This work was originally published by The World Bank in English as Facility based Service Readiness Assessment In four northern provinces in Lao PDR in 2023. © 2019 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. 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Cover photo: © HUMA / World Bank Photo credit: © HUMA / World Bank Cover design: INSMAI Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 2 EXECUTIVE SUMMARY....................................................................................................................... 11 INTRODUCTION ................................................................................................................................. 18 COUNTRY AND SECTORAL BACKGROUND ............................................................................................................ 19 DATA COLLECTION METHODS ......................................................................................................... 22 RMNCAH QAIS ............................................................................................................................................... 23 QUALITY PERFORMANCE SCORECARD.................................................................................................................. 27 RESULTS .............................................................................................................................................. 29 FEATURES OF THE FOUR TARGET PROVINCES ........................................................................................................ 29 A. FINDINGS FROM THE RMNCAH QAIS – PROVINCIAL AND DISTRICT LEVELS ....................................................... 30 1. Samples ................................................................................................................................. 31 2. Overall readiness rate .......................................................................................................... 34 3. Hygiene and sanitation infrastructure ................................................................................ 36 4. Clinical service readiness...................................................................................................... 39 Patient satisfaction ............................................................................................................... 66 5. B. FINDINGS FROM THE QPS – HEALTH CENTER LEVEL .......................................................................................... 67 1. Samples ................................................................................................................................. 68 2. Health center infrastructure ................................................................................................ 70 3. Human resources.................................................................................................................. 73 4. Financial management ......................................................................................................... 75 5. Health insurance ................................................................................................................... 75 6. Quality of communicable disease management ................................................................ 77 7. Essential equipment and medications ................................................................................ 79 8. Patient satisfaction ............................................................................................................... 80 Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 3 DISCUSSION ....................................................................................................................................... 81 HOSPITAL INFRASTRUCTURE................................................................................................................................ 81 HEALTH FINANCE ............................................................................................................................................... 83 HEALTH INSURANCE ........................................................................................................................................... 84 HUMAN RESOURCES ........................................................................................................................................... 85 CLINICAL SERVICE ............................................................................................................................................... 86 ISSUES ................................................................................................................................................. 97 RECOMMENDATIONS...................................................................................................................... 102 LIMITATIONS.................................................................................................................................... 107 APPENDICES ..................................................................................................................................... 107 APPENDIX 1: DETAILS OF RMNCHA QAIS ....................................................................................................... 107 APPENDIX 2: DETAILS OF QPS .......................................................................................................................... 115 APPENDIX 3: ITEMS FOR MEASURING SERVICE READINESS OF PROVINCIAL AND DISTRICT HOSPITALS ....................... 119 APPENDIX 4: INDICATORS FOR MEASURING SERVICE READINESS OF HEALTH CENTERS ............................................ 132 APPENDIX 5: DEMOGRAPHICS OF ASSESSMENT RESPONDENTS ............................................................................ 134 APPENDIX 6: FACTSHEETS FOR SERVICE READINESS FROM RMNCAH QAIS ........................................................ 135 APPENDIX 7: FACTSHEETS FOR SERVICE READINESS FROM QPS ........................................................................... 154 APPENDIX 8: NUMBER OF HEALTH WORKERS AT HEALTH CENTER LEVEL BY PROVINCE AND DISTRICT ...................... 157 REFERENCES ..................................................................................................................................... 158 Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 4 LIST OF TABLES Table 1 Details of the RMNCAH QAIS assessment tool ............................................................... 23 Table 2 Target populations and sample size for RMNCAH QAIS tool ................................................. 25 Table 3 Data collection schedule .............................................................................................................. 