are unsafe and contribute to drug-resistant diseases. Exemptions for the poor are supposed to be
covered by the DRF and government contributions. According to Asian Development Bank (ADB)
estimates, exemptions for hospital services range between 2.2% and 21.1% of the DRF. This
level of funding is not enough to cover the needs of the poor.
Health Insurance Schemes None of the three formal health insurance schemes—civil servant
health insurance, social security fund, and community-based health insurance—benefits the poor.
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These schemes, with a total coverage of 1% of the population, are not a viable option for making
the services more affordable to the poor in the medium term. Health Equity Funds have been
successfully pilot-tested in a few districts to compensate hospitals for the ―loss‖ they incur when
treating the poor. The MOH wants to widen the application of HEFs. (Note: CBHI can benefit the
poor if someone subsidizes their premiums.)
Financing issues documented in the Review of Ongoing Health Financing Reform in Lao
PDR and Challenges in Expanding the Current Social Protection Schemes (Annex 1.11)
Lao PDR health system is in a vicious circle of poor quality, under-utilization and under-
funding/low cost recovery. The health system is under-funded, inequitable, has weak social
protection, is inefficient and has low productivity with weak synergies between government,
donors and beneficiaries. Affordability is a major issue for a majority of people, mainly in rural
areas and mainly ethnic minorities. A set of multi-target social protection schemes is developing
but is still at infancy stage
Effectiveness & access Major discrepancies in access still exist between urban/rural, rich/poor,
ethnic groups but these are unavoidable because of the geographic characteristics and low
density. Effectiveness of the health sector is a major problem because of the diverse factors of
limited staff capacity, limited availability of qualified persons in rural areas, limited working
conditions and motivating incentives for health staff and major cultural/language barriers.
Technical and allocative efficiency of funding Low staff productivity linked to low salary and poor
working conditions, inadequate functioning technology and low demand. Extended network along
administrative lines with non-functional facilities. Low efficiency of donors‘ funding biased towards
capital items and not enough towards recurrent costs. Major conflict of interests among the staff
regarding public/private work
Equity Public health facilities/funding biased towards central level and higher quintiles of
population. High out-of-pocket expenditure. Fee-for-service and especially RDF are major
financial barriers for a majority, an incentives for irrational use of drugs and a high risk of
catastrophic health expenditures. The poor people often have accessed to substandard Primary
Health Care.
Financial protection Social protection is at infancy stage with still low coverage and only long-
term potentials. Financial barriers to seeking care, beginning with early stage of disease. High
risk of catastrophic health events leading to poverty. Specific poverty and extra barriers for ethic
minority groups. Limited but emerging safety net mechanisms including Health Equity Funds
Sustainability of funds Health insurance alone can not replace total government investment and
expenditure in personal health care at affordable contribution rates. The GOL‘s projections predict
an additional increase in the donor-financed share of H&P programs in the future. This issue
raises crucial questions about the long-term sustainability of these programs.
Health System and Immunization Barriers documented in the Comprehensive Multi-Year
Plan - National Immunization Program (Annex 1.4)
Responsibilities. Defined roles and responsibilities are often difficult to apply, due to poor and
unclear communication between vaccine providers and communities, rapid turnover of
government staff, low community demand for vaccination due to poor immunization information
delivery, socio-economic and linguistic barriers, geographic access and weak coordination with
other health interventions at all levels.
Coordination and Communication. Provinces take full responsibility for distributing vaccines to
districts, ensure vaccine availability at service, points and conduct regular monitoring and
supervision visits. However, coordination and communication flows have been identified as key
problem areas.
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Fixed Health Facilities. A large proportion of the existing health centres and district hospitals are
underutilized. In some health centres, nurses are not permanent. Due to the lack of resources,
nurses have limited training and few incentives to undertake their tasks. Several services are
based at the health centres and outreach activities such as mother and child health, EPI, and the
control of local common diseases are irregular and some may have been discontinued.
Technical and program management constraints. Every province has a dedicated immunization
focal point that works closely with MCH managers. However, the technical advice and resources
available to these teams is weak. Planning, management and monitoring of immunization
activities at the provincial level need to be strengthened. Timely data generation both in the area
of performance; surveillance; data discrepancy; data analysis; feedback for corrective actions are
main areas that need immediate intention.
Every district has an immunization officer (district EPI manager), however, in some districts there
are only one or two designated officers entirely for the immunization program. Some health
centres remain vacant, most remote health centres are staffed by 1-2 nurses and few staff
received little on-going training. The coming middle level management (MLM) training initiative for
district level managers aims to strengthen district level planning, monitoring and supervising. But
there remains a shortage of appropriately qualified staff that can practically plan and manage
immunization service effectively.
Delivery of Immunization Services. The steadily decline of routine immunization coverage rates,
high drop-out rates and declining trend in some of districts in several provinces are a major
concern. Even within provinces with higher coverage rates, there is marked variation between
districts. There is no capacity in the system to assess where the un-immunized children are and
prioritized their areas (using population, low coverage and high drop-out rates) for targeted
attention. Routine immunization coverage dropped significantly between 2006 and 2007.
Multiple tasks assigned to peripheral health workers at districts are often not planned with the
sense of a holistic overview. There is little integration of immunization service and other mother
and child health intervention programs. Immunization service delivery in urban and peri-urban
areas, where migrant families live remains a major concern. Coordination between immunization
program and urban areas‘ authorities is weak.
Data Quality. Immunization service data are lacking in terms of accuracy, consistency,
completeness and timeliness. Currently, there are large differences between reported and
evaluated coverage which makes it difficult to use data for action. This varies from province to
province and district to district. In many situations, there is lack of consistency between
information reported to province and reported to the central. This reflects the lack of data
interpretation skills and poor understanding at the health facility level on the importance of correct
reporting and recording data for analysis, and identifying for corrective action necessary to
improve immunization coverage.
Vaccine procurement and distribution. There have been substantial changes in funding of
vaccines and Laos with shortage of vaccines in 2007. There is a need for strengthening planning
and logistic for vaccine requirement and distribution at the province and district level with efficient
feedback mechanism on utilization and future demand.
Cold Chain. There is lack for monitoring of the breakdown rates for cold chain equipment and
cold chain sickness rate, and the repairing status is a major area of concern. Furthermore, The
overall national wastage rates remain a severe problem. .
Community Demand. Community demand for vaccination is low and this is especially the case
among ethic minorities who live in remote areas, have little access to public health information,
and have little understanding of common Lao language. Available data and studies, including
monitoring reports and coverage evaluation surveys revealed that where immunization coverage
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is low communities are often unaware or unconvinced of the need for routine immunization
services. Equally important, low levels of immunization are also an outcome of poor service
delivery.
Lack of knowledge of immunization is a key obstacle. The ethno-cultural beliefs about health and
illness also play an important role in discouraging people not to use immunization service.
Children‘s illness related to vaccine preventable diseases may be seen as a spiritual attack and
this shapes people‘s attitudes and health seeking behavior and keeping people away from
vaccination and families are not adequately informed about the importance of routine
immunization, where and when (pre-notification) to access services, and how to respond to side
effects.
Lack of motivation is a reinforcing barrier. The quality of service delivery is also likely to shape
people‘s attitudes and decision to immunize their children often, the experience of health system
is articulated in terms of poor quality, apathy and inaccessibility.
Surveillance and Cost Studies. There is no community-based surveillance system in Laos and
this hinders the availability of accurate information on the disease burden. There is an acute need
for more disease burden studies to quantify problems so that policymakers can take informed
decisions about the introduction of new vaccines. There is also a lack of Laos-specific cost
analysis of new vaccines and estimated financial benefits of their introduction in Laos. There is a
lack of an institutional mechanism to assess the need for new vaccines/underutilized vaccines
and coordinate appropriate research into disease burden studies and cost-benefit analysis.
Health System and Immunization Barriers documented in the Background Paper for the
Health Chapter of the Mid-term Review of NSEDP6 (Annex 1.28)
Many significant health sector health challenges remain in Lao PDR, including: High maternal
mortality ratio; High prevalence of malnutrition; Low immunization coverage through routine EPI;
Very low levels of utilization of promotive/preventive and curative/rehabilitative services especially
in rural areas; Low domestic public health expenditure with high out-of-pocket spending;
Persisting health human resource constraints in terms of quality/skill mix, quantity, distribution and
motivation; Insufficient clean water and improved sanitation services in rural areas; and Need to
further elaborate existing planning and strategic documents in a broadly consultative process.
Health System and Immunization Barriers documented in the Assessment of Skilled Birth
Attendance in Lao PDR (Annex 1.5C)
There exists a profound under-utilization of Maternal Child Health services in Lao PDR for many
reasons. 85% of the women deliver at home, most of them still believing it is not necessary to
seek medical care. There is a shortage of health providers, both in absolute numbers and in their
distribution, with most in urban settings. The available provider and facility services, often of poor
quality, attempt to function within an inadequate service delivery system (access, coordination,
communication, referral, monitoring, and evaluation). Aggravating the poor health care situation
are travel logistics; the reality is that Lao PDR at present has a dispersed, rural population, up to
21 % living in rural areas without roads.
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3.3: Barriers that are being “adequately” addressed with existing resources
The Government of Lao PDR, with support of international Development Partners, is addressing
the systemic barriers in the health system with a series of major and minor projects. These include
Structural Poverty Reduction, Major Health System Strengthening, Sector Wide Coordination,
Vertical Program and/or Localized Health System Strengthening, and Health Care Financing and
Social Protection activities.
Structural Poverty Reduction Projects. The World Bank is providing general budget support for
Poverty Reduction. The three broad policy areas for which the funds can be used are consistent
with the goals and strategies identified by Government the NGPES and reflected in IDA‘S Country
Assistance Strategy: (i) public resource management; (ii) public expenditure policy; and (iii)
sustainable growth. (Second Poverty Reduction Support Operation (Annex 1.13))
Major Health System Strengthening Projects. Development Partners are supporting Health
System Strengthening with four major projects. The Asian Development Bank is funding the
improvement of primary health care (PHC) delivery in 8 northern provinces of Lao PDR and the
strengthening in the capacity of MOH in planning, budgeting, financing, human resource
development (HRD). (Health System Development Project (Annex 1.10)). In 7 provinces in the
south of Lao PDR, the World Bank is funding activities to improve the quality and utilization of
health services, strengthening institutional capacity for health service provision and improve the
equity, efficiency, and sustainability of health financing (Health Services Improvement Project
(Annex 1.9)). The development objectives are to assist the Lao PDR to improve the health status
of its population, particularly the poor and rural population, in Project Provinces. This will be
accomplished by (i) expanding access to and improving the delivery of a basic package of health
services in seven southern and central Provinces4 through an improved planning, budgeting and
performance orientation of the District health system; (ii) building institutional capacity, both
technical and managerial, in the health workforce at all levels; and (iii) improving the equity,
efficiency and sustainability of health care financing. The Project intends to: (a) apply flexible
financing at District and Provincial health office levels annually, and respond to local priorities; and
(b) establish performance measures for program implementation and financial management, and
apply them as two of several criteria for providing the annual levels of support to Districts and
Provinces. The HSIP will be implemented over a 5 year period (2006-2010). The Luxembourg
Government is strengthening health care services delivery in Vientiane province since 1999 though
the capacity building of the provincial hospital. Since 2003, the ―Health in Vientiane project‖
(LAO/015) is supporting the Provincial Health Department in delivering preventive, promotive and
curative healthcare through intensified health staff training and decentralized health care
throughout the province including the establishment of health insurances schemes targeting the
poor. Human resource development has been strengthened since 2005 in Vientiane province
through the Nursing Training project (LAO/010). More recently the ―Lao-Luxembourg Health
Initiatives Support Programme‖ (LAO/017) for the improvement of the medical equipment
management at provincial hospital level as well as the strengthening of the national Extended
Programme of immunisation in the provinces of Bolikhamsay and Khammouane is scheduled to
start at the beginning of 2008. In this initiative a programmatic approach has been adopted to
promote better integration in the Lao health system and to support the ongoing decentralisation
process of health-care delivery. (Lao-Luxembourg health Initiatives support programme
(Annex 1.14)). The UNICEF health country program (2007-2011) objective is to improve the
health status of mothers and children by increasing access to basic health care with focus on poor
and hard to reach communities (Young Child Survival and Development program (Annex
1.17)). UNICEF provides technical and financial support to immunization service particularly in 9
provinces where UNICF provides operational cost for integrated out reach activities.
