ASIAN DEVELOPMENT BANK Operations Evaluation Department

PROJECT PERFORMANCE EVALUATION REPORT

IN

THE LAO PEOPLES DEMOCRATIC REPUBLIC

In this electronic file, the report is followed by Managements response.

Performance Evaluation Report

Project Number: PPE: LAO 25109 Loan Number: 1348-LAO(SF) May 2006

Lao Peoples Democratic Republic: Primary Health Care Project

Operations Evaluation Department

Asian Development Bank

CURRENCY EQUIVALENTS Currency Unit kip (KN) At Appraisal (August 1994) $0.0014 KN715.00 At Project Completion (October 2000) $0.0001262 KN7,920.00 ABBREVIATIONS ADB BME EIRR IMR Lao PDR MDG MMR MOPH NGO OEM PCR PCU PHC PHCEP PIO PPTA RDF TA TB U5MR UNDP Asian Development Bank benefit monitoring and evaluation economic internal rate of return infant mortality rate Lao Peoples Democratic Republic Millennium Development Goal maternal mortality rate Ministry of Public Health nongovernment organization Operations Evaluation Mission project completion report project coordinating unit primary health care Primary Health Care Expansion Project project implementation office project preparatory technical assistance revolving drug fund technical assistance tuberculosis under-5 mortality rate United Nations Development Programme NOTE In this report, $ refers to US dollars. At Operations Evaluation (April 2005) $0.0000952 KN10,500.00

KN1.00 $1.00

= =

Director General Director Team leader Team members

B. Murray, Operations Evaluation Department (OED) R.K. Leonard, Operations Evaluation Division 1, OED S. Tamondong, Evaluation Specialist, Operations Evaluation Division 1, OED C. Infantado, Portfolio Evaluation Officer, Operations Evaluation Division 1, OED I. de Guzman, Senior Evaluation Assistant, Operations Evaluation Division 1, OED B. Cafirma, Evaluation Assistant, Operations Evaluation Division 1, OED Operations Evaluation Department, PE-683

CONTENTS Page BASIC DATA EXECUTIVE SUMMARY MAP I. INTRODUCTION A. Evaluation Purpose and Process B. Project Objectives DESIGN AND IMPLEMENTATION A. Formulation B. Rationale C. Cost, Financing, and Executing Arrangements D. Procurement, Construction, and Scheduling E. Design Changes F. Outputs G. Loan Covenants PERFORMANCE ASSESSMENT A. Overall Assessment B. Relevance C. Effectiveness D. Efficiency E. Sustainability OTHER ASSESSMENTS A. Impact B. ADB and Borrower Performance C. Technical Assistance ISSUES, LESSONS, AND FOLLOW-UP ACTIONS A. Issues B. Lessons C. Follow-Up Actions iii v ix 1 1 1 3 3 3 4 5 5 5 8 8 8 8 8 10 10 12 12 14 15 16 16 16 18

II.

III.

IV.

V.

The guidelines formally adopted by the Operations Evaluation Department (OED) on avoiding conflict of interest in its independent evaluations were observed in the preparation of this report. A local team with three consultants Sounthoune Nanthavongdouangsay, Siphone Sitthavongseng, and Kongkheo Darasavong assisted during field work, and staff health consultant Stanley Zankel worked for 10 days. Marjelou Realuyo-Castillo assisted with survey analysis at the headquarters. To the knowledge of the management of OED, there were no conflicts of interest of the persons preparing, reviewing, or approving this report.

APPENDIXES 1 2 3 4 5 6 7 8 9 Operations Evaluation Mission Survey Information General Profile of Primary Health Care Centers in Xieng Khouang and Oudomxay Matrix of Survey Results Detailed Rating Economic Evaluation Household Survey 1996, and National Health Survey 2001 Progress on the Achievement of Millennium Development Goals Outcomes and Delivery Primary Health Care Centers in Oudomxay 19 20 24 34 49 54 55 58 59

Attachment:

Management Response

BASIC DATA Primary Health Care Project (Loan 1348-LAO[SF]) Project Preparation/Institution Building TA No. 1947 2291 5692a TA Project Name Type Essential Drugs Project PPTA Strengthening the ADTA Ministry of Public Health Facilitating Capacity RETA Building and Participation Activities PersonMonths 8 36 Amount $250,000 $800,000 $300,000 Approval Date 9 Sep 1993 19 Jan 1995 19 Jul 1996

Key Project Data ($ million) Total Project Cost Foreign Currency Cost Local Currency Cost ADB Loan Amount/Utilizationb ADB Loan Amount/Cancellation Key Dates Management Review Meeting Appraisal Loan Negotiations Board Approval Loan Agreement Loan Effectiveness Project Completion Loan Closing Months (effectiveness to completion) Borrower Executing Agency Mission Data Type of Mission Fact-Finding Appraisal Inception Project Administration Review Special Loan Administration Midterm Review Project Completion Operations Evaluationc

As Per ADB Loan Documents 6.25 3.68 2.57 5.00

Actual 5.32 3.20 2.12 4.48 0.22 Actual 20 Jun 1994 523 Jul 1994 1718 Nov 1994 19 Jan 1995 17 Feb 1995 4 May 1995 Dec 2000 6 Dec 2001 68

Expected

18 May 1995 Apr 2000 31 Oct 2000 59

Lao Peoples Democratic Republic Ministry of Public Health

No. of Missions 1 1 1 9 2 1 1 1

Person-Days 76 76 8 87 26 34 24 80

= unreported, ADB = Asian Development Bank, ADTA = advisory technical assistance, PPTA = project preparatory technical assistance, RETA = regional technical assistance. a Fifteen ADB operational activities involving 11 developing member countries, including Lao PDR, received support. Each supported activity received $16,500, on the average. b The loan amount was equivalent to SDR3,404,000 at the time of approval, and SDR3,232,426.24 at loan closing. The cancelled portion of the loan amounted to SDR171,573.76. c The Operations Evaluation Mission comprised Susan D. Tamondong, evaluation specialist (mission leader); a survey team with three local consultants (Sounthone Nanthavongdouangsy, Siphone Sitthavongseng, and Kongkheo Daravasong); and a staff consultant for 10 days.

EXECUTIVE SUMMARY The Primary Health Care Project was a $5.3 million Asian Development Fund loan approved on 19 January 1995 as the first Asian Development Bank (ADB) health intervention in the Lao Peoples Democratic Republic (Lao PDR). It was aimed at supporting the Governments health policy, adopted in 1993, to improve basic primary health care (PHC) services particularly in the villages. The Ministry of Public Health (MOPH) was the Executing Agency, and seven related institutions formed the project coordinating unit. The Project used a pilot approach in the two mountainous northern provinces of Xieng Khouang and Oudomxay, where project implementation offices (PIOs) were set up to monitor the Project. The main objective of the Project was to improve the quality of life in the rural areas of Lao PDR by reducing the mortality and morbidity caused by diseases that can be prevented or easily treated. The specific objectives were to (i) establish PHC services in the villages and thus improve access to basic curative and preventive services; (ii) improve the quality of care from both public and private sector providers; and (iii) improve the quality of drugs available to consumers. A technical assistance (TA) of $800,000 was attached to the loan during the first 2 years of the Project to (i) assist in the implementation of the Project, (ii) improve the skills of peripheral health workers through in-service training, and (iii) spread the benefits from the Project to the rest of the country. In addition, a regional capacity-building TA (5692: Strengthening the Ministry of Public Health) linked to the Project (i) studied community perceptions of health centers (overall satisfaction, use of the centers, drug prices and availability, informal payments, treatment by health workers, and suggested improvements in services); and (ii) assessed issues related to health workers (recruitment, assignment, deployment, housing and agricultural land provided, training received and planned, and supervision), as well as issues related to recording and reporting, difficulties with improvements in the health centers, the revolving drug fund, and the need for more female staff. The Project was completed in December 2000 and the $0.22 million undisbursed balance was cancelled when the loan closed in December 2001. The Project was carried out according to ADBs operational strategy and the health policy of the Lao PDR. The design was relevant at the time of preparation and at appraisal. The involvement of other organizations in the early stages and during implementation contributed to the success of the Project and the achievement of its broad, as well as specific, objectives. The Project built 73 primary health centers and 3 district hospitals, renovated 5 other hospitals, and supported a public health school in Oudomxay. It trained close to 6,000 health workers and staff, most of whom are still in their assigned posts. The revolving fund established to maintain the supply of drugs in the health centers is functioning efficiently. Supervision by the PIOs continues, and MOPH has maintained its budget. Project outputs were completed on time and implementation went smoothly. MOPH implemented phase 2 of the Project with the help of lessons from phase 1. The Project and the two associated TAs are rated as successful. The Primary Health Care Project in Lao PDR helped improve the quality of life in the remote northern rural communities and made people more aware of modern medicine, reproductive health, the prevention of common diseases, and the importance of hygiene. Its positive impact on health conditions and practices in the target areas, as a result of easier access to basic health facilities and services, has been significant, although the benefits cannot be quantified due to a lack of benefit monitoring. However, qualitative interviews among people in the project areas confirmed that there were significant benefits. Beyond its main objectives, the Project (i) helped strengthen the social organization in the villages through community participation in the management of the revolving fund; (ii) raised the status of women in decision

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making by involving the womens union in health center activities; and (iii) contributed to community cohesiveness by giving the village council an active role in the management of the revolving fund. The Project helped to empower women. As the primary beneficiaries of the PHC policy, womenas mothers and caregiversare the main recipients of the health education outreach programs. Knowing how to address basic health issues gave them practical skills useful in meeting the health needs of their families, and a resulting sense of confidence and well-being. The Project also helped the ethnic minorities understand the value of PHC and modern medicine. It trained and provided employment to health workers in the villages, built local capacity, and enhanced cooperation among development partners working in the health sector of Lao PDR. More importantly, the Project gave rise to a national health policy and the nationwide implementation of integrated PHC planning, budgeting, and monitoring. According to the field interviews (not validated by quantitative data from the provinces covered as none was available), the Project also helped (i) reduce the incidence of major diseases, (ii) change health attitudes from reliance on traditional habits and beliefs to a growing trust in modern medicine, and (iii) promote the increased use of health facilities among the minority groups (women, children, and ethnic tribes) in northern Lao PDR. Health workers distribute drugs that the poor can afford, and basic treatments are free. The revolving fund set up with seed money from the Project has become self-sustaining and continues to support the supply of drugs and operating expenses of the health centers. Health improvementsbetter nutrition and disease controlas well as improvements in basic education and economic opportunities have been linked to overall productivity gains in Lao PDR over the years. An analysis of economic gains during project preparation assumed that if the Project could reduce the under-5 mortality rate (U5MR) by 10% from the pre-project level of 182 per 1,000 live births to 164, it would achieve an economic rate of return of 12%. The latest national health survey (2000) showed a close to 40% average rate of decrease in U5MR between 1990 and 2000. Although the impact of a healthier population on the socioeconomic status of a country is difficult to quantify because various other factors can affect social structures and economic development, qualitative interviews during the Operations Evaluation Mission (OEM), and an MOPH survey, confirm that as health has improved, so has productivity. Cost-benefit analysis, by a different method, and projection of beneficiaries between 1995 and 2014 indicate that the Project could save more than 0.5 million work-days that would otherwise have been lost to illness, as well as out-of-pocket health expenditures. Cost savings account for 60% of economic benefits, and labor productivity 40%. The survey of 49% of health centers during the OEM confirmed that the Project (i) facilitated access to basic medicines, (ii) gave opportunities to learn modern health and reproductive practices, and (iii) provided immediate access to the PHC centers for basic health services. In other words, it is plausible to claim that the Project successfully achieved its objectives. Among the factors that contributed to the success of this pilot project, and that can be replicated are (i) the strategic placement of health centers in remote areas, (ii) the retention strategy for health workers deployed in the rural areas, (iii) the involvement of development partners in laying the project groundwork, and (iv) continuous in-service training and skills upgrading for recruited workers. Attractive salaries alone would not be enough to keep the health workers in the remote areas. The provision of housing near the health center and land near their work place that they could farm and live on was an important incentive. Grassroots mobilization was also a positive factor. Setting up the primary health centers in the villages

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increased the accessibility of basic health care. A sense of community ownership was imbued in the people and the village committee, and they readily gave their support to the health workers. Skills training must continue and control mechanisms must be put in place to allow the audit of the purchase, distribution, and use of medical equipment and supplies. The need to provide PHC services to rural areas cannot be disputed, but the cost of building and maintaining a health center without an adequate and sustainable budget allocation demands further thinking. The Project demonstrated, with positive results, that basic health services and health training can be made more accessible to the remote communities in Lao PDR. Its replication in other parts of the country merits continued support. Three recommendations for follow-up action are made including the need for (i) (ii) (iii) inclusion of injectable contraceptive in drug kits; increased support for outreach programs; and the conduct of an inventory of health centers and equipment.

Bruce Murray Director General Operations Evaluation Department

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I. A. Evaluation Purpose and Process

INTRODUCTION

1. The Operations Evaluation Mission (OEM) visited the Lao Peoples Democratic Republic (Lao PDR) on 430 April 2005 to assess the performance of the Primary Health Care Project.1 To complement and validate secondary information, the mission held discussions with officials of the Ministry of Public Health (MOPH) and stakeholders in the central, provincial, and district health departments of Xieng Khouang and Oudomxay provinces. The mission also interviewed, individually and in groups, selected village officials and residents in the project areas, health workers, beneficiaries, and various international agencies and nongovernment organizations (NGOs) supporting the health sector. A qualitative survey in the two target provinces assessed the physical conditions of the health centers and the work situation of health workers, and obtained feedback from beneficiaries about their access to health services2 (Table A1.1, Appendix 1). Thirty-six health centers49% of the 73 built under the Projectwere visited and 48 health workers were interviewed (Table A1.2, Appendix 1) in 12 randomly selected districts, covering more than 70 villages. 2. The preliminary findings of the OEM were presented at an evaluation dissemination workshop at the Lao Resident Mission on 27 April 2005. The workshop, which encouraged discussion among stakeholders, was attended by officials at all levels of MOPH and related institutions, project implementation office (PIO) representatives, and other international organizations and NGOs operating in the health sector of Lao PDR. After the purpose of the evaluation and the rating criteria were explained to the participants, the PIOs in the two target areas were asked to share the lessons from the pilot project and to discuss their activities, accomplishments, and challenges. The OEMs findings were confirmed by the workshop participants and a general consensus was reached that, given its outcome, the Project was successful, although monitoring needed improvement. 3. The Project was rated successful in the Asian Development Banks (ADBs) project completion report (PCR), which was circulated to the Board on 18 July 2002.3 This rating was based mainly on the assessed smooth implementation of the Project and the timely delivery of most outputs. The management structures and procedures were found to conform to the loan agreements. According to the PCR, TA 2291-LAO had fully met its objectives, particularly in improving the management of primary health care (PHC) service delivery and staff training. The PCR concluded that the Project had contributed to the well-being of rural communities in the remote uplands, particularly poor and ethnic minorities, although no survey of beneficiaries was done to support this premise. B. Project Objectives

4. The principal objective of the Project was to improve the health status of people in the rural areas of Lao PDR by reducing mortality from common diseases. The specific objectives were to (i) establish PHC services in the villages to improve access to basic curative and
1

ADB. 1995. Report and Recommendation of the President to the Board of Directors on a Proposed Loan to the Lao Peoples Democratic Republic for Primary Health Care Project. Manila (Loan 1348-LAO[SF], for $5 million, approved on 19 January). In selecting the areas to be surveyed, the OEM worked with provincial authorities to select accessible but geographically dispersed areas to cover a broad range of beneficiaries, health workers, and primary health centers. ADB. 2002. Project Completion Report on the Primary Health Care Project in the Lao Peoples Democratic Republic. Manila.

preventive services; (ii) improve the quality of health care from public and private sector providers; and (iii) improve the quality of drugs available to patients. 5. The Project had four components: (i) PHC, (ii) in-service training, (iii) monitoring of the pharmaceutical sector, and (iv) benefit monitoring and evaluation (BME). The specific objectives for each of these components were as follows: (i) PHC. To strengthen PHC in two northern provinces and one district in a special zone by (a) establishing 70 health posts in underserved areas; (b) providing an adequate supply of 12 critical medicines to be sold to meet the operating expenses of the health posts; (c) providing health education on topics such as the use of antimalaria bed nets and micronutrient malnutrition; (d) introducing regular and systematic supervision; and (e) renovating eight district hospitals, building three new ones, and providing essential drug and supply kits that would include anti-tuberculosis (anti-TB) drugs and reagents for sputum examination. In-service training. To improve health workers skills and knowledge by (a) setting clear guidelines for the use of health workers in preventing, diagnosing, and managing pneumonia, diarrhea, malaria, micronutrient malnutrition, and TB; (b) providing high-quality, standardized training to health workers in the project area with the help of videotapes, role playing, and simulations; and (c) training district and provincial managerial staff in health services and administration. Monitoring of the pharmaceutical sector. To strengthen the ability of MOPH to regulate the private sector, and thus ensure the quality of the drug supply and improve the knowledge and skills of private pharmacy operators, by (a) monitoring private pharmacies in the project provinces; (b) training private pharmacy staff in the rational use of drugs, means to ensure compliance, and management of the most important diseases; and (c) training MOPH pharmacies and staff from pharmaceutical factories in good pharmaceutical manufacturing practices. BME. To share the experience gained in the project area by (a) conducting periodic surveys of households, health facilities, and pharmacies; and (b) disseminating the lessons identified in the project area through workshops and study tours.