26 Table 4 Demographics, human resource for health, and health indicators by province ................ 30 Table 5 Facilities Sample ............................................................................................................................ 31 Table 6 Sample size of vignettes in QAIS ................................................................................................. 32 Table 7 Demographics of interview respondents at provincial and district level ............................. 33 Table 8 Chart review sample size in RMNCAH QAIS .............................................................................. 34 Table 9 Number of rooms by category .................................................................................................... 36 Table 10 Number of shared toilets by province ..................................................................................... 37 Table 11 Sample of facilities at health center level ................................................................................ 68 Table 12 Sample size of vignettes in QPS ................................................................................................ 68 Table 13 Demographics of interview respondents at the health center level ................................... 69 Table 14 Type of health center by province ............................................................................................ 73 Table 15 Estimated number of health worker at health center level ................................................. 73 Table 16 Results of the WASH survey in four provinces ....................................................................... 82 Table 17 The on-site assessment schedule for RMNCAH QAIS at provincial hospital ................... 108 LIST OF FIGURES Figure 1 Demographics of health workers assessed with vignettes – by profession .............. 32 Figure 2 Interview respondent's ethnicity by province ................................................................ 33 Figure 3 Total and categorical readiness rate ............................................................................... 35 Figure 4 Categorical readiness rate by facility level ..................................................................... 35 Figure 5 Readiness rate by service ................................................................................................. 35 Figure 6 Hand hygiene equipment by room type ........................................................................ 36 Figure 7 Sink condition by province ............................................................................................... 37 Figure 8 Proportion of gender-separated toilets.......................................................................... 37 Figure 9 Toilet facilities by province ............................................................................................... 38 Figure 10 Condition of sinks near toilets ....................................................................................... 38 Figure 11 Cleanliness and waste containers by room type......................................................... 39 Figure 12 Readiness rate for reproductive and adolescent health ............................................ 39 Figure 13 Number of trained health workerse ............................................................................. 40 Figure 14 Percentage of services used by teenagers ................................................................... 41 Figure 15 Ethnicity of interview respondents by age group ....................................................... 41 Figure 16 Readiness rate for cervical cancer service ................................................................... 42 Figure 17 Number of health workers trained in cervical cancer management ........................ 42 Figure 18 Women's perception of cervical cancer by ethnic group ........................................... 43 Figure 19 Women's perception of cervical cancer by province .................................................. 43 Figure 20 Readiness rate for safe abortion service...................................................................... 44 Figure 21 Number of health workers trained in safe abortion................................................... 44 Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 5 Figure 22 Percentage of healthcare workers involved in delivery ............................................. 45 Figure 23 Readiness rate for antenatal care service .................................................................... 46 Figure 24 Number of health workers trained in antenatal care ................................................. 46 Figure 25 Percentage of ANC providers trained in ANC .............................................................. 47 Figure 26 Percentage of tests performed during pregnancy by facility level ........................... 47 Figure 27 Sectional scoring rate vignette ANC1 General ANC and anemia management ...... 48 Figure 28 Sectional scoring rate of vignette ANC2 mild hypertension during pregnancy ...... 48 Figure 29 Readiness rate for intrapartum care ............................................................................ 49 Figure 30 Number of trained health workers in EmOC ............................................................... 50 Figure 31 Percentage of health workers involved in delivery trained in EmOC/CARE ............. 50 Figure 32 Sectional scoring rate of vignette EmOC1 severe pre-eclampsia.............................. 51 Figure 33 Sectional scoring rate of vignette EmOC2 postpartum hemorrhage ....................... 51 Figure 34 Readiness rate for newborn care .................................................................................. 52 Figure 35 Number of trained health workers on EENC ............................................................... 52 Figure 36 Percentage of health workers in newborn care trained in EENC: Total 61% ........... 52 Figure 37 Vignette sectional scoring rate of NH1 breathing baby, NH2 non-breathing baby 53 Figure 38 Application of skin-to-skin contact by province........................................................... 53 Figure 39 Readiness rate for postnatal care ................................................................................. 54 Figure 40 Number of health workers trained in PNC .................................................................. 54 Figure 41 Percentage of health workers in delivery trained in PNC. Total 30% ....................... 55 Figure 42 Provision of counseling in postnatal period ................................................................ 