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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)


                                                                                                   13
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



                                                                                                    14
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




                                                                                 15
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.



                                                                                                   16
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.




                                                                                                  17
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.

                                                                                                                                            18
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




                                                                                                      19
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.

                                                                                                       20
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:




                                                                                                 21
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




                                                                                                               22
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




                                                                                                            23
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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GAVI HSS Application Form 2007

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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      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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GAVI HSS Application Form 2007



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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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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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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GAVI HSS Application Form 2007

 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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GAVI HSS Application Form 2007



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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GAVI HSS Application Form 2007

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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GAVI HSS Application Form 2007

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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GAVI HSS Application Form 2007




      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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GAVI HSS Application Form 2007
                                                                                                                                       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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GAVI HSS Application Form 2007

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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GAVI HSS Application Form 2007



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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GAVI HSS Application Form 2007


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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GAVI HSS Application Form 2007

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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GAVI HSS Application Form 2007

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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GAVI HSS Application Form 2007

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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GAVI HSS Application Form 2007



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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GAVI HSS Application Form 2007

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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GAVI HSS Application Form 2007



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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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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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

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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

                                                                                              72
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




                                                                                                    74
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




                                                                                              75
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




                                                                                                     76
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)



                                                                                                    77
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




                                                                                                78
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



                                                                                                   79
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

                                                                                                                                   80
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




                                                                                 81
   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:




                                                                                                                  82
   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:




                                                                                                                                 83
  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

				
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