(ii)

(iii)

(iv)

6. ADB provided an $800,000 TA complementing the loan to support (i) project implementation during the first 2 years, (ii) in-service training for peripheral health workers, and (iii) nationwide dissemination through BME4 of the lessons from the Project. 7. A regional TA also linked to the Project was aimed at (i) studying community perceptions of health centers (overall satisfaction with and use of the centers, prices and availability of drugs, informal payments, treatment by health workers, and suggested improvements in services); and (ii) assessing issues related to health workers (recruitment, assignment, deployment, provision of housing and agricultural land, training received and planned, supervision), recording and reporting, difficulties associated with improvements in health centers, the revolving drug fund, and the need for more female staff.5
4

ADB. 1995. Technical Assistance to the Lao Peoples Democratic Republic for Strengthening the Ministry of Public Health. Manila (TA 2291-LAO, for $800,000, approved on 19 January). ADB. 1996. Technical Assistance on Facilitating Capacity Building and Participation Activities. Manila (TA 5692REG, for $300,000, approved on 19 July).

II. A. Formulation

DESIGN AND IMPLEMENTATION

8. The formulation of the Project was supported by a 1993 project preparation TA for the health sector of Lao PDR.6 On the assumption that the health of the people would improve if drugs were made available in the required quantity and quality, the Government adopted a national drug policy in 1993 to promote the proper use of essential drugs. The Project was designed to support the successful implementation of this policy by focusing on the use and provision of essential drugs as a means for improving PHC. Before the Project, few health centers provided basic curative and preventive services in the villages.7 In 1989, only 20 out of 110 district clinics actually provided health services to the population.8 Most of these were in disrepair, had few drugs and little equipment, and were staffed by poorly trained, poorly motivated, and underpaid personnel, who knew little of the causes of morbidity and mortality. As conceived, therefore, the Project would provide simple preventive and curative services in the villages, and pilot-test replicable approaches in two northern provinces.9 Emphasis was placed on civil works and equipment because of the dire lack of physical infrastructure at that time. B. Rationale

9. Lao PDR is a landlocked least-developed country (LDC) that ranks 135th out of 177 countries in the Human Development Index (HDI) of the United Nations Development Programme (UNDP).10 Its overall development goal is to graduate from being an LDC by 2020, by achieving growth with equity, eradicating basic poverty, eliminating opium production, and creating an enabling environment for overall development. Lao PDR used to be a centrally planned economy, where health care was supposed to be provided nationwide by the Government but, in fact, did not cover the rural areas. The health status of the country, particularly its rural population, was low in the 1990s. It had (i) among the highest infant mortality rate in Asia,11 (ii) widespread and chronic malnutrition, (iii) rudimentary health care infrastructure with limited accessibility, and (iv) low quality of care. The high rates of infant, child, and premature adult mortality reflect the prevalence of malaria, TB, pneumonia, diarrhea, measles, and micronutrient deficiencies. All of these are relatively easy to prevent or treat with inexpensive interventions that nonmedical staff, using simple equipment, immunization, and drugs, can carry out. But medicines, facilities, and staff qualified to combat these major

ADB. 1993. Technical Assistance to the Lao Peoples Democratic Republic for the Essential Drugs Project. Manila. Financed by Japan Special Fund (TA 1947-LAO, for $250,000, approved on 9 September). 7 Measles immunization among children, for example, was only 36% and done mostly by mobile teams. 8 Lao PDR Country Study. Available: http://www.country-studies.com (accessed 24 June 2005). 9 Xieng Khouang and Oudomxay were chosen as pilot areas because of their (i) highly rural population, (ii) limited previous access to external assistance, (iii) presence of large ethnic populations, (iv) lack of health infrastructure, and (v) low budgetary resources compared with other provinces. 10 Lao PDR had an HDI of 0.534, compared with 0.663 for developing countries and 0.729 for the world. The HDI is a summary measure of human development. It measures the average achievements of a country in terms of three basic dimensions of human development: (i) a long and healthy life, as measured by life expectancy at birth; (ii) knowledge, as measured by the adult literacy rate; and (iii) a decent standard of living, as measured by gross domestic product per capita in real terms (UNDP. 2004. Human Development Report). 11 The infant mortality rate in Lao PDR in the 1990s was 125 per 1,000 live births, and 44% of children under 5 years were malnourished (National Statistical Center. 1993. Social Indicator Survey. Vientiane.) During this period, the overall health status of Lao PDR ranked among the lowest in the world, with an average life expectancy at birth of about 50 years, and a high prevalence of preventable infectious diseases like malaria, diarrhea, and acute respiratory diseases (see footnote 1).

diseases were severely lacking. The PHC program therefore needed support, particularly to carry out preventive and curative health services in the subdistricts and villages. 10. When the Government began to implement economic reforms (embracing a more market-oriented structure) in 1986, the private sector was allowed to participate in various economic endeavors, including the provision of health services, which had previously been fully managed and financed by the Government through MOPH. With the liberalization of the health sector, public clinics and pharmacies multiplied to fill gaps in the provision of health services, especially in the remote areas. However, inadequate regulation of the quality of health services, drug production, and personnel resulted in substandard services and medicines, and insufficiently trained personnel. Thus, contrary to the Governments expectations, encouraging private individuals and institutions to participate in the health sector did nothing for the health status of the population, which remained low. Neither did health services become more accessible to marginalized groups (mainly women, children, the aged, and ethnic groups living in rural areas) in the early 1990s. 11. To address the issues in the health sector, the Government adopted in 2000, a national policy on PHC with the aim of providing health for all. This policy had three main objectives: (i) expanding access to basic health services, (ii) improving the health status of the people and the quality of services provided to them, and (iii) ensuring access to health services by vulnerable groups. A threefold strategy was adopted to meet these objectives: (i) increasing the coverage of basic health services by establishing health facilities, (ii) improving the skills and technical knowledge of health workers, and (iii) ensuring the proper management and distribution of drug kits in the villages. Lao PDR began to develop a national drug policy in 1993 to ensure access to high-quality essential drugs and their rational use. 12. To support its policy and achieve its objectives, the Government mobilized the resources, both financial and technical, of international health agencies and funding institutions. According to MOPH estimates, international assistance accounted for 75% of public funding for the health sector in the 1990s.12 The Government requested ADB to help develop mechanisms for delivering basic curative and preventive services. The Project was envisioned to pilot-test an approach to the provision of PHC that relied on deploying professional health workers in a network of village health posts. It was expected to improve the health status of the people in remote areas. Two northern provincesOudomxay and Xieng Khouangwere chosen to pilottest the strategy between 1996 and 2000. If successful, the model would be replicated nationwide. C. Cost, Financing, and Executing Arrangements

13. The appraisal cost of the Project was estimated at $6.25 million equivalent, consisting of $3.68 million equivalent in foreign exchange cost and $2.57 million equivalent in local currency cost. ADB approved a loan of SDR3.40 million ($5.00 million equivalent) from its Special Funds resources to finance 80% of the total project costthe entire foreign exchange cost and $1.32 million of the local currency costwhile the Government would finance 20% from its own resources. The actual project cost, including allowance for physical and price contingencies and for service charges on the loan during project implementation, was $5.32 million$3.20 million in foreign exchange cost and $2.12 million equivalent in local currency cost. The Government

12

MOPH, Lao PDR. 2000. Policy on Primary Health Care. Vientiane.

financed about $0.84 million13 for civil works and furniture. There were no cost overruns, although the civil works cost higher than expected at appraisal.14 The health centers in remote areas cost more to build than originally anticipated, as the inaccessibility of those places, especially during the rainy season, made it more costly to transport building materials, something that should have been foreseen. The undisbursed balance of $0.22 million was cancelled at closing in December 2001. 14. MOPH was the Executing Agency, and it established a project coordinating unit (PCU) and a steering committee, chaired by the minister and comprising members of different MOPH departments. The steering committee guided PCU during project implementation and carried out all decisions made centrally by MOPH. A technical committee composed of representatives from MOPH departments and related institutions was also established to facilitate project implementation.15 D. Procurement, Construction, and Scheduling

15. Despite the difficulties in transporting building materials to some of the most remote areas, the PHC centers were completed as scheduled. The construction unit of MOPH and the PCU coordinated well with provincial health offices. Administrative procedures and general procurement mechanisms in the public sector caused delays in the procurement of civil works, basic medical equipment, and supplies. But these delays did not affect project implementation significantly. During the OEM, the MOPH minister agreed to have the procured equipment and current conditions at all PHC centers inventoried, to improve the management of assets financed by the Project, and accountability for those assets. 16. The Project was approved on 19 January 1995, was declared effective on 4 May 1995, and was to be closed on 31 October 2000. It was carried out as planned, within the 5-year implementation period. The loan took effect with no delay and its effectivity was not extended. Although some project activities were delayed, the overall implementation ended within the stipulated period. The loan account was closed on 6 December 2001 because of a delay in receiving official receipts from the provinces. E. 17. F. Design Changes The Project underwent no design changes. It was implemented as originally designed. Outputs

18. The most immediate and apparent outputs of the Project were the establishment of new health facilities and the provision of training and supportfinancial and logisticalfor the village
13

About 16% of the actual project cost. ADB financed 84%, 4% over the maximum percentage of project costs that ADB normally finances under the cost-sharing limits for group A countries, which include Lao PDR (ADB. 2003. Operations Manual. Section H3/BP: Local Cost Financing and Cost Sharing and Section A1/OP: Classification and Graduation of Developing Member Countries. Manila). Neither the PCR nor the review of project files done while preparing this project performance evaluation report, indicated whether this excess in ADBs share was an oversight or was granted on an exceptional basis, as authorized by ADB. 14 Because of the added costs of transporting construction materials to remote areas and building health centers in those areas (see footnote 3). 15 A covenant in the loan agreement specified the involvement of seven entities in the Project: the MOPH departments of hygiene and preventive services, food and drugs, and health organization and human resources for health; the School of Public Health; the National Tuberculosis Center; the Institute of Maternal and Child Health; and the Institute of Malaria, Parasitology, and Entomology.

outreach activities of health workers. The $5.3 million loan was used to (i) build 73 PHC centers in remote areas of two northern provincesXieng Khouang (32 centers) and Oudomxay (37 centers)and in Thathom district, Xaisomboun Special Zone (4 centers); and (ii) build three district hospitals and renovate five, and train close to 6,000 health workers and MOPH staff. Each PHC center covered 3,0004,000 rural people, thus giving those people access to PHC services for the first time. All centers visited by the OEM were still operating and were staffed with at least one full-time health worker recruited and trained under the Project and employed by MOPH. Appendix 2 shows a relatively high staff retention rate; according to the survey, 73% of the health center staff in Oudomxay and 53% of those in Xieng Khouang have served in the same health center for 413 years. This retention rate might be explained by the fact that the health workers are local residents and are given an incentive package. They are provided with free accommodation in a house beside the PHC center or land near the center on which to build a house, as well as land that they can farm for supplemental income. Each health center is managed by the health workers with coordination from the village committee, which includes a representative of the womens union. The Project also provided seed money for a revolving drug fund (RDF) to purchase and distribute essential drugs. The RDFs are still functioning. The health centers provide basic services, including first aid, emergency treatment, child delivery, referrals, and outreach to remote villages. Serious illnesses are referred to district and provincial hospitals. All beneficiaries interviewed by the OEM expressed satisfaction with PHC services, although those living in remote villages wanted more frequent outreach visits.16 The centers are structurally stable, but half of them are not regularly supplied with water and 10% are not fenced. 19. The Project provided 12 essential medicines in drug kits, which were distributed through health workers in PHC centers and village health volunteers identified by the village committees. More drugs have since been added to the list. At the request of the health workers, the drugs are supplied and replenished monthly by the district from a government-owned factory in Vientiane. At first, the drug prices were set by the central MOPH. Now the government factory sets its sale price and the district determines the local price, according to the market of its center. The health workers receive the pricing list from the district and keep updated daily records of PHC activities and drug sales. The prices of drugs in villages vary from the prices at local pharmacies. Some drugs are sold below market prices while others are more expensive. The markup of 1030% goes into the RDF for operating expenses, outreach activities, maintenance, transportation, and minor repairs of health centers. The RDF is kept by the health worker, supervised by the village committee, and monitored by the district, which also audits the fund. 20. The drug kits are the primary source of medicines in Xieng Khouang and Oudomxay. Fewer people in the remote villages of Oudomxay have access to medicines. For lack of proper storage facilities (refrigerators), the health centers do not carry essential drugs like liquid-based medicines for children. Some health centers have coolers but not enough ice. Reproductive medicines (pills and injectable contraceptives), which are in great demand among the women, are not included in the drug kits; women often have to go to the district hospitals to get them. A qualitative survey was done to determine the adequacy of drug supply and access of people to medicines, and to get general feedback from the beneficiaries and health workers. Details of the survey results can be found in Appendix 3.

16

Health workers normally visit remote villages once a month. Lack of transport facilities forces them to walk long distances and renders outreach impossible during the rainy season.

21. A monitoring and supervision system, implemented by the primary health offices, was developed under the Project. In-service and special training was provided to health workers by the provincial health department in both provinces. New health-care practices and knowledge gained from training were disseminated by the health workers in the villages. The information, education, and communication activities of the health workers in immunization and disease control have had a significant positive role in raising public awareness of health, hygiene, and disease prevention among rural people in remote areas. Such awareness is important in the rural areas, as most of the major diseases (diarrhea, malaria, and iron deficiency) can be prevented with good hygiene and healthy practices. 22. The records show that training support was extended to 105 MOPH provincial health managers for a 3-month course in health administration and 134 MOPH staff members for a 1-month course conducted by the School of Public Health in Vientiane. Twenty-one provincial staff members visited Viet Nam to observe health programs and practices, 36 visited other provinces in Lao PDR, and 98 district staff members attended training in supervision. The provincial directors of Xieng Khouang and Oudomxay obtained degrees in public health in Thailand. Most of the staff trained under the Project still do similar work in the same offices; few have been rotated to other departments of MOPH. 23. According to the survey, almost all of the health workers in Oudomxay and Xieng Khouang are very satisfied with their work and feel that working in the Project has given them more knowledge (Appendix 2). All would like to have additional training, however, preferably in obstetrics and emergency cases. Most of the health workers in Oudomxay are men (93%), while there is a more even distribution between genders in Xieng Khouang (46% female and 54% male). (As discussed below, the forbidding geography, particularly in the rural areas, has quite a bit to do with the preponderance of male health workers.) These health workers provide curative and preventive health-care services to villages, covering 2385 patients a month, depending on the season. All of the women beneficiaries who were interviewed would prefer to have injectable contraceptives included in the drug kits provided to health workers, to make these birth control devices more accessible. 24. Three new district hospitals were built and five hospitals were renovated under the Project. Each district hospital serves a catchment area of about 30,000 people and receives essential drug kits similar to those provided to health centers. All these district hospitals continue to operate, although with minimal basic equipment, limited staff, and supplies. Their budget is determined by the province and comes from the central office of MOPH. The Project also supported the construction of a public health school in Oudomxay. The school produced its first 40 graduates in April 2005, at about the time of the OEM. MOPH planned to assign these graduates to their respective localities. 25. The TA assisted MOPH and related institutes in preparing simple and clear guidelines for the prevention, diagnosis, and management of common diseases like pneumonia, diarrhea, malaria, TB, and micronutrient deficiencies. Guidelines for the training of health workers and for outreach services were incorporated into the PHC modules that were field-tested during project implementation. The booklets were translated into Lao and enough copies were distributed to health workers and village health volunteers in the project areas.

G.

Loan Covenants

26. As reported in the PCR, except for delays in the submission of audited financial statements and BME reports caused by the lack of familiarity of the health centers and district hospitals with the reporting procedures, the loan covenants were generally complied with. III. A. Overall Assessment PERFORMANCE ASSESSMENT

27. Given the Projects relevance, effectiveness, efficiency, and sustainability, as discussed in the following paragraphs, the Project is rated successful.17 A full discussion of each criterion and details of the ratings given are in Appendix 4. B. Relevance

28. On a four-category scale (highly relevant, relevant, partly relevant, irrelevant), the OEM found the Project to be highly relevant. Its design was consistent with ADBs and the Governments policies. As of 1993, the Government had made little headway in its plans to reform its largely urban-oriented health system. With less than 5% of the Governments budget allocated to health, MOPH could not properly implement the health policy program for 1992 2000, which would have promoted preventive health care and better-quality service to people in remote areas, especially ethnic groups. Before the Project, PHC services were practically nonexistent in most remote villages, where major deadly diseases were highly prevalent among women, children, and ethnic groups. C. Effectiveness

29. The Project is rated effective on a four-category scale (highly effective, effective, less effective, ineffective). The project outputs(i) functional and fully equipped PHC centers in 73 villages of Xieng Khouang and Oudomxay, and (ii) an organized network of PHC service providers administratively linked to the operations of the public health sectorclearly contributed to the long-term efforts of the Government to provide viable health-care services to residents of remote villages, particularly women, children, and ethnic communities. As a result of the infrastructure and training outputs of the Project, (i) the provision of basic PHC services increased, (ii) people in remote areas gained easier access to health services, (iii) the supply of essential drugs became continuous and adequate, and (iv) functioning RDFs were developed. The findings of the MOPH 2004 household survey confirm these conclusions. The survey reported that the strategy of training village health volunteers and providing them with drug kits made PHC services more accessible to residents of eight northern Lao PDR provinces, including Xieng Khouang and Oudomxay. The survey also showed that, in general, the availability of basic drugs in all eight provinces increased from 33% to 65% in 2004.18 The health of the target beneficiaries has accordingly improved, as confirmed through qualitative interviews, field observation, and secondary data. The health improvements are reflected by an increase in the following: (i) child delivery at hospitals, from 10% to 21% (19992003); (ii) contraceptive prevalence rate, from 23% to 32% (19952000); (iii) rate of children under 5 years under treated mosquito nets, from 14% to 21% (19952003); (iv) PHC access to
17

Using a four-category rating system (highly successful, successful, partly successful, unsuccessful) and following guidelines of the Operations Evaluation Department (available at www.adb.org/evaluation). Based on an overall weighted rating of 2.20. 18 MOPH. Primary Health Care Expansion Project (PHCEP) 2004 Household Survey (pp. 89).