55 Figure 43 Length of stay after normal delivery............................................................................. 56 Figure 44 Record of PNC in MCH handbook ................................................................................. 56 Figure 45 Readiness rate for well child care ................................................................................. 57 Figure 46 Number of health workers trained in EPI .................................................................... 57 Figure 47 Percentage of healthcare workers in well child care trained in immunization ....... 58 Figure 48 Number of health workers trained in infant................................................................ 58 Figure 49 Sectional scoring rate of vignette WH1 integrated well child care ............................ 59 Figure 50 Use of MCH handbook during counseling ................................................................... 59 Figure 51 Readiness rate for sick child care .................................................................................. 60 Figure 52 Number of trained health workers in IMNCI ............................................................... 60 Figure 53 Percentage of health workers involved in sick child care trained in IMNCI ............. 61 Figure 54 Number of healthcare workers trained in IMAM and Child Illness Pocketbook ..... 61 Figure 55 Weight and height measurement at well child clinic .................................................. 62 Figure 56 Weight and height measurement at sick child clinic .................................................. 62 Figure 57 Re-evaluation of weight for height................................................................................ 63 Figure 58 Readiness rate for non-communicable diseases ........................................................ 63 Figure 59 Readiness rate for emergency care and surgical services ......................................... 65 Figure 60 Readiness rate for communicable diseases ................................................................ 65 Figure 61 Patient satisfaction from exit interviews in RMNCAH QAIS ....................................... 66 Figure 62 Satisfaction with information given by health workers .............................................. 67 Figure 63 Satisfaction with information given by healthcare workers by ethnicity ................. 67 Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 6 Figure 64 Health workers assessed with vignette by profession ............................................... 69 Figure 65 Education level by age range ......................................................................................... 69 Figure 66 Service used by age range ............................................................................................. 70 Figure 67 Infrastructure at health center level ............................................................................. 70 Figure 68 OPD Room by province .................................................................................................. 71 Figure 69 ANC Room status by province ....................................................................................... 71 Figure 70 Delivery room .................................................................................................................. 72 Figure 71 Toilet functionality by province ..................................................................................... 72 Figure 72 Medical waste handling and disposal ........................................................................... 73 Figure 73 Human resource situation at health center level ........................................................ 74 Figure 74 Financial record at health center level ......................................................................... 75 Figure 75 Number of patients by payment type and services .................................................... 75 Figure 76 Health insurance management at health center by province ................................... 76 Figure 77 Number of clients from vulnerable groups - additional payments at healthcenters .... 76 Figure 78 Nurse/doctor prescribed drugs you had to purchase in a pharmacy ...................... 77 Figure 79 Quality of TB management ............................................................................................ 77 Figure 80 Sectoral scoring rate: Tuberculosis management vignette........................................ 78 Figure 81 Pregnant women undergoing HIV rapid tests at health center level by province .. 78 Figure 82 Malaria management ..................................................................................................... 79 Figure 83 Management of medications and commodities ......................................................... 79 Figure 84 Client experience through healthcare services at health center .............................. 80 Figure 85 Adolescent birth rate per 1,000 women aged 15-198 ................................................. 86 Figure 86 Trend of the number of new implant users................................................................. 87 Figure 87 Induced abortion rate and unmet need ....................................................................... 88 Figure 88 Place of delivery .............................................................................................................. 90 Figure 89 Number of deliveries by facility level in the four target provinces ........................... 90 Figure 90 Number of deliveries (facility delivery/outreach in 2022 from HMIS) ...................... 91 Figure 91 Surgery trends in the four target provinces 2018-2224............................................... 95 Figure 92 Cesarean section trend in the four target provinces 2018-2224 ................................ 95 Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 7 In 2022 the Lao Ministry of Health conducted two assessments in four northern provinces. With financial support from the World Bank, the Korean Foundation for International Healthcare, and the United Nation Joint Program, the ministry’s Maternal and Child Health Center led the RMNCAH quality assessment. At the same time, the Department of Healthcare and Rehabilitation partnered with the Health and Nutrition Services Access Project to carry out the Quality Performance Scorecard. The World Health Organization provided technical support to both assessments, while the Japan International Cooperation Agency provided critical insights on the implementation plan and assessment tools. These assessments were made possible by generous support in research and data collection from the Japan Policy and Human Resources Development (PHRD), and the Health and Nutrition Services Access Project financed by the World Bank. The authors extend their sincere gratitude to the Maternal and Child Health Center, the department of healthcare rehabilitation, the four provincial health offices, many district health offices, provincial hospitals, district hospitals and health centers, and all the patients who volunteered to contribute to this report. Their expertise, knowledge, and resources were essential in providing the information and insights needed to better understand the state of health readiness across the four provinces. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 8 5G1S 5 Good 1 Satisfaction ADB Asian Development Bank AIDS Acquired Immunodeficiency Syndrome ANC Antenatal Care ART Anti-Retroviral Therapy COVID-19 Coronavirus Disease of 2019 DHIS2 District Health Information Software 2 DHO District Health Office DHP Department of Health Personnel DHR Department of Healthcare and Rehabilitation EENC Early Essential Newborn Care EHSP Essential Health Services Package EmOC Emergency Obstetric Care GDP Growth Domestic Product GF Global Fund to Fight AIDS, Tuberculosis and Malaria HANSA Health and Nutrition Services Access HC Health Center HIV Human Immunodeficiency Virus HMIS Health Management Information System HRH Human Resources for Health HSR Health Sector Reform HSRS Health Sector Reform Strategy IFA Iron and Folic Acid IMAM Integrated Management of Acute Malnutrition IMNCI Integrated Management of Newborn and Childhood Illnesses Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 9 IPD Inpatient Department IUD Intrauterine Contraceptive Device JICA Japan International Cooperation Agency KOFIH Korea Foundation for International Healthcare Lao PDR Lao People's Democratic Republic LSIS Lao Social Indicator Survey MCH Maternal and Child Health MNCH Maternal, Newborn and Child Health MH Maternal Health MOH Ministry of Health MUAC Mid-Upper Arm Circumference MVA Manual Vacuum Aspiration NH Newborn Health OPD Outpatient Department PHC Primary Health Care PNC Postnatal Care QAIS Quality Assessment and Improvement Support QPS Quality Performance Scorecard RHAH Reproductive and Adolescent Health RMNCAH Reproductive, Maternal, Newborn, Child, and Adolescent Health RUTF Ready-to-Use Therapeutic Food SH Sick Child Health TB Tuberculosis UHC Universal Health Coverage UNFPA United Nations Population Fund VIA Visual Inspection with Acetic Acid WH Well Child Health WHO World Health Organization Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 10 The Lao People's Democratic Republic is a landlocked, multi-ethnic Southeast Asian country with a population of 7.5 million, and 70% of its land area mountainous. Despite remarkable economic progress, Laos is still behind its neighbors in terms of poverty and inequality, which remain substantial challenges. The COVID-19 pandemic and subsequent economic decline have significantly affected the country, with recovery constrained by continuing inflation. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 11 Through the "health for all by all" mission, and strong partnerships with international organizations including the World Bank, the Lao government has made tremendous efforts to implement the National Health Sector Strategy with the aim of achieving Universal Health Coverage (UHC) and the Sustainable Development Goals. Yet, despite the remarkable progress in health outcomes, formidable challenges remain. The under-five mortality rate of 44 per 1,000 live births is still higher than among neighbors. Although the number of new Human Immunodeficiency Virus (HIV) infections is declining, nearly half of those infected do not receive adequate antiretroviral therapy. Non-communicable diseases, especially cardiovascular diseases, have emerged as a new burden, accounting for one-third of deaths. Furthermore, the COVID-19 epidemic affected every aspect of health services, including increasing service demands and healthcare costs. This report identifies issues and gaps in current service availability and readiness, and provides insights and recommendations on building a resilient healthcare system to achieve UHC. It discusses the findings of two assessments: a quality assessment in maternal child health areas, the RMNCAH QAISa, and the Quality Performance Scorecard (QPS), a quality assessment at health center level under the Health and Nutrition Services Access (HANSA) project. Four northern provinces, Phongsaly, Oudomxay, Huaphan, and Xieng Khuang, were selected as assessment sites because of their distinctive ethnic, cultural, and geographic characteristics, their inferiority to other regions in terms of health outcomes and nutritional status among mothers and children, and because they are the target areas of two current projects. The assessments were conducted from January 2022 to March 2023 in cooperation with the World Bank, the World Health Organization (WHO), and the Korean Foundation for International Healthcare (KOFIH), at 265 healthcare facilities, including 4 provincial hospitals, 27 district hospitals, and 234 health centers. a Integrated Reproductive, Maternal, Newborn, Child and Adolescent Health Quality Assessment and Improvement Support (RMNCAH QAIS) is a facility-based quality improvement activity in RMNCAH services launched in 2018. The activity includes service quality data collection through direct observation, client interview, chart review, and scenario-based service knowledge assessment (vignette), data analysis, and action plan development to improve quality services. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 12 Key findings from the RMNCAH QAIS at provincial and district level Under the RMNCAH QAIS, 285 criteria were identified for provincial hospitals and 258 for district hospitals as necessary for the provision of health services based on the Essential Health Service Package. These criteria include items of medical equipment and medication, as well as policies, human resources (trained healthcare personnel), and quality assurance mechanisms for RMNCAH services. Each criterion was unweighted and counted as one. The readiness rate was calculated with a formula: the number of available items divided by the total number of items. The overall readiness rate for the hospitals assessed was 68.8%. The readiness rates at provincial and district levels were 76.6% and 67.5% respectively. By category, human resources for RMNCAH services was least ready, while the readiness for essential services equipment was highest at 85%. A comparison by facility level reveals that there may be a problem with the placement of trained health workers for RMNCAH services at district hospitals. By service, the least satisfactory three services at