UNICEFreceived in 2008 a grand from the Government of Japan to strengthen the EPI cold chain
4
The Project covers 8 provinces: Special Region Xaisomboun, Bolikhamxai, Khammouane, Savannakhet, Champasak,
Salavan, Sekong and Attapu.
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system in Lao PDR. More than 250 health centres will be equipped with refrigerators. Health
workers will be trained on vaccine and cold chain management in order to improve the fixed site
strategy and the effectiveness of out reach activities. UNICEF is providing technical and financial
support to three poor districts in Savanaket province (Sepone, Nong and Vilaboury) to deliver MCH
package to remote villages by out reach strategy. UNICEF is working in close collaboration with
WHO, UNFP and JICA to develop the MCH core package. The integration of MCH package is in
line with UNICEF strategy to achieve the MDG4. Japan has recently announced funding the
strengthening of immunization throughout Laos with a major infrastructure grant
Sector Wide Coordination. The Government of Lao PDR is supported by International
Development Partners. However, to date, support from international and bilateral donors has
been largely uncoordinated and, as the proliferation of a large number of plans and studies
demonstrates, this itself has become a cause of ineffective and inefficient use of resources in the
Laos Health Sector. The Government of the Lao People‘s Democratic Republic and 23 Partners
in Development signed a cooperation agreement in 2006 (the Vientiane Declaration (Annex
1.15)) to make aid more effective and to assist the country in achieving the Millennium
Development Goals (MDGs) by 2015 and the long-term development goal of exiting the status of
least developed country by 2020 (the 2020 goal). In this agreement the signatories agree to
development principles detailed under the following headings: 1. Ownership; 2. Alignment; 3.
Harmonisation and Simplification; 4. Managing for Results; 5. Mutual Accountability. JICA has
assisted the MOH with two major health sector coordination projects. At the National level the
Sector Wide Coordination Mechanism has been established to coordinate the activites together the
MOH, other national stakeholders and development partners such as UN, WHO, WB, ABD,
Luxembourg, Belgium and others. The Coordination Mechanism is described in detail in section
1.1 above. Analogously, the Minimum Requirements service coordination framework provides a
mechanism to coordinate and improve the quality of acute hospital care at Provincial and District
levels. The Minimum Requirements model was tested in Vientiane Province and Oudomxay
Province and has now has been adopted for use in all Provinces (Report on MR Evaluation;
Handbook of Minimum Requirements (Annex 1.16).) The GAVI HSS Initiative will, in part,
implement these principles at the District and sub-District levels.
PHC Model Healthy Village
The 6th National Conference on Health and the 5 year plan and, more recently, the Directives of
the President of Lao PDR to the ministry of Health on 22nd January, 2008 (Annex 1.6???)
focus strengthening of Primary Health Care Delivery through Model Healthy Villages.
The Model Health Village Program has three components:
Component 1: Strengthening capacity building for health System Development in order to be able
to manage grass root level.
1. Strengthening District and Health centre staff capacity to be able to manage and advise
the development of model healthy village at grass root level.
2. Strengthening manager and technical staff capacity and village health workers for
implementing 8 PHC components
Component 2: Increasing coverage of PHC services for development areas, ethnic population
areas, remote areas to become Model Healthy Villages. The Model Health Village Program
document is linked with 6th National Conference on Health description of Lao‘s 8 elements of PHC.
The elements, derived from the Lao version of the 6th National Conference proceedings are:
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1. Increasing access to Health Education (Wash hands, cook food and use latrines
2. Clean water-environmental sanitation (Access to improved Water and Latrines, Waste
Management, remove animals from under the house)
3. Nutrition (Iodized salt, Vitamin A and Iron supplements and De-worming)
4. Immunization for Children and Women in Reproductive Age for Measles and Tetanus
5. Mother and Child Health (IMCI through family Planning/STD & HIV prevention, at least
3 Antenatal visits Deliveries by skilled birth attendants and referral to health facility if
complications & receive at least 1 post natal care; Child health and newborn care and
breast feeding)
6. Control of Common Diseases (Malaria, Dengue, Gastro-Enteritis and Acute
Respiratory Infections)
7. Primary Care
8. Drug Revolving Fund Village Drug Kits and increasing use of Traditional Medicine
Component 3: Strengthening community awareness and capacity for their own health
development.
1. Strengthening head of the community capacity for development
2. Advocacy and establishing community activities in order to be involved in developing the
Model Healthy Village.
Although the general components of Model Healthy Villages have been defined, specification of
the specific services to be provided within the components requires further work. This lack of detail
precludes immediate implementation of all the elements of the model healthy village. However,
because services in the integrated MNCH package are now defined for Lao PDR, the core of the
Model Healthy Village can now be implemented.
The Essential Package of Maternal, Neonatal and Child Care
The Maternal and Child Health Policy/Strategies/Plan of Action, described in Section 2.2 above,
lists 11 priority MCH interventions. The MOH MCH Program has drafted a table of MCH Services
to be delivered within the priority areas (Draft MCH Services Package (Annex 1.23)). An essential
package of Care on Integrated Maternal, Newborn and Child Care (MNCH) has also been drafted
(Draft Essential Package of MNCH (Annex 1.5A)) from Lao PDR adaptations of evidence based
recommendations and strategy papers by WHO, UNICEF and UNFPA, such as ―WHO and
UNICEF Regional Child Survival Strategy‖ and WHO Recommended Interventions for Improving
Maternal and Newborn Health (WHO/MPS/0705). The Essential Package of MNCH is:
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Central &
Village Outreach Health District Hospital Provincial
Item of services Resources Services Centre B A Hospital
Information or counselling O O O O O O
Condoms and oral contraceptives O O O O O O
Family
Injectable Δ O O O O
planning
IUD Δ Δ O O
Vasectomy, tubal ligation Δ O O
4 routine antenatal care visits Δ O O O O
De-worming O O O O O O
Iron & folate supplementation O O O O O O
Two doses of TT immunization or at least three in the past O O O O O
Use of insecticide-treated bed nets from prenatal to postnatal O O O O O O
Monitoring progress of pregnancy and assessment of maternal and
fetal well being O O O O
Detection of pregnancy problems (e.g. anaemia, hypertensive
Pregnancy
disorders, bleeding, mal-presentation, multiple pregnancies) O O O O
care
Syphilis testing O O O O
STI/HIV risk assessment and counselling O O O O
Information and counselling on self care at home, nutrition, sexual
activities, breastfeeding, family planning, healthy lifestyle O O O O O O
Mobilization of delivery in health facility, birth and emergency
planning, advice on danger signs and emergency preparedness O O O O O O
Back up antenatal care if complications Δ O O
Treatment of abortion complications Δ O O
First level delivery care including partograph, AMTSL[1], injectable
antibiotics, oxytocin, magnesium sulphate, neonatal resuscitation O O O O
Back up EmONC including above plus vacuum extraction, manual
Delivery removal of placenta, manual vacuum aspiration O O O
Back up/comprehensive EmONC including above all functions
plus Caesarean Section, blood transfusion O O
Central &
Community Outreach Health DH DH Provincial
Item of services Resources Services Centre B A Hospital
Immediate newborn care (thermal protection, cord care, assess
breathing, initiation of exclusive breastfeeding, infection
prevention, eye prophylaxis) Δ Δ O O O O
Newborn Neonatal resuscitation Δ Δ O O O O
care Information and counselling on home care, breastfeeding, hygiene,
advice on danger signs, emergency and follow-up O O O O O O
Immunization according to the national guidelines (BCG, HepB) Δ Δ O O O
Special newborn care
Δ O O
Community DH DH Central &
Resources Outreach Health B A Provincial
Item of services Services Centre Hospital
Information and counselling on home care, breastfeeding, hygiene,
Postnatal advice on danger signs, emergency and follow-up O O O O O O
care Routine postpartum maternal care (up to 6 weeks) Δ O O O O
Postnatal newborn care (within 7 days) Δ Δ O O O O
Promotion of breastfeeding and complementary feeding O O O O O O
Micronutrient supplementation O O O O O O
Routine immunization of the child O O O O O
TT+2 immunization to women of reproductive age to protect
Child neonatal tetanus O O O O O
health care Outpatient care of the sick child (IMCI) Δ Δ O O O
Hospital care of the sick child (IMCI) O O O
Community IMCI O
Use of insecticide-treated bed nets O O O O O O
De-worming O O O O O O
O Essential Services problem recognition and response targeted in this GAVI HSS Support
Initiative
Δ Essential but provided if accredited services and facilities are available
The MNCH paper lists items of services to be delivered, by service setting, and specific contents of
care. The Essential Package of MNCH was developed through an extensive consultation process
involving National and International Development partners and it is widely endorsed. It is currently
being discussed within the MOH for formal policy endorsement.
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Importantly, the Essential Package of MNCH is a long term ideal package of services to be
provided throughout the country and it will be phased in over the medium to long term. Although
not yet formally evaluated, it is recognised that it will be costly to provide the supporting
infrastructure and it will take time to train health care staff to deliver the full package in all service
settings.
The INGO Network have commenced rolling out the integrated package of MNCH services,
commencing with Houaphan Province; and UNFPA, UNICEF, WHO and SCA have agreed to
provide additional resources to pilot the newly agreed package of MNCH services in 10 Districts in
6 Provinces commencing in October, 2008. Immunization is a core element of the Government‘s
PHC policy and is a key component of the MNCH. The MNCH immunization line is expanded in
detail in the 5 year EPI master plan.
Vertical program (including EPI) and/or localised health facility strengthening projects.