0.5 million people living in mountainous areas (20002004); and (v) coverage of fully immunized children aged 1223 months, from 20% to 32% (19962001).19 30. The Project had two significant outcomes: (i) better access to health services, and (ii) better quality of PHC. The population covered by health services in the two provinces increased substantially with the implementation of the Project: from 36% to 84% in Xieng Khouang, and from 32% to 75% in Oudomxay.20 All of the planned health facilities were built and all of the necessary amenities and functions were in operation by 1998. Thus, it is reasonable to conclude that the service access targets for the two provinces were achieved. 31. One indicator of the improvement in the quality of health care is the application of health workers training in disease prevention and cure, administration, and reproductive health. The 120 village health workers in the pilot areas who were trained under the Project showed marked improvements in their post-test scores indicating an increase in knowledge in each of the foregoing training areas. The Project provided basic training to a total of 5,970 health staff. 32. A major component of the outreach program is drug distribution to remote villages, where the incidence of disease is high. The impact of access to drugs is most relevant and evident when key diseases exist at the time of the health workers visit and medication could give immediate relief. In the wet season, however, when the remote areas are even less accessible, village visits and other forms of access to health facilities are limited, and the drug kits are therefore not available to those who need medication. Yet, as the OEM survey results and National Health Survey 2002 data for the northern region indicate, the overall health status of the population in the pilot area has continued to improve (even after the Project). This implies that basic health-related issues are being addressed somehow, despite the still unresolved accessibility issues. 33. Since the health workers are often forced by funding constraints, distance, and poor roads to make fewer visits to villages and, for some target beneficiaries at least, health centers are still difficult to reach, especially in the wet season, preventive rather than curative care has been increasingly significant in improving the health of the population in the pilot areas. Most major diseases respond to preventive measures. The improving health indicators imply that preventive care is increasingly being practiced at the village level. This is linked to better knowledge of health issues, which, in remote villages, is provided through health education outreach. 34. The apparent success of the health education outreach indicates that the greater technical expertise of health workers helps to disseminate relevant information in the remote villages. Thus, periodic in-service training of health workers must be planned and budgeted for. Topics that could be considered, based on the OEM survey results, are curative care, reproductive health, and rational use of medicines. Maternal health-care issues, including antenatal care and emergency obstetrics care, are important in areas where women only have access to often inadequately trained traditional birth attendants. In both pilot areas, more than 80% of women still deliver babies at home, with help from friends or relatives, or without any help.21 Culturally, especially in remote villages, males are not involved in childbirth. In fact, some infant and maternal deaths have reportedly occurred because women were reluctant to seek
19

Although this data refers to the eight northern provinces covered by the follow-on project, it is plausible to conclude that similar gains resulted from the Project. 20 MOPH, Lao PDR. 1998. Primary Health Care Project, Technical Review Meeting Notes (Figure 2.2). 21 MOPH, Lao PDR. 2005. PHCEP Survey (p. 24, Figure 13).

10

antenatal and obstetric care from male health workers at the health centers. Efforts to train female traditional birth attendants to give more support to pregnant women have not been successful. Interviews with respondents reveal that female health workers are often at risk of abuse and violence when visiting remote villages. This was one reason given why health workers are mostly male, particularly in Oudomxay. D. Efficiency

35. On a four-category scale (highly efficient, efficient, less efficient, inefficient), the Project is deemed efficient. Despite delay at the start of procurement of basic medical equipment, there was no cost overrun, deliverables were met, and outputs expected at appraisal were achieved. Calculations showing the economic gains projected under the Project were included in the report and recommendation of the President (but not in the PCR), but the OEM could not locate the baseline data for the calculations and therefore used a different method to recalculate the economic gains. The economic internal rate of return was estimated at 12.2%, with net present economic value of $0.17 million. The Project helped avoid the loss of more than 0.5 million workdays to illness, and saved $0.5 million in out-of-pocket health expenditures in the target areas. A full discussion of the economic evaluation is in Appendix 5. 36. The OEM assessed whether there was good value for money in investing in facilities, equipment, and training activities. The conclusion was that project activities were suitable, costeffective, and appropriate to the health needs of the community. Training was well targeted and was delivered efficiently, as evidenced by monitoring reports and interviews. Regarding financial accountability, funds from MOPH were channeled to the provinces and districts in a transparent manner, well documented in MOPH records. Private pharmaceutical companies were not involved in drug manufacturing, which was handled by a government factory. The OEM survey found that 10% of the PHC centers built under the Project did not receive some basic medical equipment. When this matter was brought up during the wrap-up meeting, the minister of health agreed to carry out an inventory of equipment and buildings for all PHC centers. The OEM recommends follow up action on para. 62. The inventory would also assess all centers needing major repair and those that have been repaired in the past year with funds allocated from phase 2 of the Project. (The OEM survey found that all PHC centers needed repair, to fix leaking roofs and malfunctioning latrines, and put in water systems, among others.) 37. The disbursement of funds from ADB and from the Government was timely. On-site supervision visits by ADB staff were more frequent at the start of the Project and gradually diminished as project implementation progressed. The construction cost of PHCs in remote areas was underestimated, as transport of materials was more costly than originally anticipated. E. Sustainability

38. Sustainability is rated likely, on a four-category scale (most likely, likely, less likely, unlikely). Basic health has been a priority and short-term sustainability is being supported with a follow-up project, which is currently being implemented in the pilot areas. The sustainability of the Project requires (i) continued health-care support to the villages, (ii) adequate budget allocations for infrastructure and retraining needs, (iii) better-quality services, and (iv) more systematic monitoring and evaluation. 39. The Government plans to replicate in other parts of the country the promotion of PHC in remote areas demonstrated by this Project, while learning from its lessons. Phase 2 (Loan

11

1749-LAO), Primary Health Care Expansion Project (PHCEP),22 now being implemented, expands the coverage of services and areas planned for the first-phase project. The design of the follow-up project reflects several lessons from the Project, such as (i) the need to provide an adequate budget for the maintenance of the PHC centers, as repair costs could not be met by the RDF alone; (ii) the importance of achieving a balance between the different components (e.g., training, maintenance, supervision, control); and (iii) the continuing need for capacity building and service improvements. 40. The PHC system addresses the health services needs of its target beneficiaries. However, the OEM survey revealed that some activities have been downscaled for lack of financial resources and personnel. Monthly village visits by health workers are down, from 12 times in 2000 to an average of four times a year, typically coinciding with the visits from agencies supporting other programs, such as immunization or nutrition. The lack of viable means of transportation is a major reason, if not the main one, for the downscaling of outreach activities. However, most MOPH staff in the pilot provinces who were trained under the Project still perform similar functions, although some have been rotated to other departments. Given the high job satisfaction rate among health workers surveyed (73% in Xieng Khouang and 91% in Oudomxay), the retention rate likely remains high. This trend is further evidenced by the high proportion of workers who have been deployed in either province for more than 4 years (para. 18). More than half of the health workers in both provinces have been promoted to the status of civil servants and now hold tenured positionsa further incentive for them to stay on the job. Under the Project, the health workers were allowed to use a housing unit beside the health center. Health workers in the villages can also count on the Government to provide them with land to build a house and to farm, a bicycle, and farming equipment. Also, since most of the health workers are from the area, they tend to stay long in their assignments. And they are driven, despite the modest salaries, by a deep-seated desire to serve those who need help, an ethical value in Lao PDR. 41. Despite resource constraints, the health centers are still effective in providing basic health services (i.e., health education, drug sale, and curative care for minor cases) to most target villages. This shows that the PHC centers, as institutions, are robust enough to continue providing benefits on a sustainable level, even with the challenges posed by the low incomes and administrative limitations of a LDC environment. The training provided to the health workers at the start of the Project was found to be adequate for the delivery of basic health services, although all health workers interviewed during the OEM expressed the need for more training,23 preferably in obstetrics and emergency medicine. The minister of health believes that humancentered development24 is the direction for the future and the mobilization of resources, including the tapping of funding support, can also be taught in capacity-building programs. 42. The income from the RDF is enough to sustain the supply of drugs and minor repairs. While still not a major problem for all centers, funding for the repair and maintenance of facilities built under the Project is nevertheless an issue that must be addressed, as the PIOs pointed out during the OEM workshop. These facilities will increasingly depreciate over time, especially without adequate funding for maintenance and repair. MOPH responded positively by allocating

22

ADB. 2000. Report and Recommendation of the President to the Board of Directors for a Proposed Loan to the Lao Peoples Democratic Republic for the Primary Health Care Expansion Project. Manila (Loan 1749-LAO, for $20 million, approved on 24 August). 23 Refresher training for health workers in the two pilot areas was provided in 2003 under phase 2 of the Project; health workers in Xieng Khouang were retrained in family planning and basic delivery in 2004. 24 Human-centered development focuses on empowering people by building their capacity to use their full potential.

12

funds in FY20052006 within phase 2 for the repair and renovation of centers in Xieng Khouang and Oudomxay that urgently needed attention. But all centers will eventually require attention. 43. The issue of sustainability relates mostly to funding, since many of the activities in the public health sector of Lao PDR are externally funded. In the two pilot areas, the downscaling of outreach and training activities due to lack of funds shows the extent of reliance on external funding. Once the ADB-financed project ended, funds for following up the capacity developed under the Project dried up. However, from its qualitative survey, the OEM found out that trained health workers continued to share their new skills and knowledge with village health volunteers, to sustain health services provided to their communities. 44. With all these constraints, sustainability is still likely because of the strong commitment shown by the Government in supporting PHC activities and maintaining the gains in the health sector. In addition, the Project is staffed by committed health workers and volunteers who are fully integrated in the communities and consider their work as a way of life. Such strong ethical values would eventually sustain the Project in the long term. IV. A. Impact OTHER ASSESSMENTS

45. The Project has had significant institutional and development impact. The Project was carried out to improve the quality of life in rural areas by decreasing the mortality and morbidity from diseases that can be prevented or easily treated. Table A1.3 in Appendix 1 is a summary matrix of impacts in the project areas, e.g., the decrease in the infant mortality rate (IMR) from 125 per 1,000 live births to 82 (19962001), in the maternal mortality rate (MMR) from 656 per 1,000 live births to 530 (19982000), and in the child mortality rate (CMR) from 176 per 1,000 live births to 106 (19962001). The Project also contributed to the improvement of health indicators on a macro level, as it built the capacity to provide strong leadership in the health sector for planning and budgeting through the advisory technical assistance. 46. The approval of the PHC policy in 2000 and the gradual integration of PHC activities within MOPH indicate the positive institutional impact of the Project. It targeted the northern provinces and ethnic minority groups, and, according to the OEM survey, women mostly benefited. The PHCEP survey, on the other hand, indicated that the impact of the Project on womens health knowledge may not be as extensive. A likely reason for the variation is the difference in design of the two surveys. According to the PHCEP survey data on womens knowledge of preventive health care, the performance of Xieng Khouang and Oudomxay was less than the national average. However, the OEM qualitative survey revealed that health education is a major activity during quarterly visits to the villages. Thus, while it would be difficult to link the level of knowledge of mothers about PHC for diarrhea to the frequency of home treatments, for example, education could be assumed to have played an important role in the care provided to affected children, especially in the northern region. The OEM survey results indicate that health education and lectures on common diseases were basic components of the outreach activities of health workers under the Project. National Health Survey data for the northern regions consistently indicate that, for preventable diseases like malaria, respiratory illnesses, and diarrhea, and also reproductive health, the educational level of the women, particularly the mothers, is conversely related to the incidence of disease. Thus, it can be deduced that the higher the educational level achieved by the mother, the more likely it is that preventive care will be practiced at home.

13

47. The Project almost certainly contributed to progress toward the achievement of the Millennium Development Goals (MDGs) for health in Lao PDR by (i) reducing the under-5 mortality rate (U5MR), IMR, and MMR; and (ii) increasing the availability and use of contraceptives, the proportion of the population in malaria risk areas that is protected by impregnated bed nets, and the proportion of TB cases that are detected and cured under directly observed treatment short courses. More effort is nonetheless needed to increase the countrys chances of meeting the MDG targets by 2015, particularly with regard to the (i) proportion of 1-year-olds immunized against measles, (ii) proportion of 15- to 49-year-old women practicing family planning, (iii) morbidity due to malaria, and (iv) prevalence of TB. These four indicators have not shown the progress needed to achieve the MDG targets.25 The PHCEP survey, and qualitative data from the OEM survey, showed that, while the use of impregnated bed nets and contraceptives has increased, immunization coverage has declined (Appendix 6). Appendix 7 summarizes the national MDG targets, indicators, baseline data, most recent status, and goals for 2015. 1. Impact on Institutions

48. The Government has demonstrated its ownership and commitment to continue the Project until its successful completion, and has already replicated the various PHC initiatives in modified form (using the lessons emerging from the Project) and incorporated them into PHCEP. The expansion project covers all eight provinces in the northern region of Lao PDR. In January 2000, the MOPH promulgated the new PHC policy. Many of the principles, approaches, strategies, and components enumerated in the PHC policy document have evolved from the experiences learned in ADBs PHC Project (footnote 1), as well as from other health projects undertaken in Lao PDR from the early mid-1990s until 2000. 49. The experience in the pilot areas provided the Government, particularly MOPH, with a framework within which it can institute further reforms in PHC to make it more effective and use its resources efficiently. In 1999, MOPH reorganized and created the PHC and Rural Development Division to coordinate national programs on PHC. Funding for PHC activities and the health budget in general has increased from about 6% of the national budget in the past 5 years to 10% in 2005. The Project (i) promoted an integrated multisectoral approach and public health education, (ii) created jobs in villages and districts, (iii) developed skills, and (iv) strengthened community interaction with village councils and the womens union. The increased health coverage and service delivery in rural areas helped to improve the health of people and to develop peoples trust in modern medicine. 2. Socioeconomic Impact

50. The Projects socioeconomic outcome has been significant. The improvement in the health status of the population, changes in health-related attitudes and practices, and increase in the use of health facilities among the marginalized sector are some of the most relevant indicators. In general, Xieng Khouang and Oudomxay showed higher-than-average rates of immunization in 2004i.e., Bacillus Calmette-Gurin (BCG), measles, polio, diphtheria, and tetanus immunization for women of reproductive agecompared with other provinces surveyed by MOPH (Table A8.1, Appendix 8). The coverage rate for vitamin A supplementation, at 13% for Oudomxay and 21% for Xieng Khouang, is lower than the mean coverage of 30%. The
25

Lao PDR and United Nations. 2004. Millennium Development Goals Progress Report on Lao PDR.