Smaller scale but significant projects have been funded to strengthen health services at specifically
at local levels. These include Health Centre primary health care capacity building in 13 Health
Centres in Vientiane Province (First-line Health Care: The Integrated Community Health
Centers (Annex 1.8)) AusAid has undertaken a health strengthening project at the Health Centre
level in Sayaboury province (Save the Children Australia (Annex 1.21), UNFPA has
strengthened family health planning in 3 Southern Provinces in Laos (UNFPA Presentation
Slides (Annex 1.22), The Belgium Technical Corporation has strengthened Health Centre
services in Sepone District in Savankhet Province and in Vangvieng District in Vientiane Province
(First-line Health Care: The Integrated Community Health Centers (Annex 1.8)) These
projects demonstrate significant improvement in mortality, utilization, and quality of care with
integrated approaches to health care. Locally, immunization has also improved marginally.
However, more focused enhancement of capacity and rationalisation of fixed and outreach
services is required to achieve a sustained improvement in immunization coverage.
JICA has committed $2.5million over 10 years to strengthen the EPI infrastructures and with these
funds UNICEF will commence delivery of equipment in October 2008. The program will strengthen
all aspects of the cold chain for all health services down to community centres with flow on to the
villages.
Since 2002, the Global Fund has provided significant funding to combat TB, Malaria and HIV/Aids
throughout Lao PDR and the World Bank, ADB, UNDP and other partners pledged major
commitments to combat Avian Influenza. UNFPA is supporting establishment of the Logistic
Management Information System for contraceptives, which has a potential to integrate other
commodities to improve logistic management. Although these projects strengthen elements of the
health sector, they do not support PHC in general or EPI and MCH specifically.
Health Financing and Social Protection. There are a number of health financing and social
protection projects planned or in progress in Lao PDR:
The Community Based Health Insurance (CBHI) supported by WHO has been initiated in
11 districts at 6 provinces throughout the country.
The French Development Agency (AFD) is planning to support expansion of CBHI in
Vientiane Capital and Savannakhet Provinces covering 11 districts.
The Ministry of labour and social welfare operates a civil servant pension and insurance
scheme and the Social Security Office (for private formal sector employees) manages a
insurance scheme in 4 provinces. Further expansions are being planned.
ADB is planning to initiate health equity funds in Xieng Khuan, Oudomxay and Sayabury
provinces (starting in Xieng Khuan and by the end of 2010 covering the two others).
The World Bank health equity funds are being initiated in 5 districts in 4 Southern
Provinces.
Swiss Red Cross supports the operation of Health Equity funds in Nam Bak District in
Luang Prabang Province
BTC supports Health Equity funds in Sepone District in Savannakhet Province
Lux-Development supports Health Equity funds for the whole of Vientiane Province.
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These are small pilot projects which have yet to be evaluated and rolled-out to the rest of the
country. The GAVI HSS Initiative will not address direct health care financing issues but it will
address coordination of financing at the District and sub-District levels.
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3.4: Barriers not being adequately addressed that require additional support from GAVI HSS
Significant improvements in health status have been demonstrated where the health service
capacity of Health Centres and Districts has been strengthened, and overall there has been
measurable progress towards achievement of MDGs 4 and 5.
In general, however, primary health care in health centres and in villages remains inadequate.
Despite progress, maternal and Infant mortality rates are still excessively high and immunization
rates are stagnating or declining and there are concerns that progress will be difficult to achieve if
capacity at lower levels is not substantially improved.
The urgent need for strengthening Primary Health Care Delivery at Health Centres and in the
Villages through out-reach with support from District and Provincial Hospitals is emphasized in the
NSEDP6 (Annex 1.1), the Strategic Health Framework To 2020 (1.3), the MOH 5 year plan
2006-2010(Annex 1.2A & 1.2B), cMYP 2007-2012 for Immunization (Annex 1.4) the draft MCH
policy framework (Annex 1.5), The 6th National Conference on Health, the 5 year plan and, more
recently, the Directives of the President of Lao PDR to the ministry of Health on 22nd January,
2008 (Annex 1.6). The last 3 of these focus this strengthening of Primary Health Care Delivery
through Model Healthy Villages.
With the support of Development Partners the MOH is now allocating considerable resources to
the strengthening of PHC at local levels. For example, UNICEF, with funding from JICA, is
strengthening the immunization cold chain, and ADB, WB, Luxembourg and Belgium and others
are strengthening PHC with resources, facilities and service and management training. The MOH
is currently preparing a policy to implement the MNCH package throughout Laos PDR. The INGO
Network have commenced rolling out the integrated package of MNCH services, commencing with
Houaphan Province; and UNFPA, UNICEF, WHO and SCA have agreed to provide additional
resources to pilot the newly agreed package of MNCH services in 10 Districts in 6 Provinces
commencing in October, 2008. The Pilot sites where additional resources are to be allocated for
MNCH service provision are:
Integrated Package of MNCH Services Pilot Sites and Supporting Agencies
Province District Support Agencies
Oudomxay Nga UNFPA/UNICEF
Xoemgkhouang Pek, Nonghad UNFPA/WHO/UNICEF
Luang Prabang Nan, Ponxay SCA
Savannakhet Pin UNICEF
Sekong Tateng, Lamam WHO
Saravan Saravan, Ta Oy UNFPA
The SWG is starting to coordinate initiatives and activities at a national level and the MNCH
package described above was developed through the TWG MNCH/EPI in cooperation with the
Development Partners. However, at present there is little coordination and standardisation of
service delivery and development activities within and between districts. This lack of coordination
accentuates the impact of barriers to delivery of health care. In the absence of standard operating
procedures for clinical and management activities individual development partners provide their
own versions of technical and management training. This results in duplicated effort in package
development and higher overall operating and reporting costs because services and systems are
not standardised. Where different agencies operate within the same province or districts lack of
standard approaches makes it difficult to ensure effective delivery of services. To make aid more
effective, the Development Partners urgently need the MOH to coordinate, harmonise and
integrate existing initiatives and activities within and between districts.
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Weak health services problem solving skills at all levels of the health system but particularly at the
district level and below presents another major barrier to effective development and delivery of
health services. The strategy and planning framework for the integrated package of MNCH
services and the WB, ADB and other projects have management training components. However,
these have not been finalised, primarily target hospitals or districts, focus on broad management
training and/or they have not been standardised. Given the low management skills base there is a
more specific need to target skills development at selected problems specifically related to the
provision of MNCH and EPI services. MOH and WHO MCH and EPI program staff and the
stakeholders consulted in the preparation of this application advise that focused problem solving
training is urgently required, particularly at community, health centre and district levels. However,
to avoid confusion and adding layers of activity, targeted problem solving training should be
coordinated and integrated with existing training programs.
This GAVI HSS Support Initiative will prepare for the roll-out of the integrated package of MNCH by
supporting coordination and integration of MNCH service development and delivery activities and
strengthening MNCH service problem solving capacity within and between districts and between
districts, provinces and national levels. This focus supports the strengthening of health service
delivery in rural areas and complements ongoing efforts of GoL and support of development
partners. The limited scope of the objective makes it achievable given the low skills base and the
limited time-frame and budget (see sections following).
The GAVI HSS Support Initiative will directly address the second of GAVI‘s HSS priority areas, viz.
organization and management of health services [delivery] at the district level and below. The first
and third of GAVI‘s HSS priority areas are indirectly supported by these activities. Coordination
and improved problem solving capacity strengthens the 6 building blocks of Health systems:
Health Services
Human Resources
Support for
Health Information Systems
Coordination and
MNCH Problem
Medical Products and Technology
Solving Capacity
Health Financing
Health Governance and Management
Health Services: Improving coordination of resources and activities within and between districts
and improved problem solving capacity at the local level will enhance effectiveness and efficiency
of health services development activities and delivery .
Human Resources: Training in coordination and problem solving will strengthen human resources
capacity to organise and deliver services.
Health Information Systems: Identifying and collecting basic MNCH/EPI information
requirements at the local level will support strengthening of health information systems.
Medical Products and Technology Identifying medical products and technology appropriate and
affordable at local levels improves efficiency and effectiveness of service delivery
Health Financing: Improving coordination of activities within and between districts and improved
problem solving capacity at the local level will indirectly contribute to better understanding and
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better use of finances generally and addressing health care funding issues for essential services
addresses access and equity issues
Health Governance and Management: Improved problem recognition and action and
communication within and between levels of the health sector strengthens health services
management and advocacy capacity.
Although immunization is represented only by a single line in the MNCH package, it is a core
component of primary health care and is given high priority in Government policies. And the single
line is separately expanded in the Comprehensive Multi-Year Plan - National Immunization
Program (Annex 1.4). Activities in the GAVI HSS Support Initiative directly target immunization
barriers to improve coverage at the local level.
Strengthening coordination and enhanced MNCH problem solving capacity supports
implementation of the GOL/MOH model healthy village policy and delivery of PHC. It does this in
a practical, staged approach starting with a basic, well defined set of services that can be
expanded when circumstances allow.
This GAVI HSS Support Initiative will deliver:
1. Coordination of MNCH and EPI service development and delivery activities within and
between districts
2. A tool for measuring skills in recognizing and acting on MNCH and EPI service
problems at village, health centre and district levels;
3. Improved and sustained MNCH and EPI problem recognition and action at village,
health centre and district levels;
4. Improved communication of needs for and barriers to service provision between the
communities and higher levels of the health sector;
5. Improvement in Maternal and Child Health and Immunization outcomes to help
achieve the MDG 4 & 5;
The GAVI HSS Support Initiative will be initiated in 14 priority poor districts in 5 Provinces selected
after consultations between the PHO and the Provincial Governors under the direction of the
President of the GOL . The criteria used to select the provinces are:
1. Districts selected primarily classified as very poor (ranked in the 72 poorest districts
2. Districts selected are primarily remote or very remote
3. Poverty is positively correlated with MMR AND IMR and the selected districts also
have high MMR and IMR
4. Assured of provincial government and district support
5. Most of the districts do not have MNCH/PHC support from the Government or MOH.
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GAVI HSS Support Initiative Target Provinces and Districts
Province District Poverty Rank
Pek* 2
Xieng Khoang Kham 2
Khoune 1
Mai 2
Phongsaly Samphanh 1
Nhotou 1
Viengthong 1
Houa Phane Huameuang 1
Xamtay 1
Lamam* 3
Khaleum 1
Xekong
Dakcheung 1
Thateng* 3
Vientiane Capital Sangthong 2
1 Very Poor
2 Poor
3 Not Poor
* Receiving additional support from Development Partners
in MNCH pilot studies
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Section 4: Goals and Objectives of GAVI HSS Support
To the applicant
Please describe the goals of GAVI HSS Support Initiative below (Table 4.1).
Please describe (and number) the objectives of GAVI HSS Support Initiative (Table 4.2).
Please ensure that the chosen objectives are specific, measurable, achievable, realistic and
time-bound.