14

malaria control program is on track, with Xieng Khouang exhibiting the largest coverage of bednet impregnation over the previous year (close to 90%), while Oudomxay has 65% coverage. 51. In terms of access to contraceptives, the 2004 survey showed that women living in remote villages (without roads) have the lowest contraceptive prevalence rate, at around 24%, compared with 49% for rural areas with roads, and 58% in urban areas. Among married women of reproductive age, those living in rural areas without roads have the least access to birth spacing services (63%). The access rate is higher for women living in rural areas with roads (89%) and in urban areas. However, in the average household, womens knowledge of preventive health care is lower than the composite mean score (48%) for all eight provinces surveyed. Xieng Khouang had an average mean score of 44%, while Oudomxay had 25%. Appendix 6 indicates that, where the projects are directly and indirectly expected to make an impact, the two provinces performed generally above average compared with other provinces. Data for the northern regions indicate that, in the case of preventable diseases like malaria, respiratory illnesses, diarrhea, and reproductive health, the educational level of the women and mothers is conversely related to the incidence of disease. Thus, the higher the educational level achieved, the greater the likelihood of preventive care. 52. The rural minorities gained access to PHC and could afford the drugs distributed by the health workers in the villages. No significant impediments were reported by the villagers in obtaining medicines. The centers are conveniently located within villages. The RDFs are fully functioning and continues to generate income from drug sales. The income is mainly used to replenish the supply of drugs; part of the proceeds are used to operate, maintain, and make minor repairs in the health facilities. The RDF is monitored by the village council and supervised by the corresponding district. The pricing, distribution, and sale of drugs are recorded by health workers daily and systematically. However, the OEM found the subsidy rate of 510% for drugs for the very poor to be inadequate for remote areas, where most households are very poor. 53. ADB took the lead in the funding agency community for PHC support in Lao PDR. The Project, well appreciated by other funding agencies, served as a catalyst for more support for the health sector. The International Fund for Agricultural Development (IFAD) and Japan International Cooperation Agency (JICA), for example, are providing supplementary support for the activities started under the Project, such as the provision of drug kits and health training. A roundtable group on health sector started in November 2004, co-chaired by the Japanese Embassy and the World Health Organization; ADB is a participant. Monthly meetings are planned. Among the cooperating agencies dealing with health in the provinces are IFAD, JICA, Swiss Red Cross, German Agro-Action, Enfants dAilleurs, World Bank, the United Nations Childrens Fund, Save the Children, Quaker Services in Lao PDR, and Global Fund. 54. The Project helped to empower women. As the primary beneficiaries of the PHC policy, womenas mothers and caregiversare the main recipients of the health education activities of the outreach programs. Knowing how to address basic health issues provided them with practical skills and gave them a sense of confidence and well-being as they became better able to attend to the health needs of their families. The Project helped the ethnic minorities understand the value of PHC and modern medicine. B. ADB and Borrower Performance

55. Overall, the performance of ADB and the Borrower was satisfactory. The review missions, listed in the basic data section of this report, were adequate in frequency and duration. The relationships developed with MOPH, PCU, and PIOs were mutually satisfactory

15

and continue to be maintained. ADBs resident mission in Lao PDR provided support to the Project, and continues to provide support through the successor project. 56. The organization and management of the Project was well planned. The PCU and steering committee chaired by the minister of MOPH were effective. However, decision making was lengthy, as the PCU director did not have full authority to spend the approved budget. The approval process delayed some project activities. A steering committee guided PCU during project implementation and, in consultation with the participating entities represented on the technical committee established to facilitate project implementation, carried out all decisions made centrally by MOPH. The provincial PIOs in Xieng Khouang and Oudomxay were adequately staffed with a project director, a deputy, and support staff. The PIOs monitored implementation at the district level, while the districts supervised the health workers deployed in the primary health centers. The PCU coordinated and supervised the PIOs and maintained close cooperation with other agencies. The PIOs continue to work closely with the regular staff of the respective provincial health departments. The PCU is now responsible for the health projects supported by ADB and the World Bank, providing a good example of funding agency harmonization.26 This approach reduces the transaction costs to Lao PDR of working with two major sources of development funds and is consistent with the targeted reduction in the number of parallel project implementation units, as urged in the Paris Conference on Aid Effectiveness in March 2005. C. Technical Assistance

57. Three TAs were provided to support the Project: (i) project preparatory TA 1947: Essential Drugs Project (footnote 6), (ii) advisory TA 2291: Strengthening the MOPH (footnote 4), and (iii) regional TA 5692: Facilitating Capacity Building and Participation Activities in 11 DMCs (including Lao PDR) (footnote 5). All three TAs were rated successful in their technical assistance completion reports. However, the transfer of skills and knowledge under the TAs was limited by a lack of appropriate counterpart staff. TA 1947 was the basis for the preparation of the PHC Project, TA 2291 provided support in the effective implementation of the Project, and TA 5692 offered incentives for the participatory and capacity-building efforts of MOPH. TA 2291 is rated successful by the OEM, as it strengthened MOPH and helped improve the management of PHC delivery. With the help of TA 2291, project activities were closely monitored throughout implementation with regard to activities and outputs. The in-service training consultant helped MOPH staff at the district levels to develop training modules, and to design and implement an appropriate evaluation of the in-service training program. An international health management consultant provided 24 months of service (extended for another 12 months) and an in-service training expert was engaged for 12 months (extended for another 4 months). Five domestic consultants were engaged for 247 person-months 153 person-months for administration and finance, and 94 person-months for equipment procurementto strengthen the PCU. The consultants were instrumental in ensuring the Projects success and the Governments increased attention to the improved delivery of health services and staff training at all levels.

26

World Bank-financed malaria control projects in eight southern provinces, and the Swedish International Development Cooperation Agency supported projects in the pharmaceutical sector during the implementation of the PHC Project.

16

V. A. Issues

ISSUES, LESSONS, AND FOLLOW-UP ACTIONS

58. The key issues related to PHC revolve around the eradication of the major diseases that can be treated and prevented, with the help of trained health workers. The eradication of these diseases is among the MDGs (see Appendix 7). The ongoing PHCEP indicates that two issues need attention: (i) maintenance of PHC centers, and (ii) monitoring and evaluation of outcomes and impacts. 59. Maintenance of PHC Centers. The OEM identified the maintenance of PHC centers as an important issue after the Project. A number of health centers need major repairs. The necessary budget allocation for this was provided through the ADB-supported phase 2, Loan 1749-PHCEP (footnote 22). But the provincial offices claim that the budget allocations are not sufficient. The RDFs were originally designed to support the operational requirements of the health centers after the Project. The resulting cash flow is, however, insufficient to finance major infrastructure repairs. During the OEMs evaluation workshop, there appeared to be an information gap with regard to the availability of the maintenance budget provided in phase 2 as the district understood it, and as reported by the province to the central office. MOPH agreed to develop an inventory of existing facilities and equipment before the end of 2005 to accurately assess the conditions and maintenance needs of the PHC centers built in phase 1. 60. Benefit Monitoring and Evaluation. Although this was fully discussed in the PCR, the OEM found no evidence that systematic BME was carried out. This was a serious lapse, particularly for a pilot project designed to test an approach for further replication. PIO staff in the two pilot provinces should be given more training, if necessary, to effectively implement systematic monitoring and evaluation of outcomes and impacts. The National Health Survey in 2000 showed positive changes in the health condition of people in the rural areas. However, to assess progress of an individual project, monitoring and evaluation would have to be systematic covering the project area and a suitable control group, before, during, and after the Project. B. Lessons

61. The lessons from the Project have implications for future similar projects, including the ongoing PHCEP (phase 2): (i) Strategic location of health centers in remote areas. Some health centers in the Project were located in remote areas with a population of less than 1,500. Service and coverage statistics indicated that, for investment in a health center facility to be practical and affordable, the catchment area should have at least 3,0004,000 people. This lesson was taken into account in building the health centers in phase 2. Systematic collection and recording of provincial health data. Lack of baseline data in the pilot areas at the start of the Project made it difficult to assess the outcome of the Project. Thus, the importance of having systematic health data recording in place is an important lesson. Information dissemination and public awareness activities. When people are informed, they can act accordingly. As the Project showed, regular training workshops conducted among health workers to update their knowledge, and the

(ii)

(iii)

17

dissemination of health information among poor people living in remote areas, can significantly contribute to the positive impact on health as measured by its indicators. (iv) Effective outreach program and use of local human resources. A significant contribution of the Project was to provide basic PHC services to the rural poor living in remote areas. Employing local health workers and mobilizing village health volunteers increased the probability of project sustainability. Sustained flow of financial, human, and technical resources. The follow-on PHC phase 2 project(Loan 1749-LAO) (footnote 22)helped to ensure the flow of financial and technical health-care services to the pilot areas. This indicates the benefits of ADB focusing its operations and having a long-term involvement in a sector. However, the availability of funds will eventually end. Institutional reforms and appropriate budgetary allocation are needed to ensure that the project benefits are sustainable. Supervision, skills training, and skills upgrading need to be sustained to enhance the quality of services provided by health workers. The education of women is particularly important because of their role in the home (e.g., hygiene, nutrition, child care, and family planning). Coordination with other agencies. The Project demonstrated the advantages of partnership, with other development agencies collaborating from project preparation throughout project implementation. Good working relationships were developed with the World Bank, United Nations agencies, and NGOs. Funding agencies using the same PCU office provided a model for aid harmonization, resulting in complementary financial and technical support that helped to sustain the Project.

(v)

(vi)

18

C. 62.

Follow-Up Actions These follow-up actions are recommended for ADB and the Government:

Recommendations

Responsibility

Time Frame

1. Include injectable contraceptives in the drug kits

MOPH

Continuing, from the fourth quarter of 2006

2. Increase support for outreach programs in remote areas

ADB and Government

Continuing, from the fourth quarter of 2006

3. Undertake an inventory of PHC centers and equipment

MOPH

From the third quarter of 2006 to finish by the end of 2006

ADB = Asian Development Bank, MOPH = Ministry of Public Health, PHC = primary health care. Source: Operations Evaluation Mission.

Appendix 1

19

OPERATIONS EVALUATION MISSION SURVEY INFORMATION Table A1.1: OEM Survey Information
Province Xieng Khouang Name of District Nong Het Kham No. of HCs Visited 1 3 Name of HCs Visited Tham Thao Ban Dor Ban Tha Napa Nahome Navang Ban Kang Phousoung Khokka Total
HC = health center, OEM = Operations Evaluation Mission. Source: April 2005 OEM survey.

Oudomxay

Beng Houne Pakbeng

1 2 2 9

Number of Health Workers 1 2 1 2 2 2

2 12

Table A1.2: Summary of Survey Information

Item Districts Health Centers Health Workers HWs Interviewed Survey 7 22 47 3 Oudomxay Post-Survey 7 18 33 48 Xieng Khouang Survey Post-Survey 2 5 14 9 19 15 7 15

HW = health worker. Source: April 2005 OEM survey; processed survey forms (for the post-survey information).

Table A1.3: PHC Summary Matrix of Impacts

Project Output Construction of 73 health centers and 3 small district hospitals Renovation and provision of equipment to five existing hospitals with emergency services in two provinces Basic training for 5,970 health staff Strengthening of revolving drug fund scheme in district hospitals and health centers to ensure supply of essential drugs Establishment of an M&E system in the project provinces Development of a PHC policy and nationwide implementation of integrated PHC planning, budgeting, and monitoring system Impact (Project Area) IMR among poor decreased from 140 per 1,000 live births to 107 (19952000) MMR reduced from 656 per 1,000 live births to 530 (19982000) IMR reduced from 125 per 1,000 live births to 82 (19962001) CMR reduced from 176 per 1,000 live births to 106 (19962001)

CMR = child mortality rate, IMR = infant mortality rate, M&E = monitoring and evaluation, MMR = maternal mortality rate, PHC = primary health care. Source: Ministry of Public Health, Xieng Khouang and Oudomxay provincial offices.

20

Appendix 2

GENERAL PROFILE OF PRIMARY HEALTH CARE CENTERS IN XIENG KHOUANG AND OUDOMXAYa
Status Indicator A. Health Worker Profile % Share of Female HWs % Share of Male HWs Marital Status of HWs (%) Married Widow No information Ability to Communicate with Target Clients (%) Proficient No information Ethnic Affiliation (%) Lao Loum Lao Theung Lao Seung Position in Health Center (%) Head HW Deputy No information Civil Service Status (%) Civil service Contract workers No information Years of Deployment in HC (number of years, % share) 1 3 4 5 6 7 8 10 13 No information Type of Assignment (%) Assigned to HC from district or provincial hospital Volunteer No information Satisfaction with Work (%) Satisfied No information Decision to Remain in Job (%) Remain Prefer another assignment No information Oudomxay Xieng Khouang

7 93 89 10 1

46 54 80 0 20

97 3 18.2 75.8 6.1 51.5 45.5 3 55.4 21.2 9.1

86 13 73 6 20 60 13 26 66.6 13.3 20

18.8 0 3.03 3.03 3.06 48.48 6.06 3.03 6.06 6.06

6.6 6.6 0 6.6 13.3 26.6 6.6 0 0 26.0

57.58 36.36 6.06 91 9 21.21 6.06 75.76

53.3 20 26.6 73.3 26.6 66.6 0 33.3

Appendix 2

21

Status Indicator Upgrade from Contract Worker to Civil Servant (number of years, % share) 1 2 3 4 No information Pre-training Before Deployment (%) Yes No information Training Venue (%) Provincial District hospital No information Refresher Training Received retraining No retraining No information Number of Refresher Training Received per Year (Number per year, % share) 1 2 3 0 Gained Knowledge after Retraining (%) Note: For Oudomxay, 39.39% of respondents indicated B. Health Service Profile Health-Care Service Village Outreach Programs Frequency Oudomxay Xieng Khouang

22.2 22.2 33.3 22.2

0 13.3 20.0 0 66.7 73.3 26.7 26 0 74 53.3 20 26

6.06 93.94 6.06 75.75 18.19 84.84 6.06 9.09

6.06 21.21 0 72.72 51.51

6.6 46.6 6.6 40.0 66.6

PHC Services Offered 3 per year (27.8%) 4 per year (72.2%) Medicine sale and health education 24 times per year Review of health records and RDF

PHC Services Offered Declined from monthly to 14 times a year Mainly medicine sale and health education

Activity

District Hospital Supervision Frequency

Activity Note: Respondents agree that the length of visits should be extended to allow for discussion of medical issues relevant to HC.

24 times per year; lasting 13 hours per session Review of health records and RDF

22

Appendix 2

Status Indicator Patient Profile Number of patients per month Oudomxay Services provided 1200 per month (33.3%) 560 per month (44.4%) 70120 per month (22.2%) Preventive and promotive care Xieng Khouang 6070 per month

Diarrhea, acute respiratory infection, health education, BS-FP, and medicine sales

Referrals to District Hospitals (referrals per % respondent) 16 1235 no information Common Illnesses Referred to DH (% of respondents) 67% of respondents 22 % of respondents

Malaria, diarrhea, TB, obstetrics, severe injuries, and accidents (33%)

Need for Additional Training

Malaria, diarrhea, typhoid, obstetrics (56%) No information (44.44%) Malaria, diarrhea, ARI, and first aid (44.4%) Current knowledge adequate (11.12%) No information (44.44%)

C. Beneficiariesb Xieng Khouang and Oudomxay Average Age of Respondents Share by Gender (%) Marital Status (%) c Average Number of Children Share Affected by Distance of HC from Their Homes (%) Share of Those with HC as First Option for Primary Care (%) Satisfaction Rate with Services of HC (%) Share of Those Paying for HC Services (%) Average Expense per Visit to HCd Availability of HW (% share who saw HW every visit to HC) Availability of Medicine (%) 41 years old Male = 80 Female = 20 Married 4.4 90% said that distance is not deterrent to accessing HC services. 80 100 100 $0.05$4.14 30 = at times did not see HW in HC 70 = always saw HW in HC 40 = accessed medicine all the time 40 = experienced unavailability of medicine 20 = no response Fever, cough, and diarrhea Unavailability of injectable contraceptives Heavy reliance on traditional birth assistants Limited access of far-flung villages to HW (due to decreased village visits)

Illnesses Commonly Addressed at HCs Other Issues Raised by Beneficiaries

Appendix 2

23

ARI = acute respiratory infection, BS-FP = birth spacing-family planning, DH = district hospital, HC = health center, HW = health workers, PHC = primary health care, RDF = revolving drug fund, TB = tuberculosis. a For the province of Xieng Khouang, nine survey forms from 15 respondents (health workers) were reviewed. The data for Oudomxay were contained in an Excel file with entries for 18 health centers. Only nine survey forms were available for this province; thus, these were the only ones validated; the rest of the data in the file were assumed to be correct. The survey had 33 respondents. b Ten respondents were considered for this part of the survey. c This number is the average for five respondents. d This number is the average for five respondents. Conversion rate: $1 = KN10,300. Source: Validated survey forms, April 2005 OEM survey.