4.1: Goals of GAVI HSS support
The Goal of the GAVI HSS Support Initiative is to contribute to the achievement of MDGs 4
and 5 in Lao PDR by strengthening the capacity of the health sector to deliver an integrated
package of MNCH services (including EPI) at the district, health centre and village level.
4.2: Objectives of GAVI HSS Support
Section 5: GAVI HSS Activities and Implementation Schedule
The objectives of this GAVI HSS support initiative focus on resolution of issues in the six
building blocks. These include:
Health Services: Vaccine and medical products inventory control; distribution logistics; lack of
facilities or diagnostic support; infection control etc.
Human Resources: lack of or ambiguous protocols or guidelines or job descriptions; lack of
clinical or management skills; lack of motivation; lack of non-financial incentives etc.
Health Information Systems: lack of basic demographic, needs and/or activity data; duplication
and non-standard reporting requirements
Medical Products and Technology: lack of electricity; telephones; transport; lack of imaging or
surgical equipment and associated consumables; lack of pharmaceuticals; etc
Health Financing: lack of financial resources; inability to afford services; perverse incentives; low
salaries; lack of financial incentives or inability to pay for out-of-pocket expenses; escalating cost of
consumables such as petrol etc
Health Governance and Management: lack of or ambiguous or conflicting policies or guidelines;
lack of supervision and guidance; inadequate reporting mechanisms; lack of monitoring and
feedback mechanisms etc.
Objective No. 1. To facilitate MNCH and EPI development and delivery of services within
and between districts in selected provinces.
This objective will help improve deployment and availability of health and immunization services by
coordinating and linking local resources, minimising undesirable duplication and increasing
cooperation between service providers and donors in the target districts. It will build on and link
with the Minimum Requirements service coordination framework which provides a mechanism to
facilitate the improvement of the quality of acute hospital care at Provincial and District levels.
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Activities related to objective 1 are:
1.1 Compile an inventory of MNCH and EPI service capacity and current development activities in
each village, health centre and district hospital for the targeted districts including fixed site and
outreach services.
The inventory will be a checklist covering all the services listed in the integrated package of MNCH
with Immunization services expanded from the 5 year immunization plan and an annotation to note
the source of support. Development of the inventory will be coordinated by the TWG MNCH/EPI
using the SBA field assessment tool from the Assessment of Skilled Birth Attendance study
(Annex 1.5C) adapted for the broader range of services to be provided in the MNCH package.
The MNCH centre will manage inventory compilation. In Districts and Health Centres the inventory
will be compiled by Provincial MNCH staff; and in villages by the Health Centre staff. Compilation
of the inventory will be coordinated with routine outreach activities. All villages and health centres
in the target area will be covered.
Information on sources of support will identify further information sources that will be analysed for
potential for harmonisation, alignment and coordination within and between districts in: operational
procedures, guidelines and training; logistics including travel and distribution chains; shared
service provision; incentive schemes; funding and reporting.
Activity 1.1 will identify specific MNCH/EPI needs in each village, health centre and district that
need supporting and/or have potential for harmonisation, alignment and coordination. The
districts targeted for this support were selected on the basis of intrinsic need. The information to
be collected in action item 1.1 is required to advocate for, plan for and implement specific remedial
action in relation to MNCH/EPI service development and provision in the target areas. The
information will be conveyed to the MOH; Development Partners and Provinces for resourcing
support and coordination at the national and provincial levels.
1.2 Facilitate three monthly MNCH/EPI development meetings to improve and integrate services
within and between districts.
The head of each targeted District MNCH/EPI service and representatives of development partners
working in the districts will hold service development coordination meetings each 3 months using
the minimum requirements model adapted to MNCH/EPI services. The purpose of these
meetings will be to harmonise, align and coordinate operational procedures, guidelines and
training; logistics including travel and distribution chains; shared service provision; funding and
reporting within and between districts. Villages will participate in other meetings (see below) and
they will not participate in these coordination meetings.
Improvement measures to be taken include: duplication of vaccine, drugs and medical
consumables supply chains; variable training resources and modalities; duplication and non-
standard reporting requirements; lack of flexibility in staff and/or financial resources etc.
The meetings will be convened at the Provincial Health Office. Proceedings of the meetings will be
recorded and reported to the Provincial Health Service and the MNCH Centre. The meetings will
address issues documented in Activities 1.1 above and 2.4.3 below and any other matters that
lead improvement in the availability, quality and use of health services.
Activity 1.2 will establish a process for improving MNCH and EPI development activities necessary
for efficient implementation and operation of services within and between districts. Proceedings
will be recorded and conveyed to the MOH and Development partners for action in the SWG.
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1.3 Coach Village, Health Centre and District staff in MNCH and EPI problem recognition and to
facilitate action.
The aim of this activity is to coach staff at local levels to recognise problems and to facilitate action
aimed at resolution of the problems. Two categories of problem will be recognised. Problems that
can be resolved within existing resources locally such changing timetables to coordinate related
activities, sharing common training modules or multi tasking for delivery of services; and those
which require support from other levels such as policy constraints on hiring or incentive payments,
SWAp funding, or financing of essential services.
Facilitators with experience in remote health services MNCH/EPI development will be engaged to
assist Village, Health Centre and District staff to recognise and respond appropriately to MNCH
and EPI service problems. The facilitators will travel between and work with districts and support
district outreach teams visiting health centres and villages. All health centres in the targeted
districts will be visited by the facilitators. However, because of time and resource constraints only
10% of villages will be directly supported in this activity. The villages to be included will be
determined in consultation with MOH, Provincial and District stakeholders.
It is not expected all the problems cited above will be solved. Instead the facilitators will focus on 3
specific questions: When do we know we have a problem? How can we fix this problem? And
Who do we need to assist us to fix this problem. This focus will help empower staff to recognise
and respond to problems either by attempting to resolve them within available resources, or to
seek assistance. The facilitators will establish communication links between villages, health
centres, districts, provinces and the National level to report on, monitor and follow response to
problems. Sustained in-service support for these activities will facilitate development of problem
solving and action skills.
Supportive supervision (coaching) is a key consideration included in the integrated strategy for
MNCH services. The facilitators supporting this activity 2.2 will work with the MNCH/EPI outreach
teams to coach members in service problem recognition, action and follow-up. A sustained period
of on-the-job coaching of the outreach teams will help develop and reinforce essential
organisational, logistic and related health services strengthening skills.
Success of this process is dependent on MOH, Development Partners and Provincial support for
and responsive processing of valid requests for essential supplies, equipment, technical training
and support and related matters. As indicated in the minutes of the SWG approving this
application, there was direct and indirect recognition for the need for this support and, if need can
be demonstrated, resources will be allocated to the areas of need.
The facilitators will participate in the Three monthly MNCH service development coordination
meetings (Activity 1.2) and the Bi-monthly meetings of village health volunteers and representative
members of village health committees (Activity 2.4)
This activity will support village, health centre and district level personnel to recognise and respond
to MNCH and EPI problem; and to communicate the problems to health sector managers and
development partners. The facilitator will coach personnel to proactively respond to issues by
taking action locally, or by calling for assistance. The facilitators will demonstrate that observing a
problem and doing nothing is not an acceptable response. Activity 2.2 will strengthen HR capacity
to organise and deliver services at the village, health centre and district levels. It will generate
supportive communication links with higher levels of the health sector. MNCH/EPI problems will be
solved by redeployment of local resources and/or by soliciting support for other sources. This will
have a direct effect on availability and use of health services, and immunization coverage.
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GAVI HSS Application Form 2007
Objective No. 2. To enhance MNCH and EPI services problem recognition skills and then to
take action for selected priority issues at the village, health centre and district levels.
This objective will help improve utilization of health services and immunization coverage by
improving community understanding of health care needs, mobilizing communities ability to identify
health care need and facilitating community support for the use of life saving essential MNCH
services in appropriate settings. This objective will achieve two key results: it will mobilise
individuals in the village, health centres and district levels to take some type action when they
observe MNCH/EPI problems instead of waiting for the problem to resolve itself; and it promotes
information sharing and mutual assistance within and between service levels.
Effective delivery of health services at the local level requires the support from all levels of the
health sector, from the village level to the national level. Because resources are limited, the
primary focus of this initiative is from the village level to the district level. However, Provincial and
National mechanisms for monitoring and support supervision as well as response to problems in
MNCH and EPI services will also be considered and, where necessary, strengthened with
additional MOH and Development Partner support responses.
Activities related to objective 2 are:
2.1 Develop and test a questionnaire to assess village, health centre and district level skills in
recognition of and response to MNCH and EPI problems.
The question set will be developed in TWG coordinated workshops involving a sample of MNCH
and EPI service providers from village, health centre and district levels and field tested to ensure
the questions can be understood and generate meaningful responses at the target service levels.
This activity will develop a set of questions which will determine how well individuals recognise
MNCH and EPI service needs and problems; and if and/or how they respond to these problems.
The information is required to target training and resourcing needs; and to help evaluate the impact
of intervention programs.
The following draft questionnaire will be administered by Health Centre Outreach staff to village
health volunteers and village health committee members subject to endorsement by the TWG.
Similar questionnaires, adapted to the levels, will be compiled for Health Centre staff (fixed site and
outreach), for district Primary Health Care and MNCH/EPI staff and for the district outreach teams.
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GAVI HSS Application Form 2007
Q 1: Can you describe some of the things you can do in your village for the following? (Awareness of Essential Services)
No. Essential
MNCH Service Categories Services for 1 2 3 4 5
category
Family Planning 2
Pregnancy Care 5
Delivery 0
Newborn Care 3
Postnatal Care 2
Child Health Care 5
No of Other
Other PHC Services 1 2 3 4 5
PHC Services
Drug Kit
Safe water supply;
Sanitation;
Safe food in the village and nutrition;
Priority preventable health problems;
if no If talked to
have you talked with someone about someone do
this? (Tick for yes) you think
Village Barriers Tick for yes
someone they can
someone in
Noone outside the help? (Tick
the village
village for yes)
Q 2: In your village: (local HSS Building Blocks)
We know how to do all these things (Skills)
We have enough Equipment and Supplies (Services)
We have enough Drugs (Medicines)
Q 3: In your village when a woman is nearly ready to have a baby or if someone is very sick (access to support)
The village health committee knows what to do (management)
We can call for help (communications)
We can send the person to a health centre or hospital (referal)
People cannot afford to leave the village (finances)
We do not have transport to go somewhere else (transport)
It is too difficult to travel somewhere else (environment)
People don't like to leave the village (expectations)
People don't like the outside services (quality of referal service)
Demographic Data Number
Q 2: In your village:
How many people?
How many women?
How many babies?
How many children under 5?
How many women pregnant?
Number of people died in the last 3 months
Number of women died when they were having a baby
Number of babies died
Number of children under 5 (not babies)
The questionnaire can optionally include questions on additional PHC services.
The deliverable resulting from this activity will be an approved questionnaire (translated into Lao or
a language appropriate for the village respondents) which can be used to assess the ability of
individuals to recognise and respond to MNCH and EPI service problems. This questionnaire will
help improve health service delivery, utilization and immunization coverage because objective
evidence relating to weaknesses and/or trends in skills (in this case problem recognition and
action) makes it easier to advocate for, plan for and implement remedial action.