MATRIX OF SURVEY RESULTS

Reference Period Pilot Area Status (as of Phase 1 (19962000) April 2005) (b) (c) Types of health workers: Most HCs (85% OX, 67% Assigned XK) still have 2 HWs Contract workers/ Almost all HWs in OX are Volunteers male Task division: Almost equal distribution Staff HC, between genders in XK Village outreach (46% female, 54% male) activities All HWs received training 2 HWs per center for 3045 days before Recruited locally deployment Trained regularly Salary levels (in KN000) Provided with land for of HWs and share per cultivation and income range (%) generation - 145200 (15%) Worked full-time, paid in - 250300 (55%) full, and given allowances - 301350 (20%) for outreach activities - 351400 (10%)

24

PHC Service and Activities (a) Health Workers (HWs)

Reason for Observed Discrepancy (d) Decrease in the budgetary allocation for HC after phase 1 Funding for training and outreach programs came from the Project Low salary and incentive package

Implications for PHC Service Provision (e) Remote locations in catchment areas, with outreach activities limited to times when EPI services are provided by PHD and DH High retention rate due to local recruitment strategy (not remuneration package) Since most HWs are men, and men are not traditionally involved in the birthing process, there is limited access to antenatal services as this does not conform with traditional village practices

Appendix 3

HW Training/ In-Service Training

Assisted in the preparation of guidelines for prevention, diagnosis, and management of common diseases such as pneumonia, diarrhea, malaria, TB, and micronutrient malnutrition Output: PHC training modules with information on: outreach activities data recording use of drugs actions to

Specific training design and implementation program not mentioned. Apparently, those conducted under the phase 1 project still being implemented. Among the most commonly mentioned training courses provided for HWs are: - Preventive health care for common diseases (malaria, impregnated bed net, diarrhea, TB, HIV, and STI) - Health education

Budgetary constraints prevent conduct of regular training design and implementation of new training materials (i.e., for obstetrics and curative care)

Need to train more women Refresher training needs to continue

PHC Service and Activities (a)

Reference Period Pilot Area Status (as of April 2005) Phase 1 (19962000) (b) (c) improve quality - RDF management of care - Birth spacingfamily planning Developed additional - Immunization training materials - Administration and (i.e., videos, audiomanagement of HC visual equipment) (including recording and Before deployment, filing of reports) 3045 days in-service - Outreach management training in the following areas: Main issue is the frequency of Diagnosis training has declined from ARI 1 per month during phase Diarrhea 1 to an average of 24 times Malaria a year, after phase 1 TB HIV/AIDS A few HWs mentioned that MCH and FP further training in obstetrics RDF and emerging diseases Refresher courses (particular to their catchment 5,970 health personnel areas) is preferred over those took basic training typically offered by the DH/PH courses distributed as follows: 4,971, strengthening of PHC services 340, management and supervision 305, monitoring of pharmaceutical sector 354, BME Refresher courses consist mainly of review of topics in in-service training; they last for 15 days and are conducted yearly

Reason for Observed Discrepancy (d)

Implications for PHC Service Provision (e)

Appendix 3

25

26

PHC Service and Activities (a) Health Centers

Reference Period Pilot Area Status (as of April 2005) Phase 1 (19962000) (b) (c) 73 small health centers HCs are still in operation (built between 1996 and HCs are still in (relatively) 1997) good condition, needing 37 in OX only minor repairs or renovations in later 32 in XK ensuing years (i.e., 4 in Thathom leaking roof) Housing facility for HWs Lack of fences in some (in the HC) HC issue due to Specifications: squatting 35 sq m floor area Most HC (85% OX, 67% Examination and XK) still have 2 HWs treatment room Range of cases handled Child and maternal per day is still the same, care room at 23 patients Receives an average Same types of diseases of 25 outpatient are being treated (i.e., visits per day malaria, diarrhea, ARI), (malaria, diarrhea, typically corresponding ARI) with seasonal changes Outreach activities: Almost all HWs now immunization for reside in their own pregnant women and residences within the infants, vitamin A village supplements for 20% of HCs need children additional furniture

Reason for Observed Discrepancy (d) Income from RDF generally not enough to cover maintenance of HCs Lack of budgetary support for maintenance, administrative, operations (especially outreach activities) costs

Implications for PHC Service Provision (e) HCs are still able to provide intended services to the residents of catchment areas Access to HCs is an issue during the rainy season

Appendix 3

PHC Service and Activities (a) PHC Services

Village-Level PHC

Reference Period Pilot Area Status (as of April 2005) Phase 1 (19962000) (b) (c) Basic services (PHC) Village-level PHC only, complicated cases services referred to PH or DH - Health education (whichever is nearer) on three cleans, Receives an average of immunization, 25 outpatient visits per planning, seasonal day (malaria, diarrhea, diseases ARI) - Vitamin A Monthly outreach distribution activities Range among HCs: Sale of drugs for the most 6075 per month common diseases 100120 for BS-FP per identified by the MOPH month Some deliveries (where there are women HWs) Services vary per season (according to which diseases are prevalent) Some villages do not fully accept modern ideas about health, especially child and maternal care Monthly visits to villages Mainly EPI and health to provide basic health education services 34 times a year Monthly outreach (corresponding with EPI activities cover schedule of DH) immunization for Average of five patients pregnant women and per month are referred to infants, health education DH (i.e., disease control, Illnesses referred to DH reproductive health) are accidents, appendicitis, severe malaria, abnormal delivery, typhoid, acute diarrhea, and surgery cases

Reason for Observed Discrepancy (d) Lack of budgetary allocation hampers delivery of services to far-flung villages, especially during the rainy season Village outreach activities are confined to health education, EPI services, and info dissemination re reproductive health Village attitudes toward child growth and development have not changed; reliance on traditional practices still persists

Implications for PHC Service Provision (e) Infant and maternal mortality may be decreased if more women HWs were to assist in delivery

Limited budget to conduct village-level outreach activities

Outreach health services continue to be provided by PHC centers through village health volunteers

Appendix 3

27

28

PHC Service and Activities (a) Supervision

Reference Period Pilot Area Status (as of April 2005) Phase 1 (19962000) (b) (c) Once a month (for the Average 34 times per duration of the Project) year Developed integrated Some SFs noted that supervisory checklist short duration and (20 indicators) infrequency of HW responsible for supervisory activities project targets, quality of reason for inability to care, and updating of provide proper and inRDF depth guidance on health Project: development of issues in the catchment checklist, training of areas; supervisors supervisors, provision of typically have time only to per diem and check medical and RDF transportation for records during their visits supervisory activity On-site supervision Health information provided mostly by the system (17 items) at the PH HC level compiled monthly, and aggregated at the provincial level Supervision designed to come both from both the district and the province

Reason for Observed Discrepancy (d) District hospitals have limited funds to conduct more frequent visits for monitoring

Implications for PHC Service Provision (e) Supervision from district level needs to improve

Appendix 3

PHC Service and Activities (a) District and/or Provincial Hospitals

Reference Period Pilot Area Status (as of April 2005) Phase 1 (19962000) (b) (c) 3 new DHs built (Mok, No direct information Nonghet in XK, Thathom) from SFs Renovation of five existing hospitals (Nga, Namo, Houn, Pakbeng in OX, and Kham in XK) Catchment population = 30,000 Essential and basic drug kits, plus anti-TB drugs, injectable antibiotics, antimalarial drugs, medical supplies for basic laboratory diagnostic services 1530 wooden beds, Access is an issue (because of poor roads or lack of transportation links to villages); thus, utilization is low Quality and level of care not much higher than in HCs Minimal basic equipment, poorly trained staff, and inadequate budget Collection from RDF, cost-sharing scheme, and government operating budget enough only for basic curative services

Reason for Observed Discrepancy (d)

Implications for PHC Service Provision (e)

Appendix 3

29

30

PHC Service and Activities (a) Referral to Provincial and/or District Hospitals

Reference Period Pilot Area Status (as of April 2005) Phase 1 (19962000) (b) (c) Average 36 times per HCs are designed to year respond to primary health-care cases, while the PH and DH are to address more complicated health cases National Health Survey 2000 indicated that the distribution of water systems in the north is as follows: Rivers/Ponds, 43.8% Unprotected water wells,,12% Gravity-fed systems, 6%). This indicates that majority of the population in the north still do not have access to safe water sources Per PPER survey (April 2005), only 50% of the water supply is functional in the dry season.

Reason for Observed Discrepancy (d) There is no baseline information regarding PHC caseload of PH and DH during phase 1; thus, changes over time cannot be documented

Water Supply

Water supply systems in the north typically consists of the following: Rivers or ponds Unprotected water wells Gravity-fed systems

No baseline information provided

Implications for PHC Service Provision (e) HWs typically have no time to adequately discuss villagelevel health issues with target beneficiaries during outreach activities; thus, there is no clear indication as to the type and magnitude of cases that are referred to the PH/DH Most of the prevalent diseases in Lao PDR are waterborne diseases and preventable; thus, to significantly improve the health status of the population, especially in the north where access to safe water is most constrained, the water supply issue must be addressed

Appendix 3

Latrine

Latrines were built in the HCs

Most of the latrines are still functional; a little over 50% are operational in the dry season because of the decrease in the water supply Latrine use rate is relatively low (30% of population has no functional latrine) Most latrines in HCs are dirty and need repair

Water sources, in general, in the north are constrained (even compared with the national standard)

Improper disposal of human waste, which (according to the NHS 2000) is still prevalent in the north, is identified as a major cause of the high incidence of diarrhea during the wet season

PHC Service and Activities (a) Medical Supplies

Reference Period Pilot Area Status (as of April 2005) Phase 1 (19962000) (b) (c) Medicine/Drug kits containing All HCs indicate that drug kits the following: are replenished regularly and - Cotrimoxazole tablets are adequate for needs of - Paracetamol tablets 500 mg catchment area - Mebendazole tablets 100 mg - Chloroquine tablets 150 mg Medicine kit contains: - Fansidar tablets 15 mg -No liquid medication (adult - Vitamin A capsules 200,000 oral pills often divided into IU dosages fit for children) - Oral rehydration salts -Reproductive medicines (pills packets and injectables) not included - Chlorphenaramine tablets 4 although demand for such is mg high - Magnesium hydroxide - Chlorhexidine liquid - Tetracycline ophthalmic ointment - Gentian violet powder - Alcohol 60% - Gauze - Tape - Sputum cups and covers - Anti-malaria bed nets - Pyrmenthrin insecticide

Reason for Observed Discrepancy (d) The disease profile in some villages have changed. Thus, in most cases, new medicines have been added.

Implications for PHC Service Provision (e) List of medicines requested per HC indicates the types of diseases that are being treated in that area. Supplies of new drugs provided by MOPH upon request

Appendix 3

31

32

PHC Service and Activities (a) Medical Equipment

Reference Period Pilot Area Status (as of April 2005) Phase 1 (19962000) (b) (c) List of medical equipment Almost all of the equipment is provided: still functioning properly; in - Stethoscope (1) areas where repairs or - Child scale (1) replacements are needed, - Adult scale (1) absence of equipment not a - Sphygmomanometer (1) hindrance to provision of PHC - Thermometer (3) - Bandage scissors (2) - Suture scissors - Needle drivers (2) - Sterilizer/Pressure cooker (1) - Clay stove (2) - Kerosene lamps (2) - Tables (2) - Chairs (4) Reporting system developed for the activities of the Project Various forms were designed Reporting systems and some forms are no longer in use after phase 1

Reason for Observed Discrepancy (d) Normal wear and tear of equipment over time

Implications for PHC Service Provision (e) Mostly used for patients who avail of PHC services in the HC After phase 1, village-level activities have become less technical (i.e., health education) and largely EPIrelated

Appendix 3

Reports and Forms (Finance, administration, health profile, and health status)

Lack of forms Limited supervision and training (sustainability of practice was affected)

Records are less organized Inefficiency in administrative and reporting activities

PHC Service and Activities (a) Revolving Drug Fund (RDF)

Reference Period Pilot Area Status (as of April 2005) Phase 1 (19962000) (b) (c) The RDF was implemented as In some HCs, managed originally conceived and drugs by village-level RDF were distributed efficiently. committee In some, approval from DH needed by HC All HCs maintain records for their RDF Average income from medicine sales each month is KN250,000. Members of the committee are: - Head of village - Representatives of: womens association, youth association, and Lao Front for Construction

Reason for Observed Discrepancy (d)

Implications for PHC Service Provision (e) RDF records are maintained in PHC centers

AIDS = acquired immunodeficiency syndrome, ARI = acute respiratory infection, BME = benefit monitoring and evaluation, BS-FP = birth spacingfamily planning, DH = district hospital, EPI = Expanded Program of Immunization, FP = family planning, HC = health center, HIV = human immunodeficiency virus, HW = health workers, IU = International Units, Lao PDR = Lao Peoples Democratic Republic, MCH = maternal-child health, mg = milligrams, MOPH = Ministry of Public Health, NHS = National Health Survey, OX = Oudomxay, PH = Public Health, PHC = primary health care, PHD = public health district, PPER = project performance evaluation report, RDF = revolving drug fund, SF = survey form, sq m = square meter, STI = sexually transmitted infection, TB = tuberculosis, XK = Xieng Khouang. a The source of most of the information in column 2 is ADB. 2002. Project Completion Report on the Primary Health Care Project for the Lao Peoples Democratic Republic. Manila. b The information in columns 3 to 5 was taken mainly from the results of the OEM survey in April 2005. Supplemental information in column 3 was gathered from various ADB project documents and online information about the health status and infrastructure of Lao PDR. c Cases often referred to provincial or district hospitals are appendicitis, difficult pregnancies, acute respiratory tract infections, and surgery cases. d Common maintenance issues for HCs are repair of roof, repainting, and water supply. e Information under phase 1 is culled from ADB. 2002. Project Completion Report on the Primary Health Care Project for the Lao Peoples Democratic Republic. Manila. Source: Operations Evaluation Mission.

Appendix 3

33

34

Appendix 4

DETAILED RATING A. Relevance

1. Overall, the Project is deemed to be highly relevant. The Project was instrumental in assisting the Lao Peoples Democratic Republic (Lao PDR) in its development strategy of pilottesting appropriate modalities to (i) strengthen Primary Helath Care (PHC) services, (ii) develop human resources in the field of health, and (iii) establish appropriate cost-sharing schemes to sustain project inputs. At the time of project approval, the Ministry of Public Health (MOPH) had very little experience with PHC. Much of the health care delivery infrastructure was in disarray after the collapse of the commune system. MOPH needed new directions and strategies to address the poor health situation in much of the rural countryside and remote mountainous areas. The Project has fulfilled these expectations. The Project has assisted Lao PDR in implementing its general development strategy of alleviating poverty, and promoting equity of health-care services for women, children, and ethnic minorities. By making affordable essential drugs more readily available and nearer to the home of potential clients, MOPH has been able to promote poverty reduction among underserved populations. Table A4.1: Project Relevance Highly Relevant Partly Relevant

Sub-Criteria 1. Relevance of project outputs to achievement of project goals (i.e., improved health status of people in rural areas) and purposes (i.e., increased accessibility to PHC services at the village level, enhanced quality of care in public and private sectors, and improved availability of drugs to consumers): -Output Ia: Developing physical infrastructure -Output Ib: Distributing essential drugs -Output II: Providing in-service training to peripheral health workers -Output III: Monitoring the pharmaceutical sector -Output IV: Implementing BME and developing management capacity 2. Priority in the context of the DMCs development strategy (i.e., MOPHs policy of strengthening PHC services, developing human resources in the field of health, and implementing cost-sharing schemes) at time of approval 3. Priority of the DMCs development strategy (e.g., poverty reduction, equity of health-care services for women, children, and ethnic minorities) at time of evaluation

Relevant

Irrelevant

X X X X X

Appendix 4

35

4. Priority in context of ADBs development strategy (i.e., improving the health of women and underserved ethnic minority groups in the Lao PDR) at the time of evaluation Overall Rating = Highly Relevant Rating Value = 3

Weight = 20% Score = 0.60

ADB = Asian Development Bank, BME = benefit monitoring and evaluation, DMC = developing member country, Lao PDR = Lao Peoples Democratic Republic, MOPH = Ministry of Public Health, PHC = Primary Health Care. Source: Operations Evalutation Mission.

B.

Effectiveness

2. Overall, the Project is deemed to be effective. It has successfully achieved all of the project physical outputs. All 73 health centers have been built and were operational during the Project, and up to the time of the evaluation mission. The centers included 32 sites in Xieng Khouang, 37 sites in Oudomxay, and 4 additional sites in Thathom district in the Xaysomboune special zone. Thathom used to be a district in Xieng Khouang province. The Project built three new hospitals (i.e., Mok and Nonghet district hospitals in Xieng Khouang, and Thathom district hospital in the Xaysomboune special zone), and renovated five district hospitals (i.e., Kham district hospital in Xieng Khouang, and the Nga, Namo, Pakbeng, and Houne district hospitals in Oudomxay). Each of these hospitals was fully operational during the Project and up to the time of the Operations Evaluation Mission (OEM). 3. The Project has successfully achieved most of other intended outputs as well. It has trained and retrained about 6,000 individuals. The vast majority of these were village health volunteers (VHVs) trained to provide information on birth spacing-family planning (BS-FP) and to teach villagers how to use and properly impregnate bed nets. The focal point of the training component, however, was the training of project implementation office (PIO) trainers, district supervisors, and the cadre of health workers deployed to the new health centers. The Project developed a series of training modules and new teaching methodologies that used role playing, case studies, and practical hands-on training to more easily transfer new knowledge and develop competency-based skills. 4. A key component of the project design was routine monitoring and supervision through monthly site visits to each health center in the project intervention area. On-site monitoring and supervisory checklists were developed, as well as monthly recording and reporting booklets, to facilitate a review of activities at the health center or in villages in the catchment areas. Topics included the level of specific PHC services delivered, the types and amounts of essential drugs disbursed, proceeds from the sale of these drugs, the status of the health center and medical equipment, and unresolved problems and issues. Unfortunately, this monitoring did not extend to recording health outcomes. 5. Each health center was provided with a kit of essential diagnostic medical equipment, as well as essential drugs to treat patients. The proceeds earned from the sale of essential drugs to patients were used to replenish stocks. Although the items on the essential drug list have been modified during and after the Project, these items still focus on treating common ailments

36

Appendix 4

in the project intervention area. All evidence indicates that the prices of the essential drugs are reasonable and affordable for most people living in the health center catchment areas. Both formal and informal mechanisms are in place to ensure that all people, regardless of their ability to pay, immediately receive treatment and essential drugs when they fall ill. The replenishment of essential drugs is generally smooth and the supply of medicine at the health center always appears to be adequate. 6. There are weaknesses in medical distribution, however. The health centers have no medications specifically for infants and young children (e.g., syrups or child-level dosages). Adult dosages are simply reduced to smaller portions for young children. Another problem, which may have developed after the evaluation of the Project, is that patients have to go to the health center to receive medicine for illnesses, instead of obtaining curative services during the expanded program of immunization (EPI) outreach to outlying communities in the health center catchment area. 7. Project outputs are likely to lead to project outcomes. Quarterly immunizations to prevent six communicable and potentially fatal diseases (tuberculosis, diphtheria, pertussis, polio, measles, and tetanus) are provided to infants and young children, in their home villages. During these sessions, vitamin A supplements are also distributed to children under 5 years. These preventive services, combined with curative care to treat youngsters suffering from diarrhea, acute respiratory infections, and malaria, have undoubtedly reduced infant and childhood morbidity and mortality caused by common ailments or serious communicable diseases. Anecdotal reports, however, indicate that EPI coverage is not increasing in certain catchment areas, and this may influence childhood mortality and morbidity rates in the future. 8. The Project has introduced BS-FP services to hundreds of communities and many thousands of women, as well as couples, have elected to accept modern contraceptives to space the timing of births or to limit fertility. This intervention, in and of itself, will have a great impact on reducing maternal mortality. The Project has also provided a great deal of health education on the importance of antenatal, delivery, and postnatal care for pregnant women. Each year, several hundred deliveries are attended by health center workers, but this service is sporadic, with some sites providing a great deal of delivery service, while others do not perform any deliveries. An important development, however, is that most health centers annually refer 25 women experiencing prolonged labor or serious complications associated with delivery to district hospitals for further attention and more appropriate care. This action has undoubtedly saved the lives of many women and reduced maternal morbidity and mortality rates. It is important for the Project to revise some of its PHC service delivery modalities so that more promotive, preventive, and curative health services are available during outreach visits to outlying villages in the catchment area than only from the static health center itself. Table A4.2: Project Effectiveness Highly Effective Partly Effective

Sub-Criteria 1. Achievement of project physical outputs: - Construction of 73 subdistrict/village health centers - Construction of 3 district hospitals - Renovation of 5 district hospitals

Effective

Ineffective

X X X

Appendix 4

37

Sub-Criteria 2. Achievement of non-physical outputs: - Training/Retraining of health staff - Development of training manuals and materials - Routine monitoring and supervision - Provision of affordable PHC services for rural clients - Initial supply of essential medical supplies and equipment - Resupply of essential medical supplies and equipment 3. Likelihood of project outputs leading to project outcomes: - Reduced infant and young-childhood morbidity and mortality caused by common ailments - Improved immunization to prevent serious and fatal communicable diseases - Reduced maternal morbidity and mortality during pregnancy, at the time of delivery, and shortly after birth

Highly Effective

Effective X X X X

Partly Effective

Ineffective

X X

X X X

Overall Rating = Effective Rating Value = 2

Weight = 30% Score = 0.60

PHC = primary health care. Source: Operations Evaluation Mission.