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2.2 Facilitate bi-monthly MNCH/EPI problem solving meetings for village health volunteers and
representative members of village health committees
Two monthly meetings of village health volunteers and one or two representatives of village health
committees from 10% of the villages in the target districts will be convened to to share experiences
and to discuss MNCH problem recognition and action. These meetings will be grass-roots
problem solving forums. Problems, responses, requests for support and follow-up will be recorded.
The meetings will be held in designated centres. Provincial and National staff will participate in the
discussions.
The deliverables from this activity are village, health centre and district level personnel trained in
essential services MNCH and EPI problem recognition and response; and grass-roots based
health services problem solving forums. This activity will strengthen HR capacity to organise and
deliver services specifically at the village level and generate supportive links with higher levels of
the health sector. MNCH/EPI problems will be solved by redeployment of local resources and/or
by soliciting support for other sources so this activity will have a direct effect on availability and use
of health services, and immunization coverage.
2.4 Assess the impact of the GAVI HSS Support on delivery of MNCH/EPI services at the district,
health centre and village levels.
Evaluation is an integral component of the management process. The initiative will assess the
change in problem recognition and related responses on delivery of MNCH and EPI services. The
evaluation is build into design of the initiative and not conducted as a separate, independent
activity to be undertaken on completion of the initiative. A baseline of skills will be recorded at the
beginning in months 3-6 and change in skills will be recorded in the last month of the GAVI HSS
Support Initiative.
The deliverable from this activity will be quantification of the service impact of the problem
recognition and response skills training program.
2.5 Program Support, Supplies and Related Costs
The initiative will require administrative and project support from the MOH DPF, DH and the Centre
for MNCH. The initiative will pay per diem for participating national counterparts; travel costs; On-
costs for administrative staff in DPF; DP; DH; MCH; EPI; Translation costs; and consumables and
refreshments for workshops and meetings; Operational costs to support the supervision;
telecommunications; fuel; audit fees.
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Section 5: GAVI HSS Activities and Implementation Schedule
To the applicant
For each objective identified in Table 4.2, please give details of the major activities that will be
undertaken in order to achieve the stated objective and the implementation schedule for each
of these activities over the duration of the GAVI HSS support (Table 5.2 overleaf).
Note: GAVI recommend that GAVI HSS supports a few prioritised objectives and activities only. It
should be possible to implement, monitor and evaluate the activities over the life of the GAVI HSS
support.
Note: Please add (or delete) rows so that Table 5.2 contains the correct number of objectives for
your GAVI HSS application, and the correct number of activities for each of your core objectives.
Note: Please add (or delete) years so that Table 5.2 reflects duration of your GAVI HSS application
To the applicant
Please identify below how you intend to sustain, both technically and financially, the impact
achieved with GAVI HSS support (5.1) when GAVI HSS resources are no longer available.
5.1: Sustainability of GAVI HSS support
Strengthening of Health Services: The GOL and the Development Partners are actively working
to improving HR skills and the quality of Health Care facilities. Key DPs supporting health in the
GAVI HSS focus provinces/districts (e.g. ADB, World Concern) have been identified and
approached. The GAVI HSS Support Initiative complements these activities. The combined
activities will improve the effectiveness and efficiency of PHC at District, Health Centre and Village
levels. Emphasis on improvement of the quality of services at these levels and more systematic
delivery of Health Promotion and Education programs through MNCH will promote demand for
fixed site (Health Centre) services and reduce the need for outreach services especially in villages
with access to services.
Integration of Programs and Projects: The MOH has developed and is using the SWC
Mechanism to share information within the MOH and with Development Partners. This coordinates
development activities. The GAVI HSS Support Initiative builds on the Integrated MNCH package
designed to be implemented at the District, Health Centre and Village levels. Integrated service
delivery, unified reporting and coordinated funding will help to channel resources from overheads
to services. This process will be further facilitated by the expected improvements in District, Health
Centre and Village problem identification and response skills.
Pre Service and Post-graduate Education of Service Providers. Ongoing HR education and
training activities will generate a sustainable pool of PHC providers. The Skilled Birth Attendance
Development Plan for La PDR (Annex 1.5B) supplements the integrated package of MNCH
services strategy and provides a comprehensive plan for development of SBAs. This plan has
widespread support both within the MOH and in the development partner community and it is in the
process of being implemented through the SWC mechanism.
Establishment of Posts, Improved Service Conditions and Incentives: PACSA is developing
new guidelines and regulations for the establishment of Posts and associated service conditions,
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GAVI HSS Application Form 2007
including performance based incentives specifically for Rural areas. The MOH itself is currently
assessing different incentive mechanisms for potential application across the country. This will
relax constraints on employment of staff in the health sector and align reimbursements and
incentives with the Education sector where staff enjoy higher incomes and better service
conditions. These initiatives will help improve morale in the health sector and lead to improved
productivity and quality of care. The cost of these initiatives is anticipated in the NSEDP6.
Some Development Partners are already funding incentive schemes throughout Lao PDR, in local
settings and/or for vertical programs. These schemes cover non-salary service costs such as per
diem payments and costs of travel and performance related non-salary payments. Different
incentive schemes are being implemented in the north by ADB, the south by the World Bank and
locally by other Development Partners such as Lux-Development, AusAid, the Belgium
Development Corporation, and UNICEF. This GAVI HSS Support Initiative will design a set of
incentives for village, health centre and district levels which encourages active problem recognition
and response activities at these levels; and negotiate with the MOH and Development partners to
sustain the incentives.
Financial Sustainability: In 2005, the MOH estimated Per Capita Expenditure on health in Lao
PDR to be $US17. MOH details of health expenditures include:
General government expenditure on health (GGHE) as % of
Total Health Expenditure (THE) 20.6
Private sector expenditure on health (PvtHE) as % of THE 79.4
GGHE as % of General government expenditure 4.15
Social security funds as % of GGHE 12.9
Prepaid and risk-pooling plans as % of PvtHE 0.5
Private households' out-of-pocket payment as % of PvtHE 92.7
Non-profit institutions expenditure on health as % of PvtHE 6.8
Capital, recurrent and performance related incentive expenditures are currently jointly shared by
the GOL/MOH and the Development Partners and there are formal commitments to support the
development of MNCH (see Table 8.3) . The GAVI HSS Incentive is designed to improve the
effectiveness and efficiency of MNCH delivery. There is an expectation that this initiative will
achieve better health outcomes and service quality. Major Development Partners such as the
World Bank, the Asian Development Bank, Lux-Development and WHO are actively negotiating
with the GOL to phase in increased Government Financing. The Government has declared the
Health Sector to be one of 4 priority development areas. As part of this priority, the GOL made a
commitment to increase expenditures on Health. The GOL and Development Partners are
actively strengthening the economy of Lao PDR generally, and major development projects, such
as hydro electricity schemes and mines will increase revenues for Government. As more
Government finances flow into the Health sector, more funds will become available for PHC in the
Provinces where the GAVI HSS Support Initiative is being implemented.
As indicated in section 3.3, the MOH and Development Partners are exploring alternative funding
mechanisms in major projects. Civil Service and Social Security Office now insure about 65
thousand people (approximately 1% of the population). Health Equity funds cover about 25
thousand Private Health Insurance about 2 thousand and Community Based Health Insurance
about 25 thousand. These financial initiatives are designed to improve sustainability of health
services. Supplementing and/or replacement of Government funding through these mechanisms
will release further funds for MNCH.
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GAVI HSS Application Form 2007
Advocacy for Health Care: The GAVI HSS Support Initiative will strengthen MNCH and EPI
problem recognition and response skills. Advocacy on the need for health care and barriers to the
provision of care will be a major component of problem response. This will lead to greater
recognition of health care problems by community leaders, specifically the Provincial Governors,
the District Leaders and the Village Health Committee. Experience with projects such as the
recent Measles Campaign and the local Health Centre strengthening projects in Lao PDR shows
this will have two major effects:
Community leaders will mobilize additional local funds and/or in kind support for health
services to supplement Government and Development Partner support expenditures.
Community leaders will begin to promote appropriate use of PHC (including EPI and
MCH). Investments through other HSS programs will progressively improve Facilities,
Equipment and the general skills of health care staff in the Districts and the Health
Centres. Promotion of appropriate use of Health Care combined with improved quality
Building of services will change the health services seeking behaviour of Village Families and
on Lessons Learned: The NSEDP6 has emphasizes the need to build on lessons
Two key lessons are: (1) that Centres are used when villagers need health care.
learned. make it more likely that Health Economic growth must be linked to social progress (such
as poverty reduction and gender equality) and equity, cultural development and environmental
conservation, including the strong development of education and training, and scientific and
technological capacities; and (2) that continued reform of the public administration, including
central and local organizations and the civil service, consistent with the country‘s socio-economic
development level is essential. Further, the specific successes of HSS projects in Lao such as the
Kidsmile and the BTC projects show that improvements in the standard of care and the quality of
services leads to relatively low cost increases in demand for health care, capacity to deliver health
care, and greatly improved health care outcomes. By applying and building on these lessons the
GAVI HSS Support Initiative increases the chances that the activities can be sustained.
Enhanced Problem Recognition and Response Capacity: The GAVI HSS Support Initiative will
strengthen village, health centre and district level capacity to identify and respond to MNCH and
EPI problems. This increased capacity will strengthen the capacity and involvement of community
participation in health care needs assessment and health service delivery, in particular in capacity
to recognise and to seek assistance for health care issues that should and can be addressed at
different levels of the health care system. A specific aim is to reduce the risk of childbirth and
neonatal complications by increasing the proportion of births attended by SBAs with the support of
accredited birthing centres.
Importantly, this GAVI HSS support initiative supports planned activities of the MOH and the
Development Partners. Strengthening MNCH and EPI problem identification and response skills at
the local Level will increase the chances that the MNCH and EPI initiatives can be sustained.
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5.2: Major Activities and Implementation Schedule
Year 1 Year 2
Activity
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Improve MNCH/EPI services at District Level
Compile an inventory of MNCH and EPI service capacity x x
Improve services within and between districts. x x x x x x
Coach problem recognition and facilitate problem solving action x x x x x x x x
Improve services at the village level
Develop and test a questionnaire to assess recognition of and response skills. x
Facilitate problem solving at village level x x x x x x x x
Evaluation and Support
Assess the impact of the GAVI HSS Support on delivery services x x
Program Support, Supplies and Related Costs x x x x x x x x
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GAVI HSS Application Form 2007
Section 6: Monitoring, Evaluation and Operational Research
To the applicant
All applications must include the three main GAVI HSS impact / outcome indicators:
i) National DTP3 coverage (%)
ii) Number / % of districts achieving ≥ 80% DTP3 coverage5
iii) Under five mortality rate (per 1000)
Please list up to three more impact / outcome indicators that can be used to assess the impact
of GAVI HSS on improving immunisation and other child and maternal health services.
Note: It is strongly suggested that the chosen indicators are linked with proposal objectives and not
necessarily with activities.
For all indicators, please give a data source, the baseline value of the indicator and date, and a
target level and date. Some indicators may have more than one data source (Table 6.1).
Note: The chosen indicators should be drawn from those used for monitoring the National Health
Sector Plan (or equivalent) and ideally be measured already (i.e. not an extra burden to measure).
They do not have to be GAVI HSS specific. Examples of additional impact and outcome indicators
are given in the tables below. It is recommended that when activities are implemented primarily at
sub-national level that indicators are monitored, to the extent possible, at sub-nationally as well.
Examples of Impact Indicators
Maternal mortality ratio
Examples of Outcome Indicators
National measles coverage
Proportion of districts with coverage at 80% or above
Hib coverage
HepB coverage, BCG coverage
DTP1-DTP3 drop-out rate
Proportion of births attended by skilled health personnel
Antenatal care use
Vitamin A supplementation rate
Intervention Possible indicators
Immunisation National measles coverage; proportion of districts with coverage at 80% or above;
BCG coverage; Polio 3 coverage; Hib coverage; HepB3 coverage
Maternity care Antenatal care use; skilled birth attendance; tetanus toxoid 2 or more doses;
caesarean section rate; postnatal care
Family planning Contraceptive use among women
Treatment of sick oral rehydration therapy and continued feeding for children with diarrhoea; Care
children seeking for pneumonia; Antibiotic treatment for pneumonia
Nutrition Breastfeeding rate; (start on first day, exclusive at 0-3 months, supplements at 6-9
months); vitamin A supplementation rate to children 6-59 months (within last 6
months) and postpartum to mother within 8 weeks
Water/sanitation Access to safe water source; adequate sanitary facilities
Tuberculosis DOTS treatment coverage (treatment success rate times case detection rate)
Malaria Children with fever receiving anti-malarials; children sleeping under ITN
AIDS % of HIV-positive pregnant women receiving anti retro-viral treatment; PMTCT
5
If number of districts is provided than the total number of districts in the country must also be provided.
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GAVI HSS Application Form 2007
among pregnant women
To the applicant
Please list up to 6 output indicators based on the selected activities in section 5. (Table 6.2).
For all indicators, please give a data source, the baseline value of the indicator and date, a
target level and date, as well as a numerator and denominator. Some indicators may have
more than one data source (Table 6.1).
Note: Examples of output indicators that could be used, with the related numerator, denominator (if
applicable) and data source are shown below. Existing sources of information should be used to
collect the information on the selected indicators wherever possible. In some countries there may
be a need to carry out health facility surveys, household surveys, or establish demographic
surveillance. If extra funds are required for these activities, they should be included.
Examples of Output Indicators
Indicator Numerator Denominator Data Source
Systematic Number of health centres visited at least 6 times Total number of Health facility
Supervision in the last year using a quantified checklist health centres survey
Knowledge of Mean score of health workers in public and Health facility
Health Workers NGO health centres on verbal knowledge test survey
including case scenarios
Drug availability Average number of ten selected essential drugs HMIS & Health
index that are in stock in sampled health centres facility survey
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GAVI HSS Application Form 2007
6.1: Impact and Outcome Indicators
7
Indicator Data Source Baseline Source Date of Target Date for
6
Value Baseline Target
Health Centre Staff Collects at the
Village level; Submit through MOH EPI
1. National DTP3 coverage (%) 81 2006 85 2010
District up to EPI National Data Collection
Base
Health Centre Staff Collects at the
2. Number / % of districts achieving ≥80% Village level; Submit through MOH EPI
63 2006 80 2010
DTP3 coverage District up to EPI National Data Collection
Base
Household Survey – Population
Census Collected every 10 years;
Population
3. Under five mortality rate (per 1000) Reproductive Health Survey 98 2005 70 2015
Census 2005
every 5 years Conducted by
National Statistics Centre
Household Survey – Population
Census Collected every 10 years;
4. Infant (< 1 year) mortality rate (per 1000 Population
Reproductive Health Survey 70 2005 45 2015
live births) Census 2005
every 5 years Conducted by
National Statistics Centre
5. Maternal Mortality Rate (per 100,000 live Household Survey – Population Population
405 2005 260 2015
births) Census Collected every 10 years; Census 2005
Note: Baseline data for the 5 baseline impact indicators are available at National and Provincial levels. For the GAVI HSS impact assessment, only
National statistics will be collected in 2010-2012. At the Provincial and District levels populations and births are difficult to enumerate and further
studies will be required to evaluate the impact at these levels. These more detailed evaluations will be conducted as part of the GAVI HSS Initiative if
funding is extended beyond the life of NSEDP6.
6
If baseline data is not available indicate whether baseline data collection is planned and when
7
Important for easy accessing and cross referencing
65
GAVI HSS Application Form 2007
6.2: Output Indicators
Indicator Numerator Denominator Data Source Baseline Source Date of Target Date for
Value Baseline Target
th
1 Districts with Number of Number of PHO records of 0 NA 2008 100% of 4 Quarter
active MNCH/EPI Districts targeted meetings districts Year 2
Coordination participating in districts
Meetings Coordination
Meetings
th
2 Villages with Number of 10% of targeted PHO records of 0 NA 2008 100% of 4 Quarter
active MNCH/EPI Villages villages meetings participati Year 2
Problem participating in ng villages
recognition and Problem solving
action meetings Meetings
rd th
3 Improvement in Change in Baseline Project Survey To be Project 3 Quarter 100% of 4 Quarter
MNCH/EPI Service MNCH/EPI MNCH/EPI defined in Year 1 participati Year 2
Recognition service Service Project ng
Recognition Recognition Villages
score score increase
score
rd th
4 Improvement in Change in score Baseline score Project Survey To be Project 3 Quarter 100% of 4 Quarter
MNCH/EPI Service MNCH/EPI MNCH/EPI defined in Year 1 participati Year 2
Recognition requesting requesting Project ng
support support Villages
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GAVI HSS Application Form 2007
To the applicant
Please describe how the data will be collected, analyzed and used. Existing data collection and
analysis methods should be used wherever possible. Please indicate how data will be used at
local levels and ways of sharing with other stakeholders in the last column (Table 6.3).
6.3: Data collection, analysis and use
Indicator Data collection Data analysis Use of data
Impact and outcome
1. National DTP3 coverage (%) Data will be used to
indicate relative
performance and to
target areas for
Analysed by MOH
intervention at the
EPI Program in MCH
Health Centre Staff Health Centre,
Centre in consultation
Collects at the Village District and Provincial
with MOH Planning
level; Submit through Levels. Data will be
and Budgeting
District up to EPI supplied to the village
Department;
National Data Base health committees;
Summary of status
The District leaders;
for Districts
the Provincial
Governor and the
MOH for action and
support;
2. Number / % of districts Data will be used to
achieving ≥80% DTP3 coverage indicate relative
performance and to
target areas for
Analysed by MOH
intervention at the
EPI Program in MCH
Health Centre Staff Health Centre,
Centre in consultation
Collects at the Village District and Provincial
with MOH Planning
level; Submit through Levels. Data will be
and Budgeting
District up to EPI supplied to the village
Department;
National Data Base health committees;
Summary of status
The District leaders;
for Districts
the Provincial
Governor and the
MOH for action and
support;
3. Under five mortality rate (per Data will be used to
Analysed by the
1000) indicate relative
National Statistics
performance and to
Department in the
target areas for
Household Survey – Ministry of Planning
intervention at the
Population Census and Investment in
Health Centre,
Collected every 10 consultation with
District and Provincial
years; Reproductive MOH Planning and
Levels. Data will be
Health Survey every Budgeting
supplied to the village
5 years Conducted Department and the
health committees;
by National Statistics MCH Centre.
The District leaders;
Centre National Level only;
the Provincial
Separate Evaluation
Governor and the
Required for
MOH for action and
Provinces
support;
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GAVI HSS Application Form 2007
4. Infant (< 1 year) mortality rate Data will be used to
Analysed by the
(per 1000 live births) indicate relative
National Statistics
performance and to
Department in the
target areas for
Household Survey – Ministry of Planning
intervention at the
Population Census and Investment in
Health Centre,
Collected every 10 consultation with
District and Provincial
years; Reproductive MOH Planning and
Levels. Data will be
Health Survey every Budgeting
supplied to the village
5 years Conducted Department and the
health committees;
by National Statistics MCH Centre.
The District leaders;
Centre National Level only;
the Provincial
Separate Evaluation
Governor and the
Required for
MOH for action and
Provinces
support;
5. Maternal Mortality Rate (per Data will be used to
Analysed by the
100,000 live births) indicate relative
National Statistics
performance and to
Department in the
target areas for
Household Survey – Ministry of Planning
intervention at the
Population Census and Investment in
Health Centre,
Collected every 10 consultation with
District and Provincial
years; Reproductive MOH Planning and
Levels. Data will be
Health Survey every Budgeting
supplied to the village
5 years Conducted Department and the
health committees;
by National Statistics MCH Centre.
The District leaders;
Centre National Level only;
the Provincial
Separate Evaluation
Governor and the
Required for
MOH for action and
Provinces
support;
Output
1. inventory of MNCH/EPI Information will be
Service Capacity in Target used to advocate for,
Districts plan for, implement
and monitor change
MNCH Centre
in service capacity;
Analysis of
TWG Records of information to be
MNCH/EPI service
Activities shared with other
Capacity in Target
MOH Departments
Districts
and Development
Partners through
SWG and TWG
MNCH/EPI
2. Minutes of District Coordination Information will be
Meetings used to advocate for,
plan for, implement
and monitor change
MNCH Centre in service capacity;
Analysis of information to be
PHO Records of Contribution towards shared with other
Meetings Improved MOH Departments
Coordination of and Development
MNCH/EPI services Partners through
SWG and TWG
MNCH/EPI
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GAVI HSS Application Form 2007
3. Questionnaire to assess Information will be
Problem Identification and used to advocate for,
Responses plan for, implement
MNCH Centre and monitor change
Analysis of in service capacity;
TWG Records of MNCH/EPI problem information to be
Activities recognition and shared with other
response in Target MOH Departments
Districts and Development
Partners through
SWG and TWG
MNCH/EPI
2. Minutes of Village Level Information will be
MNCH/EPI Problem recognition used to advocate for,
and action Meetings plan for, implement
and monitor change
MNCH Centre
in service capacity;
Analysis of
PHO Records of information to be
Contribution towards
Meetings shared with other
Improved resolution
MOH Departments
of MNCH/EPI issues
and Development
Partners through
SWG and TWG
MNCH/EPI
3. Assessment of Problem Information will be
Identification and Responses used to advocate for,
plan for, implement
MNCH Centre and monitor change
Analysis of in service capacity;
MNCH Records of MNCH/EPI problem information to be
Analysis recognition and shared with other
response skills in MOH Departments
Target Districts and Development
Partners through
SWG and TWG
MNCH/EPI
Baseline data for the 5 baseline impact indicators are available at National and Provincial levels.