C.

Efficiency

9. Efficiency of Process. The project process was considered efficient. The Asian Development Bank (ADB) headquarters reviewed and disbursed requests for replenishment of funds for the project imprest account in a timely manner and according to the annual work plan and schedule. ADB headquarters conducted regular on-site mission visits throughout the Project, and was able to keep abreast of all major developments, as well as review and discuss project progress and constraints with senior MOPH officials, expatriate technical consultants, and members of the project coordinating unit (PCU) and PIOs. 10. The project executing and implementing agencies at the central level and in the two provinces were similarly able to implement project activities in an efficient and timely manner. Initially, there were certain delays as Ministry of Finance and MOPH personnel familiarized themselves with ADB guidelines and procedures. There were also unforeseen delays in health center construction and the procurement of essential medical supplies and equipment, but these

38

Appendix 4

difficulties were soon resolved and project implementation was generally completed according to schedule. 11. ADB and MOPH facilitated the recruitment of two expatriate consultants, under a separate technical assistance (TA) agreement, to assist on institutional strengthening of MOPH. This was a fortuitous development, as MOPH had limited human resources at the time of project approval. The two external consultants, both fluent in Lao, were requested to assist with project management and implementation and training development. The TA came at the beginning of project implementation and, thus, the two PHC specialists were able to help the PCU and PIOs design an appropriate and practical master plan. They were also instrumental in assisting their MOPH colleagues in complying with ADB financial and administrative procedures and guidelines. The TA supported MOPHs social preparation efforts, as communities were invited to participate in the civil works component by providing appropriate in kind contributions. The TA helped orient trainers to focus more attention on promotive and preventive health care than merely training health workers to provide curative care, as was the case with previous training initiatives conducted under the auspices of MOPH. The TA also introduced central and provincial managers to the concept of ongoing monitoring and supervision and accordingly developed new checklists to monitor and review levels of PHC service delivery, adequacy of essential drugs and medical equipment, and unresolved problems at peripheral health centers. The TA greatly improved the capacity of the PCU and PIOs to manage and implement project activities, as well as other national health initiatives, in a more systematic and appropriate manner. It also fostered a greater degree of cooperation and coordination between different health departments and health sectors than had been achieved in the past. Without the technical advice provided by the TA, it is highly unlikely that the Project would have achieved the level of success that it eventually had. The human resources developed during the Project are now being used for PHC and other health initiatives. 12. MOPH disbursed its counterpart funds in a timely manner. Some problems were encountered with respect to the construction of health centers. The most serious issue concerned the contribution in kind to be made by local communities. This was initially set at a level equivalent to 36% of the health facility construction cost. Both MOPH and ADB originally underestimated how difficult it would be to build health centers in remote areas that lacked allweather roads or local construction materials (e.g., sand, gravel, stones, wood). This placed a great physical and financial burden on many poor communities that had to provide the labor to help transport these materials to the health center sites. During the midterm review, this issue was resolved by reducing the community contribution in kind to 12% and increasing ADBs share. 13. Efficiency of Investment. Project investments were generally efficient. The OEM calculated the economic internal rate of return at 12.2% (Appendix 5). The civil works construction and renovations were relatively modest and consistent with the level of basic and referral health services expected at these facilities. Health centers generally had (i) a patient waiting area, (ii) a patient examination roomcumoffice, and (iii) a separate room for patients who needed to remain overnight or for a couple of days for treatment or recovery. The health facilities were either built of wood or made from brick-cement, or a combination of these materials. Each health center complex contained a detached structure used for staff housing. This premise was built from the same type of building materials used for the health center. The health center also had a latrine and a separate water supply system for the health workers and patients. The land provided for health center construction was large enough to accommodate future renovations or additional construction in the event that more health workers were deployed to the facility, or additional space was needed to provide specific or more

Appendix 4

39

sophisticated (e.g., delivery) health services. The only serious problem with the civil works component is that certain health centers were built in mountainous or other areas where the water supply is either insufficient throughout the year or where the quality of potable water is not as good as originally envisioned. Some health center workers have dug shallow wells or use other sources of potable water to resolve this problem. MOPH has already begun to include the availability of a suitable and sufficient water system as a key requirement for future PHC civil works investments. 14. Each health center originally received an essential medical supply kit to cover 1,000 people per year. These essential drugs have been replenished through various means, to ensure an adequate supply in each health facility at all times. The items on the essential drug list were consistent with the common ailments in each health center catchment area, and with the level of health worker PHC skills. The essential drug list originally included only oral medications, but as health workers received additional in-service training, the list was expanded to include selected injectable antibiotics for more serious health problems. Each health center also received a basic diagnostic and medical equipment kit, the contents of which were also consistent with the level of care expected from the health workers. Certain health centers have recently had access to a wider assortment of medical equipment based on the capacity of their health workers to provide more sophisticated PHC services (e.g., delivery and intrauterine device services). This additional equipment has been distributed to the health center only after the prerequisite training for local health workers in the proper use of these more expensive items. 15. Training has been the key component of the Project. The Project has developed a series of modules for basic in-service and refresher training courses for trainers, health workers, and district supervisors, and for specific topics such as management and supervision; EPI; birth spacing for VHVs; revolving drug fund for provincial and district health staff; training for the monitoring of the pharmaceutical sector; benefit monitoring and evaluation (BME); the prevention, early detection, and treatment of malaria; and the use of impregnated bed nets. These training courses have generally lasted 14 weeks, although certain components for selected individuals have been designed for a 3- to 6-month period. Holding most of the training at the provincial and district hospitals kept training costs to a minimum. The training methods were geared to providing trainees with practical hands-on experience. This facilitated the acquisition of required knowledge and skills relatively quickly, and within the context of immediate use at the health center. Frequent and consistent monthly on-site supervision helped trainers and other field supervisors from the provinces and districts to observe how trainees were doing expected tasks, and to take appropriate corrective actions or suggest measures to resolve outstanding problems and issues while at the health center. Although this process of regular training and frequent on-site supervision was time-consuming, it was also extremely cost-effective and allowed newly hired and deployed health workers to start providing basic PHC services almost immediately in their respective health center catchment areas. 16. Although refresher-training opportunities for health center workers are still regularly available, they have become less frequent because of lack of funds from MOPH. Since many of these health workers have been deployed to their health center site for 413 years, their training must be fine-tuned to cover those important promotive, preventive, and curative PHC topics where they still do not have enough skills and knowledge or need additional input. Similarly, the frequency of regular on-site supervision from the provincial and district level has declined in the last 2 years. In many ways, this is a natural development as the Project becomes part of the routine health-care delivery system. However, many health workers require regular technical

40

Appendix 4

support from more senior health officials to be effective at their expected tasks, as well as to resolve problems in their respective catchment areas. 17. The Project also conducted a series of surveys to monitor and evaluate the impact of the Project on people living in Xieng Khouang and Oudomxay. In 1995, the Project conducted a baseline survey to document the health status and related factors affecting health in the project intervention area. In 1998, another large survey was conducted to assess client use and satisfaction with PHC services provided by the expanded network of health centers. Health center workers were interviewed to determine their level of job satisfaction, as well as their intention to remain at their current post. Besides these special surveys, the Project held technical workshops and regular meetings to disseminate information about the status of project implementation, and to review important lessons learned. An important component of BME was the routine on-site monitoring of project activities originating from the central level and down to the village-level health centers. These monitoring activities were cost-effective and allowed project managers to continually assess the project progress. However, no follow-up data on health status of the target population was collected. The ADB PHC Expansion Project has just completed a large household health survey in all eight provinces in the northern region. The results of this survey should help MOPH assess the health status of mothers, infants, young children, and other residents in the expanded project intervention area. Table A4.3: Project Efficiency Highly Efficient Less Efficient

Sub-Criteria 1. Efficiency of Process a. Manner of ADBs internal processing of the Project b. Organization and management of executing and implementing agencies at central and provincial levels c. Efficiency in recruiting consultants d. Efficiency in implementing civil works and procuring medical supplies and equipment in a timely manner e. Timely and adequate availability of counterpart funding 2. Efficiency of Investments a. Economic internal rate of return b. Cost of civil works construction and renovations consistent with level of basic and referral health care expected at these facilities c. Cost of essential medical supplies and diagnostic equipment consistent with level of care expected at these facilities d. Cost of training, supervision, and BME consistent with level of quality of basic health services for rural areas

Efficient X X

Inefficient

X X

x X

Appendix 4

41

Sub-Criteria Overall Rating = Efficient Rating Value = 2

Highly Efficient

Efficient Weight = 30% Score = 0.60

Less Efficient

Inefficient

ADB = Asian Development Bank, BME = benefit monitoring and evaluation. Source: Operations Evaluation Mission.

D.

Sustainability

18. Overall, the sustainability of the Project is likely. The Project has helped create a demand for basic, preventive, and curative health services in many rural and remote areas that previously were beyond the range of the Governments health service delivery system. A potential impediment to sustaining this newly created demand for PHC services is the current strategy of not taking advantage of regular outreach activities to outlying communities in the health center catchment areas to provide comprehensive, integrated PHC services to all eligible or interested clients. Instead, these visits focus primarily on the provision of EPI services to infants, young children, and pregnant women. All PHC services should be available during these on-site visits. By providing a wide range of comprehensive services, the health workers will gain credibility with the local population, and may soon be able to discuss issues and begin providing important health services that did not use to be in demand (e.g., antenatal and postnatal care). 19. All health centers now have at least one health worker each to ensure their continued operation and the provision of basic PHC services to local residents. MOPH, however, must ensure that these health workers undergo continual refresher training so that they can acquire the knowledge and skills to provide high-quality preventive and curative care. The monthly patient caseload is still relatively low compared with the population of the health center catchment areas. These low numbers may reflect inadequate skill levels to address certain issues (e.g., antenatal care, delivery, postnatal care), or the fact that local residents are expected to come to the static health center to obtain most PHC services. To increase patient caseloads, MOPH should try to ensure that every health center has at least two qualified health workers, and preferably that one is female or from an ethnic minority, as was the case during the Project. MOPH is now training a new cadre of nurses for deployment to health centers in Xieng Khouang and Oudomxay. Many of these trainees are female and ethnic minority members. Maternal and child health and BS-FP should spearhead the PHC service delivery program. To that end, many of the present health center workers will need further training, as well as regular assistance from district supervisors to create both a demand for, as well as a supply of, high-quality services for women and children. 20. The Project has shown that it can establish a sustainable revolving drug fund for health centers that will ensure an adequate supply of affordable essential drugs to all local residents at the time of illness. MOPH should periodically review the essential drug lists and see to it that they are consistent with the new knowledge and skills obtained by health workers through inservice training. Medication for infants and young children should be part of these essential drug lists. 21. During the Project, there was an adequate budget for operation and maintenance costs for health centers. At that time, the health facilities were relatively new and did not require major renovations. Since then, however, many health centers have required minor maintenance and

42

Appendix 4

repairs. Other sites have required major renovations to replace ceilings and roofs damaged, for example, by termites. The ADB PHC Expansion Project contains an operation and maintenance budget for the large network of health centers built in Xieng Khouang and Oudomxay. Accordingly, many health facilities have received timely renovations and repairs in 2004, about 79 years after their original construction. Some health centers still require maintenance inputs. MOPH must include adequate funding for the continued operation and maintenance of the health centers. 22. A key component of the Project was the strengthening of human resources capacities in the field of health in Xieng Khouang and Oudomxay. Project managers and supervisors from the provinces and districts were oriented and trained to support the expanded PHC service delivery system. Health workers deployed to the large network of health centers received basic inservice and regular refresher and continuing education training throughout the Project. The training gave the health workers the necessary technical and managerial skills to (i) operate the health centers, (ii) oversee the revolving drug fund, and (iii) provide all basic PHC services for local residents in their catchment area. It is clear from the OEM that many health workers need to continue their in-service education to function at an optimal level, as well as to address outstanding health issues and problems. The ADB PHC Expansion Project has budgeted funds for this in-service continuing education process. A key component of the process is regular and appropriate on-site supervision by experienced individuals who can fine-tune the technical and managerial skills of the health workers and see to it that these skills are put to effective use. Regular on-site supervision is crucial for monitoring progress and for ensuring that serious problems and outstanding issues are addressed early. On-site supervision is also essential for sustaining the morale of health center staff. 23. During the Project, health center workers were provided with medical diagnostic and equipment kits appropriate to their level of knowledge and skills. Many of these items have a natural life span and must be periodically replaced or repaired. Other items, originally not included in the medical equipment kits, will need to be procured as health workers develop new skills and can provide a wider range of PHC services. While this issue has not yet caused any undue problems, MOPH needs to ensure adequate funding in the future. 24. MOPH established an enabling environment for project oversight and implementation, according to loan covenant agreements. It created a national steering committee and a PCU at the central level to administer the Project and provide guidance for PHC policy development during the Project. At the same time, each province established a PIO to coordinate and implement all project activities in their respective provinces. The PCU and PIOs were staffed with full-time health officials, and supported by representatives from different health departments (at the central level) or health sections (at the provincial level) to ensure smooth project implementation and coordination with other national health initiatives. This new organizational framework operated throughout the Project, and has continued to do so as part of the ADB PHC Expansion Project and within the context of the National Primary Health Care Program that has now permeated down to all provinces in Lao PDR. 25. The Government, from the start of the Project, has demonstrated its ownership and commitment to continue the Project until successful completion and has already replicated the PHC initiatives, in modified form, using the lessons from the Project, and incorporated them into the Expansion Project. The expansion project covers all eight provinces in the northern region of Lao PDR. In January 2000, MOPH promulgated a new PHC policy. Many of the principles, approaches, strategies, and components enumerated in the PHC policy document have evolved

Appendix 4

43

from the experiences learned in the Project and from other PHC projects undertaken in the Lao PDR from the mid-1990s to 2000. 26. Community participation has been an integral strategy of the Project. Communities were involved in the selection of sites for the health centers. They also provided the labor to transport local construction materials (e.g., wood, sand, gravel, stones) to these sites. Since many of these items were not available near the identified health center sites, local communities had to exert tremendous physical efforts and time, especially in remote mountainous areas, where facilities were not necessarily located near all-weather roads. The communities have continued to provide support to the health center workers by sending representatives (e.g., VHVs and traditional birth attendants) for training so they can participate in important health activities or to provide selected PHC services to villagers. The VHVs and traditional birth attendants, supported by local leaders and members of mass organizations, have been instrumental in educating communities about the importance of BS-FP and ways of preventing malaria. VHVs have been trained to impregnate bed nets. These two interventions have dramatically reduced morbidity and mortality associated with malaria, and created demand for modern BS-FP services. In addition, village committees have helped provide, during the Project, oversight of the use of the proceeds from the sale of essential drugs to ensure that health centers always have an adequate supply of essential medicines. This active involvement and participation has helped ensure that basic health services are available to the poor, ethnic minorities, and other underserved groups. A key measure of future project success will be whether PIOs can continue to encourage local communities to remain actively involved in the provision of basic PHC services. MOPH, PCU, and PIOs may need to develop new ways of motivating communities to continue their active involvement with health activities, to improve the health status of local residents. Table A4.4: Project Sustainability Most Likely X Less Likely

Sub-Criteria 1. Creation and maintenance of demand for basic preventive, promotive, and curative health services in rural and remote areas 2. Availability of at least one health worker at each health center to allow these facilities to continue to operate 3. Availability of cost recovery mechanisms to ensure an adequate supply of essential drugs for clients at rural and remote health centers 4. Probability of funds availability (cash flow) for continued operations and maintenance of health centers 5. Probability of technical and managerial skills to continue providing basic health services

Likely

Unlikely

44

Appendix 4

Sub-Criteria 6. Probability of appropriate technology and equipment to operate the Project

Most Likely

Likely X

Less Likely

Unlikely

7. Probability of an enabling environment (e.g., policies, administrative reorganizations at central and provincial levels) in which the Project is operating at the time of evaluation 8. Government ownership and commitment to continue the Project, as well as to modify and replicate lessons learned in other PHC initiatives in Lao PDR 9. Probable continuance of community participation and beneficiary incentives to ensure that basic health services are available for the poor, ethnic minorities, and other underserved groups. Overall Rating = Likely Sustainable Rating Value = 2 X

Weight = 20% Score = 0.40

Lao PDR = Lao Peoples Democratic Republic, PHC = primary health care. Source: Operations Evaluation Mission.

E.

Assessment of Overall Project Performance Table A4.5: Overall Project Rating Weighted Rating 0.60 0.60 0.60 0.40 2. 20

Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating

Assessment Highly Relevant Effective Efficient Likely Successful

Rating (03) 3 2 2 2

Weight (%) 20.0 30.0 30.0 20.0 100.0

Rating Scale: HS = highly successful (overall weighted average, or OWA is >2.7); S = successful (OWA is between 1.6 and 2); PS = partly successful (OWA is between 0.8 and 1.6); U = unsuccessful (OWA is < 0.8). Source: Operations Evaluation Mission.

Appendix 4

45

F. 27.

Impacts The Project had significant institutional development and other impacts.

28. The Project has dramatically increased accessibility to a wide range of comprehensive health services that previously were either unavailable or not within the frame of reference of selected project target groups. This development has obviously modified the informal norms and practices of people in the project intervention area to better understand and appreciate the myriad factors that affect their health. Increased accessibility has also made it easier for many of the target groups to take advantage of important promotive, preventive, and curative health services directly offered in their communities or at the health center. The Project has had greater success with influencing certain norms and practices more than it has for others. It has, for example, been very successful in encouraging women of reproductive age and couples to select an appropriate BS-FP method. It is probably more accurate to add that the Project has helped provide a supply of safe and effective contraceptives to meet a previously expressed or unexpressed demand for couples to decide on the number and spacing of children in their respective families. The Project has also achieved great success in providing infants and young children with immunizations that prevent six communicable, and often fatal, diseases. During these EPI sessions, in each village in the health center catchment area, young children are also provided with vitamin A supplements to protect them against serious ophthalmology problems that can lead to blindness. Similarly, the Project has had great success in making villagers and communities aware of how malaria is transmitted, and helped inaugurate effective prevention, early detection, and treatment strategies that include the use of impregnated bed nets. These changes in informal norms and practices have had a great impact on improving child and maternal health and reducing morbidity and mortality, especially in remote ethnic minority communities. The Project has had less success in encouraging communities to build household latrines or improve their potable water supply. Not having enough financial resources or interest to install these interventions is a constraint. Many health workers have also not succeeded in encouraging pregnant women to allow a trained health worker to provide antenatal, delivery, and postnatal services. Some constraints and problems could probably be more easily resolved if health center workers were supported and could spend more time in outlying communities, as well as provided comprehensive, integrated health services while conducting outreach activities rather than merely focusing on EPI service delivery. 29. In 1999, MOPH was reorganized. The PHC and Rural Development Division was created as part of the cabinet section. This new body was made responsible for coordinating the national PHC program including (i) overall planning, coordinating with international assistance agencies supporting PHC activities or related national vertical health programs (e.g., EPI, birth spacing and reproductive health, safe motherhood, human immunodeficiency virus/acquired immunodeficiency syndrome control and prevention); and (ii) improving the health monitoring and evaluation systems. Provincial PHC coordination units were also established in all 17 provinces and one special zone in the country for more effective coordination of PHC activities. This reorganization clearly highlights the priority that MOPH has placed on PHC as a strategy to attain health and socioeconomic development goals, as formally expressed in its Millenium Development Goals. It also highlights the need to coordinate and standardize different PHC approaches aimed at providing basic health-care services to the entire population at the grassroots level, especially mothers, young children, and other underserved groups. 30. The Project has successfully encouraged communities in each health center catchment area to provide time, labor, and local natural resources to build their own health center and improve the health status of local residents. This contribution in kind originally represented

46

Appendix 4

36% of the estimated construction costs. This process has stimulated community ownership for the newly expanded network of health centers, and generated active support and cooperation for the health workers assigned to these sites. Requiring communities from the start of project design and implementation to participate in the establishment and management of the comprehensive PHC service delivery system is an important process in outlining the explicit responsibilities that both local communities and health authorities must share to ensure success. A major lesson learned, by the Project, is that MOPH and international funding agencies must be able to realistically assess the level of contributions in kind that villages, especially poor ethnic minority communities, can provide before these efforts become an undue burden on the local population. It may perhaps be more useful for part of the contribution in kind to be reimbursed in the form of a special village outreach health service delivery fund which will allow health workers to more easily visit each community in their catchment area monthly or quarterly. This fund can be used to pay for the transport of essential drugs, contraceptive commodities, and other medical supplies and equipment needed to provide comprehensive promotive, preventive, and curative services to interested clients or patients in need of acute care. It can also be used to pay modest honoraria or per diems so that health workers do not have to use their own limited personal funds while performing services for their catchment area. 31. The Project has had a significant impact on reducing poverty by making basic health services more accessible, readily available, and affordable to all people and segments of society. The creation of a large network of health centers has increased health coverage from about 33% to 80% of all people living in Xieng Khouang and Oudomxay in a relatively short time. An important aspect of this expanded coverage has been the fact that it has primarily taken place in rural, remote, and ethnic minority inhabited areas where poor and previously underserved communities had little access to government health services. The provision of comprehensive promotive, preventive, and curative health care at health centers, and directly in communities themselves, has reduced morbidity and mortality related to common ailments, as well as reduced anxiety among the target population. An improved health status has undoubtedly improved the economic situation of many families, as members are less likely to fall seriously ill and therefore less likely to spend time and money traveling long distances to district and provincial hospitals. The reduction in morbidity has also allowed families living in rural and remote communities to be more economically productive, as members spend less time ill and away from economic pursuits or (in the case of mothers and women) simply taking care of other family members who are ill. 32. The Project has probably had a a positive impact on the environment by building environment friendly health centers. The sites selected for construction did not require the destruction of natural forests or the substantial use of local building materials (wood, sand, gravel, stones) that could have a negative impact on the environment. The health centers use natural lighting and ventilation for the comfort of both health workers and patients. This has reduced the need for electricity or other sources of power to operate the health center. 33. The Project has had a very significant impact on social development by increasing job opportunities for local people to become government health workers. When the Project started, about two thirds of the health personnel deployed to the newly expanded network of health centers in Xieng Khouang (62%) and Oudomxay (68%) were local medical practitioners (phaet ban) who were initially employed as contract workers. Many of these individuals were ethnic minority members, and could therefore communicate easily with local residents in their respective catchment areas. A majority of these contract workers are still employed and working in their original posts. Most have had their employment status upgraded to government

Appendix 4

47

civil servant. Others simply need to complete 3 years of acceptable service as part of their contractual agreement with provincial health authorities to have their status upgraded. At the present time, the nursing colleges in Xieng Khouang and Oudomxay are completing the training of the first class of auxiliary nurses, many of whom will be deployed to the health center network in these two provinces. To upgrade the quality of health care provided by health centers, and to more easily approach selected project target groups such as mothers and women, provincial health authorities selected many ethnic minority women to be part of the first auxiliary nursetrainee cohort. This strategy should improve cultural acceptability for antenatal, delivery, postnatal, immunization, and other important PHC services, especially among ethnic minority women. The Project has also provided new skill creation opportunities by training large numbers of VHVs and traditional birth attendants to be able to discuss important health issues, such as BS-FP and the prevention, early detection, and treatment of malaria. VHVs have been trained to impregnate bed nets, and this intervention has already had an impressive impact on reducing the prevalence of malaria in the project intervention area. The Project has also initiated social preparation activities to encourage communities to take an active role in promoting and maintaining good health. Community participation has been crucial in the construction of the local health facilities, the co-management and oversight of the health center revolving drug fund, and the certification of indigent households eligible for free medication. 34. The Project has had an important impact on local political development by encouraging other sectors and mass organizations to be involved in health center-sponsored activities. Village leaders and members of mass organizations like the Lao Womens Union and the National Front for Construction have been instrumental in supporting provincial and district health authorities organize training for VHVs and traditional birth attendants, as well as promoting regular outreach activities such as EPI and the distribution of vitamin A supplements. During the Project, village health committees provided oversight of the use of proceeds collected from the sale of essential drugs to ensure an adequate supply of medicine at all health centers. These committees also authorized the use of these funds for outreach activities as well as for minor repairs at the health center. Table A4.6: Project Impacts

Sub-Criteria A. Institutional Impacts 1. MOPH updates PHC policies in line with new developments, expressed needs, and lessons learned from the Project 2. The informal norms and practices of project target groups have been changed, as reflected by service acceptance and improved health status 3. PHC organizational framework at central and provincial levels has been strengthened to continue and expand PHC initiatives in Lao PDR

Substantial

Significant

Moderate

Negligible

48

Appendix 4

Sub-Criteria 4. Technical and managerial skill levels and capacities to plan, implement, and monitor PHC and other health initiatives at the central, province, and district levels have been strengthened 5. Communities are willing to contribute time, labor, and resources to develop and manage PHC services aimed at improving their own health status B. Socioeconomic Impacts 1. Impact on poverty, by making basic health services available to all people and segments of society 2. Impact on the environment, by constructing health facilities that are environment friendly 3. Impact on social development, by increasing job opportunities for local people to become health workers or health volunteers, as well as promoting community participation in the management and oversight of their health 4. Impact on political development, by encouraging an integrated, multisectoral approach to the provision of health education and basic health services by government agencies, mass organizations, and local communities Overall Rating = Significant

Substantial

Significant X

Moderate

Negligible

Lao PDR = Lao Peoples Democratic Republic, MOPH = Ministry of Public Health, PHC = primary health care Source: Operations Evaluation Mission.

Appendix 5

49

ECONOMIC EVALUATION A. Introduction

1. Better health status is linked to productivity gains for most developing economies as it implies improvements in nutrition, disease control, basic education, and increased economic opportunities for majority of the population. In the report and recommendation of the President (RRP),1 economic gains resulting from decreases in the under-5 mortality rate (U5MR), measured in terms of future additional value of the marginal product of labor, was computed to have an economic internal rate of return (EIRR) of 12% if the U5MR decreased by 10%.2 An attempt was made to update and recalculate the computation for the EIRR based on the methodology used by the RRP. Unfortunately, not enough data were available, and the supplementary appendix related to the economic analysis as indicated by the RRP was not in the archives and project files. Following the method used in the project completion report (PCR),3 where effectiveness of the Project was gauged of the basis on the status of key health indicators for Xieng Khouang and Oudomxay, it can be surmised that the Project had a positive effect on health indicators. At the national level, for example, the average rate of decrease in U5MR between 1990 and 2000 is close to 40%. The PCR showed a decrease in the infant mortality rate (IMR) and U5MR from 1996 to 2000. The Operations Evaluation Mission (OEM) tried to update this information and sought data from the national census, but, unfortunately, no data are available to date. The result of the Primary Health Care Expansion Project (PHCEP) survey, however, gave an indication of the status of some key indicators in the PCR analysis (see Table A5). The OEM noted that the figures for 2004 are not comparable with those in 1996 and 2000, since the survey is not the same as those used in the 2 previous years in sample size and methodology. An alternative computation of project efficiency was computed, using the methodology presented in detail in this Appendix. While this is not directly comparable with the findings in the RRP and PCR, because of differences in the methodology used, the computed figures provide concrete indications of the gains from the Project. The impact of the Project, resulting in a (computed) 0.5 million avoided days due to illness and out-of-pocket health expenditure cost savings of $0.5 million in the project areas, is an estimated EIRR of 12.2%, and an economic net present value of $0.17 million. Cost savings and labor productivity account for 60% and 40% of total economic benefits, respectively. 2. The economic impact of a healthier population is difficult to capture quantitatively in this paper, as various factors affect social structures and economic development. However, there is a consensus on two things: (i) the important role of women in the implementation of Primary Health Care (PHC), and (ii) the contribution of a young, healthy population in sustaining a production-based economy, such as the Lao Peoples Democratic Republic (Lao PDR). The outcome of the Project was the improvement of health status among its target beneficiaries, composed of the poor people in the pilot areas, as a consequence of easier access to PHC. This improvement was noted qualitatively during the OEM and shown in the PHCEP household survey results using health indicators.

ADB. 2000. Report and Recommendation of the President to the Board of Directors for a Proposed Loan to the Lao Peoples Republic for the Primary Health Care Expansion Project. Manila (Loan 1749-LAO, for $20 million, approved on 24 August). ADB. 1994. Report and Recommendation of the President to the Board of Directors on a Proposed Loan to the Lao Peoples Democratic Republic for Primary Health Care Project. Manila. ADB. 2002. Project Completion Report on the Primary Health Care Project in the Lao Peoples Democratic Republic. Manila.

50

Appendix 5

3. While a quantitative measurement of the socioeconomic effects of the provision of PHC services in the two pilot provinces was not derived during the OEM survey, all of the beneficiaries interviewed indicated that the presence of health centers in their villages contributed to the following: (i) easier access to medicines, (ii) basic health and reproductive education, and (iii) immediate access to health personnel. These factors, as other health policy studies have confirmed, have positive effects on productivity and the well-being of a given population. B. Project Objectives

4. The Project financed the construction of 73 primary health centers and 3 district hospitals, renovated 5 other hospitals, and supported a public health school. About 6,000 health workers were trained and a revolving fund was established to maintain the supply of drugs. The Project contributed to improving health status indicators in Lao PDR. In 1988, the IMR was 109 per 1,000 live births. By 2001, it had declined to 82 per 1,000 live births. The maternal mortality rate, on the other hand, was 656 per 10,000 live births in 1990 and declined to 530 per 10,000 in 2000.4 5. The EIRR for the Project was estimated as part of project preparation. It was assumed that the key economic gain from the Project would be the added future value of labor from a decrease in the U5MR (footnote 2). The analysis suggested a 10% reduction in the U5MR would yield an EIRR of 12%. Since this analysis was undertaken, ADB5 has developed procedures for valuing economic benefits from increased labor productivity as a result of decreased incidence of ill-health and also from cost savings from decreased health service expenditure. The valuation procedure adopted in these guidelines was used for this ex-post economic evaluation of the Primary Health Care Project for Lao PDR. Key assumptions used in the analysis are given below. C. Cost-Benefit Analysis

6. The quantitative cost-benefit analysis for the Project follows the methodologies outlined in ADBs Guidelines for the Economic Analysis of Projects (2003). Key assumptions include (i) (ii) Discount rate. The economic opportunity cost of capital is 12%. Projection of project benefits and costs. The period of analysis covers 20 years. Benefits and costs were converted into constant 2006 dollar prices. Key benefits incorporated in the economic evaluation framework involve cost savings from reduced out-of-pocket health expenditure and productivity benefits from increased labor supply. Economic cost of labor. The opportunity cost of labor or the shadow wage rate (SWR) for both urban and rural adults was calculated at $0.5 per day. This estimate is derived from basic statistics for Lao PDR.6

(iii)

ADB. 2002. Project Completion Report on the Primary Health Care Project in the Lao Peoples Democratic Republic. Manila (Loan 1348-LAO[SF]). Bloom, E. and P. Choynowski. 2003. Economic Analysis of Health Projects: A Case Study in Cambodia, ERD Technical Note No. 6. Manila: ADB; and Musgrove, P.A. 2003. Health Economics in Development. World Bank. Government of Lao PDR. 2000. Basic Statistics of the Lao PDR 19752000. Vientiane: State Planning Committee.

Appendix 5

51

D.

Economic Costs

7. Base investment costs are in constant 2006 dollar prices. Costs were derived from disbursements over the implementation period, adjusted for inflation into 2006 dollar terms. Incremental recurrent costs were calculated for the 15 years following the 5-year project implementation period. E. Economic Benefits

8. The Project will improve the socioeconomic condition of the target beneficiaries. Key project benefits were estimated in the following ways: (i) cost savings due to increased health awareness and reduced disease prevalence, and (ii) enhanced income of both rural and urban income earners who care for the sick. Costs and benefits are outlined in Table A5 for investment and recurrent expenditures over a 20-year projection. Key benefits include the following: 9. Cost Savings due to Increased Health Service Coverage. Resource or out-of-pocket savings may flow from (i) increased access to health services to reduce transport costs, and (ii) more efficient and rational diagnosis and treatment to reduce cost of treatment. Improvements in health status as a result of health awareness activities lead to significant decreases in out-of-pocket health expenditures. In 2001, it was estimated that out-of-pocket health expenditures in Lao PDR were in the order of $7 per person.7 10. A range of other studies support this level of health expenditure. For example, Schwartz8 estimated 58% of health expenditure was from households in 1998, or $6.7 per person. A recent costing analysis by World Health Organization (2005) suggested average out-of-pocket expenditure was in the order of $6.6 per person. Bloom and Choynowski (2003) calculated that out-of-pocket health expenditure would decrease with the availability of improved health services in Cambodia. In their study, it was assumed that expenditure would decrease by $6 per person in areas targeted by an Asian Development Bank-supported health project in that country. This decrease is equivalent to a reduction of about 23%. If a similar decrease in out-ofpocket expenditure is assumed for Lao PDR, then a cost saving of $1.5 per person would be realized. This assumption was used for the economic evaluation, and is assumed to be captured by project beneficiaries as the reach of newly established health centers and district hospitals is increased. 11. Increased Income through Reduced Sick Leave or Time for Caring. Adults often have to care for sick children, or they may contract infectious disease themselves and suffer reduced work productivity and foregone income through premature death. The nature of these productivity losses has received limited attention in the literature, although demographic and household surveys indicate that considerable time is lost through transportation and care of sick family members. For example, surveys of the costs of caring and transporting family members affected by human immunodeficiency virus/acquired immunodeficiency syndrome to health facilities within Asia and Africa are shown to be considerable.9

7 8

World Health Organization. 2004. World Health Yearbook. Geneva. Schwartz, J. Brad. 1999. Public and Private Health Expenditures in Lao PDR: ADB Primary Helath Care Expansion Project. Vientianne. For example, in Bloom, D., P. Jacobs, and K. Fassbender. 1999. The Impact of HIV/AIDS Morality on Households in Thailand. The measurement of indirect costs in the health economics evaluation literature. Int J Technol Assess Health Care. Bangkok. 14:799808.