At this stage the authorities are planning compilation only of National statistics for the 5 baseline
indicators in 2010-2012.
At the Provincial and District levels populations and births are difficult to enumerate and further
studies will be required to determine the impact at these levels. Because there is no effective
baseline at the District level, these studies will have a qualitative component.
The MOH Planning and Budgeting Department will collect data for the selected output indicator as
part of the GAVI HSS initiative.
The MOH will monitor the activities listed in 6.3 OUTPUT Indicators above and report on
achievements .
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GAVI HSS Application Form 2007
To the applicant
Please indicate if the M&E system needs to be strengthened to measure the listed indicators
and if so describe which indicators specifically need strengthening. (Table 6.4).
Please indicate if the GAVI HSS application includes elements of operational research that
address some of the health systems barriers to better inform the decision making processes or
health outcome. (Table 6.5).
6.4: Strengthening M&E system
Monitoring and Evaluation needs to be strengthened throughout the Health Sector. Information
systems, where they exist, are fragmented and project or program based. Few guidelines are
used, there is no quality control and very poor use of data for management, evaluation or research.
The MOH, with the support of Development Partners, is undertaking extensive development work
to address this deficiency. The GAVI HSS Support Initiative will complement these activities by
improving collection, management and use of data at the District, Health Centre and Village levels;
and promoting integration of information systems such as EPI, Family Planning and Commodity
logistics and planning in the District level Coordination Meetings and in the Village level problem
recognition and response meetings. The GAVI HSS Support Initiative will explicitly improve
capacity to collect basic demographic data at the village level in planned skills development and
evaluation activities.
The information gathered will support evaluation and provide objective evidence of Initiative
impacts and change in availability and quality of MNCH/EPI services.
6.5: Operational Research
The GAVI HSS Support Initiative will support the implementation of existing Government Policies.
The importance of Operational Research is recognised. However, at this stage it is not anticipated
funds provided through this initiative will be used for operational research.
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GAVI HSS Application Form 2007
Section 7: Implementation Arrangements
To the applicant
Please describe how the GAVI HSS support will be managed (Table 7.1). Please also indicate
the roles and responsibilities of all key partners in GAVI HSS implementation (Table 7.2).
Note: GAVI encourages aligning GAVI HSS with existing country mechanisms. Applicants are
strongly discouraged from establishing a project management unit (PMU) for GAVI HSS. Support
for PMUs will only be considered under exceptional circumstances, based on a strong rationale.
7.1: Management of GAVI HSS support
Management mechanism Description
At the time of drafting this proposal the individual
Name of lead individual / unit responsible for is Dr. Prasongsidh BOUPHA, Deputy Director
managing GAVI HSS implementation / M&E etc. General of the Department of Planning and
Budgeting, MOH.
The SWC mechanism is used to align the
Role of HSCC (or equivalent) in implementation of activities of the Development Partners to help
GAVI HSS and M&E achieve GOL and MOH objectives in general, and
the GAVI HSS Initiative objectives specifically.
At the national level, the MOH Steering
Committee, which also steers the SWC
mechanism, will over-see the GAVI HSS and
ongoing M&E activities. This addresses
coordination of activities within and between MOH
programs.
The SWC mechanism is used to align the
activities of the Development Partners to in
general to help achieve GOL and MOH objectives,
Mechanism for coordinating GAVI HSS with other and specifically to help achieve the objectives of
system activities and programs the GAVI HSS Initiative.
At the Provincial and District Levels, the GAVI
HSS activities will be coordinated by the
Department of Planning and Budgeting and the
PHO.
At the District Level and sub-district levels, the
coordination functions of the District Health
Administration Unit will be strengthened as part of
the GAVI HSS initiative
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GAVI HSS Application Form 2007
7.2: Roles and responsibilities of key partners (HSCC members and others)
Title / Post Organisation HSCC Roles and responsibilities of this partner in
member the GAVI HSS implementation
yes/no
Chair of the MOH Steering Committee
Minister of
MOH Yes Ministerial Oversight and personal support for
Health
the activities
MOH Steering
Committee
Members (Vice-
Coordinating the activities on their own areas
Ministers, seven MOH Yes
of responsibility within the MOH
Departmental
Director
Generals)
Deputy Director General of Planning &
Budgeting Department,
National Director of GAVI HSS
Dr Prasongsidh
MOH Yes Delegated responsibility by the Minister of
BOUPHA
Health for overall implementation of the GAVI
HSS initiative; authorized to approved budget
and expenditure of Department of Hygiene
Director Responsible for administrative oversight of
Department of MOH Yes the initiative; reports to Steering Committee
Hygiene and SWG
Responsible for administrative oversight of
Treatment
MOH Yes the initiative; reports to Steering Committee
Department
and SWG
Operational Executive Officer
Dr. Soulivanh
MOH Yes Assistant to the National Director of GAVI
PHOLSENA
HSS
Responsible for technical implementation of
Director MNCH
MOH Yes the initiative; reports to Department of
Centre
Hygiene and the TWG
Responsible for technical implementation of
Director EPI
MOH Yes the initiative; reports to Department of
Centre
Hygiene and the TWG
Technical Team
(Representatives
from seven
Responsible for activity implementations
Departments MOH No
within their department responsibilities
and related
vertical
programs)
Provincial Executive Officer
PHO Deputy Responsible for overall implementation and
MOH No
Director coordination of the GAVI HSS initiative within
their province
PHO Technical Supervision and facilitation of the activity
MOH No
Team implementation in the districts
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GAVI HSS Application Form 2007
Senior Officer in Charge
DHO Deputy Responsible for overall implementation and
MOH No
Director coordination of the GAVI HSS initiative within
their district
DHO
Implementation of activities within their district
Administration MOH No
and sub-district (Health Centres and villages)
Unit
WHO; JICA;
ADB; WB;
UNICEF/UNFPA
Development Coordinating the GAVI HSS initiative with
nominated Yes
Partners their responsible program
Representatives
on Health Sector
Working Group
To the applicant
Please give the financial management arrangements for GAVI HSS support. GAVI encourages
funds to be managed „on-budget‟. Please describe how this will be achieved (Table 7.3).
Please describe any procurement mechanisms that will be used for GAVI HSS (Table 7.4).
7.3: Financial management of GAVI HSS support
Mechanism / procedure Description
Normal Government Channels will be used to channel funds.
Mechanism for channelling GAVI The MOH Bank account will be used to channel the money into Lao
HSS funds into the country PDR. To facilitate management and auditing, GAVI HSS Initiative
expenditures will be recorded in a separate sub-account.
Department of Planning and Finance transfers funds to MNCH
Centre when expenditures have been approved by the Department
Mechanism for channelling GAVI
of Hygiene; MNCH Centre distributes funds to Provinces, Districts
HSS funds from central level to the
and Health Centres based on approved funding requests; MNCH
periphery
Centre approves funding of Village level expenses and allocates
funds through districts for meetings.
There will be three levels of responsibility for approving budget use:
DPF approves overall budgets on request by DH; DH approves
Mechanism (and responsibility) for
budgets submitted by MNCH Centre; MNCH prepares budgets for
budget use and approval
Project Activities, Provinces, Districts and Villages and submits to
DH.
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GAVI HSS Application Form 2007
Disbursement of funds at the national level to the MNCH Centre will
be authorised by Dr. Prasongsidh BOUPHA, Deputy Director
General of the Department of Planning and Budgeting, MOH or his
successor;
Mechanism for disbursement of
GAVI HSS funds
Disbursement of funds at the sub-national levels will be delegated
MNCH Centre based on achievement of approved milestones and
agreed expenditures documented activity budgets
Internal Audit through the MOH audit procedures
Auditing procedures External Audit by accredited external audit firm commissioned for
and budgeted for in the GAVI HSS initiative
7.4: Procurement mechanisms
Procurement Rules of the GOL and MOH will be applied where necessary.
To the applicant
Please describe arrangements for reporting on the progress in implementing and using GAVI
HSS funds, including the responsible entity for preparing the APR. (Table 7.5)
Note: The GAVI Annual Progress Report, due annually on 15 May, should demonstrate: proof of
appropriate accountability for use of GAVI HSS funds, financial audit and proper procurement (in
line with national regulations or via UNICEF); efficient and effective disbursement (from national to
sub-national levels; in the context of a SWAp mechanism, if applicable); and evidence on progress
on whether expected annual output targets and longer term outcome targets are being achieved.
7.5: Reporting arrangements
Financial Reporting
Health Centres will submit to Districts and District Administration Units will submit standard
quarterly reports to the Provinces. Provinces will submit a standard aggregate report to the MOH
Department of Hygiene. The Department of Hygiene will report Quarterly to the MOH Steering
Committee and Annually to GAVI. Reports will also be shared with the Provincial Governors and
the District and Village Leadership.
MNCH/EPI Coordination and Problem Solving Meetings
Record of meetings will be submitted to MNCH Centre and distributed to SWG and TWG members
with a final report to GAVI
MNCH/EPI Inventory and Problem Recognition/Action Skills Assessment
Reports to be prepared by MNCH Centre and distributed to SWG and TWG members with copies
to GAVI
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GAVI HSS Application Form 2007
Objective 2009 2010
All Target Districts submit
minutes of 2 coordination
Objective No. 1. To Completed inventory of meetings to MNCH
facilitate MNCH and EPI MNCH/EPI Service Centre.
development and delivery Capacity in Target Analysis of coordination
of services within and Districts minute meetings
between districts in All Target Districts submit demonstrates meetings
selected provinces. minutes of 1 coordination make significant
meeting to MNCH Centre contribution to local
coordination activities
All Target Districts submit
minutes of 1 Village level
MNCH/EPI Issues
meeting for 10% of
Questionnaire to assess
villages to MNCH
Objective No. 2. To Problem Identification
Assessment of
enhance MNCH and EPI and Responses
MNCH/EPI problem and
services problem Completed for Village,
response skills in
recognition skills and Health Centre and District
Villages, Health Centres
then to take action for Levels
and Districts
selected priority issues at All Target Districts submit
Analysis of MNCH/EPI
the village, health centre minutes of 1 Village level
Issues meeting
and district levels. MNCH/EPI Issues
demonstrates meetings
meeting for 10% of
make significant
villages to MNCH
contribution to improving
availability and use of
local services
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GAVI HSS Application Form 2007
To the applicant
Some countries will require technical assistance to implement GAVI HSS support. Please
identify what technical assistance will be required during the life of GAVI HSS support, as well
as the anticipated source of technical assistance if known (Table 7.6).
7.6: Technical assistance requirements
Activities requiring technical assistance Anticipated Anticipated Anticipated
duration timing (year, source (local,
quarter) partner etc.)
Preparation of MNCH/EPI Capacity Inventory 6 Months Q1-2 Yr 1 Contract
Consultant
Questionnaire to assess problem recognition 2 Months Q1 Yr 1 Contract
and response skills Consultant
Sustained In-service MNCH/EPI Problem 24 Months Q1 Yr 1 – Q4 Contract
Solving coaching Yr 2 Consultant
Evaluation 2 Weeks Q4 Yr 2 Contract
Consultant
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GAVI HSS Application Form 2007
Section 8: Costs and Funding for GAVI HSS
To the applicant
Please calculate the costs of all activities for the duration of the GAVI HSS support. Please add
or delete rows / columns to give the right number of objectives, activities and years. (Table 8.1)
Note: Please ensure that all support costs for management, M&E, and technical assistance are
included. Please convert all costs to US$ (at the current exchange rate), and ensure that GAVI
deflators are used for future costs (see guidelines on the GAVI website: www.gavialliance.org ).
Note: The overall total request for GAVI HSS funds in table 8.1 should not exceed the overall total
of GAVI HSS funds allocated in table 8.2. Funds may be requested in annual trenches according to
estimated annual activity costs. These may vary annually from the allocation figures in table 8.2.
8.1: Cost of implementing GAVI HSS activities
To the applicant
Please calculate the amount of funds available per year from GAVI for the proposed GAVI HSS
activities, based on the annual number of births and GNI per capita as follows (Table 8.2):
- If GNI < $365 per capita, country is eligible to receive up to $5 per capita
- If GNI > $365 per capita, country is eligible to receive up to $2.5 per capita
Note: The following example assumes the birth cohort in the year of GAVI application is 100,000,
and gives the total fund allocations if the GNI < $365 per capita and if the GNI > $365 per capita.
8.2: Calculation of GAVI HSS country allocation
Allocation per year (US$)
Year of Year 1 of Year 2 of TOTAL
GAVI HSS Allocation GAVI implement implement
FUNDS
application ation ation
2009 2010
Birth cohort 213,860 218,943
Allocation per newborn $2.5 $2.5
Annual allocation $534,649 $547,358 $1,082,007
Source and date of GNI and birth cohort information:
GNI: 6th NSEDP 2006-2010 (2005)
Birth cohort: Population Census (2005)
Total Other: Birth Cohort Projections -- Population Census (2005)
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GAVI HSS Application Form 2007
To the applicant:
Note: Table 8.3 is not a compulsory table.
Please endeavour to identify the total amount of all expected health system strengthening
related spending in the country during the life of the GAVI HSS application (Table 8.3).
Note: Please specify the contributions from the Government, GAVI and the main funding partners
or agencies. If there are more than four main contributors, please insert more rows. Please indicate
the names of the partners in the table, and group together all remaining expected contributions.
Please indicate the source of the data (Public Expenditure Review, MTEF, donor reports etc).
8.3: Sources of all expected funding for health systems strengthening activities
Allocation per year (US$)
Year of Year 1 of Year 2 of TOTAL
Funding Sources GAVI implement implement
FUNDS
application ation ation
20… 20… 20…
GAVI
534,649 547,358 1,082,007
Government Health
Expenditure at selected
three provinces 1,932,000 1,970,000 2,000,000 5,902,000
Government on HSS
activities 1,887,000 2,076,000 2,283,000 6,246,000
Development partners
commitment on HSS
activities (ADB, WB,
JICA, Luxemburg
Development and
others) 40,225,000 26,500,000 21,339,000 88,064,000
TOTAL FUNDING
44,044,000 31,080,649 26,169,358 101,294,007
Government Health
Expenditure at National
Level 5,856,000 6,442,000 7,086,000 19,384,000
Source of information on funding sources:
GAVI: Computed by MOH
Government: MOH Department of Planning and Budgeting internal sources
Combined Donors: MOH Department of Planning and Budgeting internal sources
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GAVI HSS Application Form 2007
Section 9: Endorsement of the Application
To the applicant:
Representatives of the Ministry of Health and Ministry of Finance, and the Chair of the Health
Sector Coordinating Committee (HSCC), or equivalent, should sign the GAVI HSS application.
All HSCC members should sign the minutes of the meeting where the GAVI HSS application
was endorsed. This should be submitted with the application (numbered and listed in Annex 1).
Please give the name and contact details of the person for GAVI to contact if there are queries.
Note: The signature of HSCC members represents their agreement with the information and plans
provided in this application, as well as their support for the implementation of the plans. It does not
imply any financial or legal commitment on the part of the partner agency or individual.
9.1: Government endorsement
The Government of Lao PDR commits itself to providing immunisation and other child and
maternal health services on a sustainable basis. Performance on strengthening health systems will
be reviewed annually through a transparent monitoring system. The Government requests that the
GAVI Alliance funding partners contribute financial assistance to support the strengthening of
health systems as outlined in this application.
Ministry of Health: Ministry of Finance:
Name: Name:
Title / Post: Title / Post:
Signature: Signature:
Date: Date:
9.2: Endorsement by Health Sector Coordination Committee (HSCC) or country equivalent
Members of the Health Sector Coordination Committee or equivalent endorsed this application at a
meeting on …………………………………... ………...The signed minutes are attached as Annex 1.
Chair of HSCC (or equivalent):
Name: Post / Organisation:
Signature: Date:
9.3: Person to contact in case of enquiries:
Name: Dr. Soulivanh Pholsena, Title: Planning Medical Officer,
Department of Planning & Budgeting, MOH
Tel No: +856 2078 2313 Address:
Fax No.
Email: dr.pholsena@gmail.com
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GAVI HSS Application Form 2007
ANNEX 1 Documents Submitted in Support of the GAVI HSS Application
To the applicant:
Please number and list in the table below all the documents submitted with this application.
Note: All supporting documentation should be available in English or French, as electronic copies
wherever possible. Only documents specifically referred to in the application should be submitted.
Available Attachment
Document (with equivalent name used in-country) Duration Number
(Yes/No)
National Health Sector Strategic Plan (or equivalent)
6th National Socio-Economic Development Plan Yes 2006-2010 Annex 1.1
Five Year Health Development Plan - 6th National Yes 2006–2010 Annex 1.2A
Conference for Health PowerPoint Presentation
Five Year Health Development Plan - Development Yes 2006–2010 Annex 1.2B
Partners PowerPoint Presentation
Health Master Plan 2020 – Executive Summary Yes 2002-2020 Annex 1.3
Comprehensive Multi-Year Plan - National Yes 2007-2011 Annex 1.4
Immunization Program
Maternal and Child Health Policy/Strategies/Plan of Yes 2005-2020 Annex 1.5
Action
Directive of the President of Lao PDR to the Ministry Yes
of Health on Model Healthy Villages - Summary of 2008 - 2010 Annex 1.6
model healthy village Program
cMYP8 Yes 2007-2011 Annex 1.4
No –
MTEF9 Medium Term Expenditure Plan for Health Currently
2006-2010
Sector Under Development by MoF being
translated
PRSP8 Poverty Reduction Support Operation Yes 2006- Annex 1.7
Recent Health Sector Assessment documents
Comprehensive Multi-Year Plan - National Yes 2007-2011 Annex 1.4
Immunization Program
First-line Health Care: The Integrated Community
Yes 2004-2007 Annex 1.8
Health Centers
2005 –
Health Services Improvement Project (HSIP) Yes Annex 1.9
2010??
Health System Development Project (Grant) Yes 2007 - 2011 Annex 1.10
Review of Ongoing Health Financing Reform in Lao Yes 2007 Annex 1.11
PDR and Challenges in Expanding the Current
8
If available – and if not, the National Immunisation Plan plus Financial Sustainability Plan
9
if available please forward the pages relevant to Health Systems Strengthening and this GAVI HSS application
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GAVI HSS Application Form 2007
Social Protection Schemes
The Fundamentals of the Sector Coordination
Yes 2006-2010 Annex 1.12
Mechanism for Health
Second Poverty Reduction Support Operation Yes 2006-2009? Annex 1.13
Lao-Luxembourg health Initiatives support
Yes 2008-2012 Annex 1.14
programme
Vientiane Declaration Yes 2006 - Annex 1.15
Report on MR Evaluation Yes 2004-2007 Annex 1.16
Young Child Survival and Development program
Yes 2007- Annex 1.17
Summary
Handbook of Minimum Requirements Yes 2007- Annex 1.18
Strategic Plan
Yes 2008- Annex 1.19
For Strengthening Health Systems
Annex
United Nations Development Assistance Framework
2002-2006 1.20A,
for the Lao PDR Yes
2007-2011 Annex
1.20B
Save the Children Australia Yes 1991-2004 Annex 1.21
UNFPA Presentation Slides Yes 2008 Annex 1.22
Draft MCH Services Package Yes 2008- Annex 1.23
Draft Essential Package of MNCH Yes 2008- Annex 1.24
HSCC minutes, signed by Chair of HSCC
10th
Minutes of SWC SWG (O) signed by chair Yes September Annex 1.26
2008
Health Strategy to 2020 Yes 2000-2020 Annex 1.27
Mid-term review of health chapter NSEDP6 Yes 2006-2010 Annex 1.28
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GAVI HSS Application Form 2007
ANNEX 2 Banking Form
GLOBAL ALLIANCE FOR VACCINES AND
Banking Form
IMMUNISATION
SECTION 1 (To be completed by payee)
In accordance with the decision on financial support made by the Global Alliance for
Vaccines and Immunisation dated . . . . . . . . . . . , the Government of . . . . . . . . . . . . . . . . . . .
hereby requests that a payment be made, via electronic bank transfer, as detailed below:
Name of
Institution:
(Account Holder)
Address:
City – Country:
Telephone No.: Fax No.:
(To be filled in by GAVI Currency of the
Amount in USD:
Secretariat) bank account:
For credit to:
Bank account’s
title
Bank account
No.:
At:
Bank’s name
Is the bank account exclusively to be used by this
YES ( ) NO ( )
program?
By whom is the account audited?
Signature of Government‘s authorizing official:
Name: Seal:
Title:
Signature:
Date:
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GAVI HSS Application Form 2007
SECTION 2 (To be completed by the Bank)
CORRESPONDENT BANK
FINANCIAL INSTITUTION
(In the United States)
Bank Name:
Branch
Name:
Address:
City –
Country:
Swift code:
Sort code:
ABA No.:
Telephone
No.:
Fax No.:
I certify that the account No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Is held by
(Institution name) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .at this banking institution.
The account is to be signed jointly by at
Name of bank’s authorizing official:
least …… (number of signatories) of the
following authorized signatories:
Signature
1 :
Name:
Title: Date:
2 Seal:
Name:
Title:
3
Name:
Title:
4
Name:
Title:
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GAVI HSS Application Form 2007
COVERING LETTER
(To be completed by UNICEF representative on letter-headed paper)
TO: GAVI – Secretariat
Att. Dr Julian Lob-Levyt
Executive Secretary
C/o UNICEF
Palais de Nations
CH 1211 Geneva 10
Switzerland
On the ……………………………… I received the original of the BANKING DETAILS form,
which is attached.
I certify that the form does bear the signatures of the following officials:
Name Title
Government’s
authorizing official
Bank’s authorizing
official
Signature of UNICEF Representative:
Name
Signature
Date
84