52

Appendix 5

12. Bloom and Choynowski (2003) estimated that improved health services in Cambodia would result in a 2.3-day average reduction in per capita lost days of work due to illness. Health surveys in Lao PDR indicate that health status has improved over the period of the PHCEP. In light of these gains, it is assumed that each person of working age within the project target areas has saved an average of 4 days of lost labor per year. 13. Increased Service Coverage. The loan was used to build 73 PHC centers primarily in Xieng Khoung and Oudomxay provinces. Each PHC center serves about 3,0004,000 people. Given the population in these provinces of about 0.5 million people, the PHC facilities serve around 50% of the population. At the time of the OEM, all centers were still operational. Health service coverage is assumed to increase in similar incremental steps of 10% per year until the coverage ceiling of 50% is reached. F. Economic Internal Rate of Return

14. The benefits of the Project result in more than 0.5 million avoided days of lost workdays due to illness and out-of-pocket health expenditure cost savings of $0.5 million in the project target areas. The resulting EIRR is 12.2%, and the economic net present value is $0.17 million. Cost savings and labor productivity account for 60% and 40% of total economic benefits, respectively. Table A5: Cost-Benefit Analysis and Projection of Beneficiaries
Labor Productivity Increased Labor Service Increased Economic Labor Coverage Benefit Year (%) (days) ($ m) 1995 0% 1996 10% 102,500 0.05 1997 20% 210,000 0.11 1998 30% 322,500 0.16 1999 40% 440,000 0.22 2000 50% 562,500 0.28 2001 50% 575,000 0.29 2002 50% 587,500 0.29 2003 50% 600,000 0.30 2004 50% 612,500 0.31 2005 50% 625,000 0.31 2006 50% 637,500 0.32 2007 50% 650,000 0.33 2008 50% 662,500 0.33 2009 50% 675,000 0.34 2010 50% 687,500 0.34 2011 50% 700,000 0.35 2012 50% 712,500 0.36 2013 50% 725,000 0.36 2014 50% 737,500 0.37 Total 10,825,000 5.41 = not available, NPV = net present value. Source: Operations Evaluation Mission. Cost Saving Reduced Health Expend. ($ m) 0.08 0.16 0.24 0.33 0.42 0.43 0.44 0.45 0.46 0.47 0.48 0.49 0.50 0.51 0.52 0.52 0.53 0.54 0.55 8.12 Gross Benefit ($ m) 0.13 0.26 0.40 0.55 0.70 0.72 0.73 0.75 0.77 0.78 0.80 0.81 0.83 0.84 0.86 0.87 0.89 0.91 0.92 13.53 Invest. Cost ($ m) 0.01 0.79 1.04 1.08 0.82 0.83 0.11 4.68 Recurrent Cost ($ m) 0.00 0.20 0.26 0.27 0.21 0.21 0.03 0.03 0.03 0.03 0.03 0.03 0.03 0.03 0.03 0.03 0.03 0.03 0.03 0.03 1.53 Net Benefit ($ m) (0.02) (0.85) (1.04) (0.94) (0.48) (0.34) 0.58 0.71 0.72 0.74 0.75 0.77 0.78 0.80 0.82 0.83 0.85 0.86 0.88 0.89 7.32 NPV (2006) ($ m) (0.05) (2.65) (2.89) (2.33) (1.06) (0.67) 1.02 1.11 1.01 0.93 0.84 0.77 0.70 0.64 0.58 0.53 0.48 0.44 0.40 0.36 0.17

Appendix 5

53

G.

Conclusions

15. The international literature indicates that the economic returns from investments in health are substantial. Economic analysis undertaken in this report suggests that investment in the Lao PDR PHCEP has been economically attractive. Vulnerable groups, such as ethnic minorities were the beneficiaries from such an investment.

54

Appendix 6

HOUSEHOLD SURVEY 1996 AND NATIONAL HEALTH SURVEY 2001

Indicator Infant mortality rate U5MR per 1,000 live births Maternal Mortality rate per 1,000 live births d Fully immunized children (aged 12.23 months) (in % coverage) Under-5 vitamin A supplementation (6 months5 years)e Under 5: Impregnated bed nets ordinary bed nets % of villagers using public health services other than immunization % of villages receiving four EPI visits per year % EMWRA in rural areas using modern contraceptive method % EMWRA in rural areas who know at least one modern contraceptive method Total fertility rates f % of EMWRA received tetanus toxoid 1996a (%) 125 175.8 2000b (%) 82 106 530 32.4 2004c Oudomxay Xieng Khouang

20

77 61 25 25 17 43

53 (BCG) 59 (Measles) 17 (Polio) 16 (DPT 21 50

1.39 66.7 12.0 32.8 0 9.0-18.0

28.8 82.7 67.9 72.1

14

28

44

8.6 7.0 45 36 62 (49% national) % of EMWRA seeking antenatal care 12 (87% at 28.7 hospitals) % of EMWRA aware of HIV/AIDS 40 52.8 = not available, AIDS = acquired immunodeficiency syndrome, BCG = Bacillus Calmette-Gurin, DPT = diphtheria, EMWRA = ever married women of reproductive age, EPI = Expanded Program of Immunization, HIV = human immunodeficiency virus, U5MR = under-5 mortality rate. a Household Survey, 1996. Extracted from Table A8 (p. 42) PCR, 20 July 2002. b National Health Survey, 2001. Extracted from Table 11.1 (p. 42) Project Completion Report, 20 July 2002. c ADB. 2005. Report and Recommendation of the President ot the Board of Directors for a Proposed Loan to the Lao Peoples Democratic Republic for the Primary Health Care Expansion Project. Manila. The survey sample size and methodology used to determine the health status for 1996 and 2000 are not comparable with those for 2004. d For 2004, no aggregate information on immunization is available, thus performance in the major components of the immunization program were itemized. Given this, the data are only indicative of the state in 2004 and may not be directly comparable with the figures for 1996 and 2000. e For 2004, this covers children who received at least two doses of vitamin A during the year. f For 2004, this covers those who had at least two doses of tetanus toxoid the year before the survey. Source: Asian Development Bank. 2002. Project Completion Report in the Lao Peoples Democratic Republic. Manila. 18 June, Table 11.1, p. 42 (1995 data from Household Survey 1995, 2000 data national health survey 2001). Source of basic information, Ministry of Public Health (Lao Peoples Democratic Republic), 2002.

Appendix 7

55

PROGRESS ON THE ACHIEVEMENT OF MILLENNIUM DEVELOPMENT GOALS Most Recent Status 106 (1999)

Target Target 5: Reduce by two thirds the under-5 mortality rate

Target 6: Reduce by three quarters the maternal mortality ratio

Target 7: Have halted by 2015, and begun to reverse, the spread of HIV/AIDS

Indicator 013: Under-5 mortality rate (deaths per 1,000 live births) 014: Infant mortality rate (deaths per 1,000 live births) 015: Proportion of 1-year old children immunized against measles (% of 12 23 months old children surveyed) 016: Maternal mortality ratio (deaths per 100,000 live births) 016a: Contraceptive prevalence rate 017: Proportion of births attended by skilled health personnel 018a: HIV prevalence among 1524-year old commercial service womena 019a: Proportion of 1524-year old women who have ever used a condom during sexual intercourse 019b: Proportion of 1524-year old commercial service women reporting consistent use of a condom with nonregular sexual partners in the past 12 months

Baseline 170 (1990)

2015 Target 55 deaths per 1,000 live births 45 deaths per 1,000 live births 90%

134 (1990)

82 (1999)

62% (1996)

42% (2000)

750 (1990)

530 (2000)

185 deaths per 100,000 live births 55%

13% (1990)

32% (2000)

14% (1994)

17% (1999)

80%

No data earlier than 2001

0.4% (2001)

<1%

0.9% (1994)

0.7% (2000)

20%

No data earlier than 2000

45% (2000)

70%

56

Appendix 7

Target

Target 8: Have halted by 2015 and begun to reverse, the incidence of malaria and other major diseases

Indicator 020a: Proportion of 1524-year old women who know how to prevent RTIs/STDs 020b: Proportion of 1524-year old commercial service women who correctly identify ways of preventing sexual transmission of HIV and who reject major misconceptions about HIV transmission or prevention 021: Death rate associated with malaria (per 100,000) 021a: Morbidity rate due to malaria (suspected cases per year per 1,000) 022: Proportion of population in malaria risk areas using effective malaria prevention and treatment measures 022a: Proportion of population in malaria risk areas protected by impregnated bed nets 023: Prevalence rate associated with tuberculosis (per 100,000) 024.1: Proportion of tuberculosis cases detected under DOTS 024.2: Proportion of

Baseline No data earlier than 2000

Most Recent Status 32% using a condom (2000)

2015 Target 70%

No data earlier than 2000

20% using a condom consistently (2000)

70%

9 (1990)

3.5 (2002)

0.2 per 100,000

44 (1990)

48 (2002)

15 per 1,000

No data earlier than 2000

24% treated bed nets (2000)

100%

25% (1999)

60% (2002)

100%

144 (1990)

144 (1990)

50 per 100,000

24% (1996)

47% (2002)

70%

72% (1996)

83% (2002)

85%

Appendix 7

57

Target

Indicator tuberculosis cases cured under DOTS

Baseline

Most Recent Status

2015 Target

AIDS = acquired immunodeficiency syndrome, DOTS = directly observed treatment short course (TB), HIV = human immunodeficiency virus, RTI = reproductive tract infection, STD = sexually transmitted disease. a Defining and identifying women who sell sex for money in the Lao Peoples Democratic Republic can be particularly difficult. The term service women refers to women, usually working in small drink shops and nightclubs, who may engage in commercial sex transactions, but their employment in these venues does not automatically signify that they are selling sex. Source: Government of the Lao Peoples Democratic Republic and United Nations. 2004. Millennium Development Goals Progress Report for Lao PDR. Vientianne.

58

Appendix 8

OUTCOMES AND DELIVERY Table A8.1: Preventive Health Service Outcomes

Indicator BCG coverage Measles coverage Polio coverage (polio 3) DPT 3 coverage FIC coverage Percentage of women of reproductive age 1549 fully immunized with TT (at least two doses) Percentage of children under 5 sleeping under an impregnated bed net Percentage of children who received at least two doses of vitamin A during the last year Contraceptive prevalence rate Composite Mean Score Preventive Health Service Outcome Xieng Khouang 53 59 17 16 62 50 21 24 33

Oudomxay
77 61 25 25 36 43 17 18 34

BCG = bacillus Calmette-Gurin, DPT = diphtheria, FIC = fully immunized child, TT = tetanus toxin. Source: MOPH. 2005. Primary Health Care Expansion Project 2004 Household Survey. Table 7.

Table A8.2: Government Health Service Delivery

Indicator Percentage of villages within 1 hour of a health center during dry season Percentage of villages within 1 hour of a health center or a hospital during dry season Percentage of villages with minimum four EPI visits during the last year Percentage of villages with minimum one bed net impregnation session during the last year. Percentage of household which impregnated at least one bednet during the last year Percent of patients seeking care at government facilities at the first instance Percent of deliveries attended by a trained medical practitioner Percent of deliveries made at the hospital Composite Mean Score Government Health Service Delivery Oudomxay 41 45 14 50 34 19 18 12 33 Xieng Khouang 63 71 8 71 57 49 10 10 44

EPI = Expanded Program of Immunization. Source: MOPH. 2005. Primary Health Care Expansion Project 2004 Household Survey. Table 7.

Appendix 9

59

PRIMARY HEALTH CARE CENTERS IN OUDOMXAY

Pho Ome Health Center, Namor District

Na khok Health Center, Nga District

Nahome Health Center, Beng District

Saysana Health Center, Pakbeng District

MANAGEMENT RESPONSE TO THE PROJECT PERFORMANCE EVALUATION REPORT FOR THE PRIMARY HEALTH CARE PROJECT IN THE LAO PEOPLES DEMOCRATIC REPUBLIC (Loan 1348-LAO[SF])

On 10 July 2006, the Director General, Operations Evaluation Department, received the following response from the Managing Director General on behalf of Management:

1. Management finds OEDs Project Performance Evaluation Report (PPER) well prepared with a commendable effort to evaluate the performance of the Project in the two remote provinces in Lao Peoples Democratic Republic (PDR). The overall assessment and rating is similar to the Project Completion Report. Management response focuses on some lessons learned and OED recommendations. A. Overall Assessment

2. Design and Formulation. The Project concentrated on improving access through construction and operationalization of health centers. We note that some activities assigned to the Project are actually implemented under the follow-up project, Loan 1749-LAO: Primary Health Care Expansion Project (PHCEP), including village health volunteer program and hospital improvement components. 3. Performance. We note the overall positive assessment of project performance. As ongoing PCHEP, as the second phase project, is almost completed, it is difficult to distinguish inputs and outcomes of the Project and PCHEP. 4. We agree with the finding that funding constraints affect the performance of health centers and outreach services, but that despite these constraints, services are still effective in providing basic services (paras. 29, 33, and 41). As recurrent costs constraints are still a major issue, this is a priority issue being addressed under the upcoming health sector development program and through improving revenues and expenditures, including a containment of new infrastructure. 5. Other Assessments. Management agrees that reproductive health services for rural women need further improvement (para. 51). We also agree that subsidy for drugs are too low for the rural poor (paras. 5253), and note that ADB will assist the Government in addressing this issue under the Health Sector Development Program. While there was a substantial reduction of the total fertility rate under the PHCEP, the reduction of the maternal mortality ratio was slower, as it takes more time to provide appropriate staff and referral services. 6. We agree with the issue of inadequate delegation of financial decision making authority (para. 56). This has two dimensions: the Ministry of Finance that remains the Executing Agency for many sectors in Lao PDR is perceived to

have less financial management capacity, and within the line ministry, delegation of financial decision making is also centralized. 7. On harmonization. In addition to joint project administration with the World Bank project, it may be noted that the steering committee was not project specific, but oversaw all ministerial activities (paras. 56 and 14). This helps considerably in donor coordination. B. Issues, Lessons Learned, and Follow-up Actions

8. Management agrees that the maintenance of health centers was inadequate after project completion. This issue was noted by the Ministry of Health and additional funds for maintenance have been made available under the follow-up ADB project (PHCEP), and repair and maintenance is currently ongoing. One issue here was the emphasis on low cost buildings partly using local materials supplied by communities as their contribution, which affected the quality of materials while increasing community ownership. As funds for maintenance will remain tight, engendering strong community ownership for the rural health center, which is considered feasible in these locations, may partly solve the maintenance problem. 9. The PPER observes that there was no evidence that a systematic benefit monitoring and evaluation (BME) was carried out. Management notes that BME was very much part of the design (a separate component) and given high priority by the mission leader at that time (as evidenced by back-to-office reports and reporting on, among others, utilization rate of health services over the project years). However, as noted in para. 61, item (ii), we agree with the lack of province-specific baseline data, which, in the subsequent project, has been covered. 10. Management agrees on the importance of placing health centers in strategic locations. The Project was based on global standard to provide rural populations with access to a health center within a few hours of walk. However, the low population density in Lao PDRs mountains makes this costly. Using the norm of 3,0004,000 people per health center, as suggested by the PPER, would deny many rural poor, in particular ethnic minorities, reasonable access to health services. Under the second project, detailed health zoning was done to determine the optimal location of health centers. This brought down the number of health centers that had to be constructed, and made staffing and maintenance easier. It was complemented with training of village health volunteers to provide immediate access at village level. C. Follow-up Actions

11. Regarding the recommendation of including injectable contraceptives in drug kits, the Government has approved the inclusion of oral contraceptives and condoms in the drug kits. 12. Regarding the recommendation of increasing support for outreach programs, the follow-up project has piloted the increase of the budget for

outreach services, and this will be taken up scale in the third phase, the Health Sector Development Program. 13. The proposed inventory of existing facilities and equipment will be repeated regularly. D. Conclusions

14. Management agrees with the reports overall assessment and rating, and appreciates the many positive aspects of this Project as recorded in the PPER, which, as noted, reflect a combination of Government commitment, core management capacity, and willingness to learn and improve; while working in a difficult physical, social, and financial environment.