provincial hospitals included communicable diseases at 64.5%, cervical cancer at 66.7%, and non-communicable diseases at 68.9%. At the district hospitals, those were non-communicable diseases at 55.5%, newborn health at 61.6%, and communicable diseases at 62.3%. A contributing factor to the low readiness rate for communicable diseases at provincial hospitals was a lack of antiretroviral drugs, which may be because only Huaphan provincial hospital has been designated as an antiretroviral therapy (ART) site. At the district hospitals, the lower rate for communicable diseases was caused by tuberculosis drugs. For non-communicable diseases, medications for hypertension and diabetes were often inadequate, while mental health services were completely unprepared. A lack of trained health workers was the main cause of lower rates of newborn care at district hospitals. The RMNCAH QAIS also assessed patient satisfaction and health workers' service knowledge. More than 90% of patients interviewed, regardless of the type of service, indicated that they were satisfied; one in five was not satisfied with the explanations and information provided by health workers. There was a clear ethnic disparity, with a lower satisfaction percentage of 64.4% among the Mon-Khmer, compared to 86.6% among the Hmong-Iumien. The results of the vignette assessment support this finding; the sectional scoring rate in each vignette's explanation and counseling sections was consistently lower than in the others. Assessing hand hygiene facilities as an indicator of basic readiness, 73.8%, or 203 out of 275 rooms, had adequate sinks or alcohol hand sanitizers. 134 (68.7%) of the 195 sinks were properly equipped with clean running water, soap, and hand-drying equipment. Regarding toilet condition, only 9.8% of toilets (11/112) had adequate sinks nearby. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 13 Key findings from the QPS at health center level The QPS assessment conducted in four provinces focused on three key areas: Structural Quality, Process Quality, and Outcome Quality. The overall QPS score across these areas was 81%. Approximately 85% of centers were deemed ready on the health facility infrastructure score. However, it was observed that 15% of centers lacked separate rooms for outpatient department (OPD), ANC, and delivery services. Electricity supply was also a concern for around 65% of facilities, particularly in Huaphan and Xieng Khuang provinces. When it came to cleanliness performance, the overall rate was 94%. However, 20% of rooms in health centers lacked adequate sinks; more OPD and ANC rooms were found lacking in soap and hand towels than delivery rooms. Toilet facilities were well-maintained at 97%, and medical waste handling and disposal scored 91%. Staff management received a high rate of 96%. Notably, 93% of health centers had at least one clinical health worker who could effectively communicate in the language of the catchment population. However, the QPS only recorded whether at least one person was available for each type of clinical health role; it is not known whether there was a gap between workload and staff allocation. Indicators for implementation of the exemption scheme in the National Health Insurance (NHI) are promising, with 65% of interviewed respondents (432/662) having access to free healthcare services. However, around 37% of clients from vulnerable groups across five services had to purchase drugs from pharmacies, and 25% paid additional fees to health facilities. Furthermore, most health facilities report delays in processing claims. This may be related to financial management issues, as the accuracy of financial quarterly reporting is 77%. Approximately 32% of health centers in Oudomxay province and 20% in other provinces face challenges in preparing these reports. This situation has implications for facility management and operation, and indicates a need for clarity in implementing the exemption scheme and distinguishing which services or medications require out-of-pocket payments. In terms of communicable disease management, performance rates were relatively low. The tuberculosis (TB) rate stood at 52%, HIV at 15%, and malaria at 54%. Although the evaluation of TB knowledge yielded good results, treatment capacity for these diseases was limited due to factors such as drug availability and the significantly low number of patients in the four provinces. This underscores the importance of maintaining knowledge for effective treatment management. Essential medical supply readiness scored high at 98%. However, it should be noted that not all items on the essential medicine list were checked during the assessment; the readiness for clinical management may be overestimated. Lastly, feedback from 662 patients and caregivers who received maternal and child services indicated an overall satisfaction rate of 90%. Of these respondents, 93% reported positive experiences with health workers regarding their friendliness, and short waiting times. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 14 Issues identified Issue 1: Quantity, quality, and deployment of human resources for health The quantity, quality, and deployment of human resources is a major bottleneck in providing quality essential health services. The availability of human resources for health is overwhelmingly inadequate compared to WHO recommendations. The gap between the current practice level and the level stipulated in guidelines has been identified and addressed with post-graduate training, but implementation does not seem efficient. Health worker allocation against service demands and utilization raises concerns about maintaining health workers’ knowledge and skills, as service quality may be compromised. Issue 2: Lack of essential equipment and medication A lack of essential equipment and medicines to provide essential health services is observed, perhaps caused by financial difficulties in procurement caused by the country’s economic situation, the low priority given to purchasing equipment and medications due to less frequent use, or a lack of intention to provide services under tight financing. Issue 3: Underserviced essential services Some essential health services, such as for non-communicable diseases, cancer and palliative care, surgical care, and mental health, are not adequately provided. Because of the lack of detailed and nationwide data, current service demand is still not fully understood. Issue 4: Imbalance between demand and availability of essential services The interrelationship between service provision, demand, and utilization may shape inadequate service readiness for some services. There are concerns about preparedness for diseases or conditions that are less frequently encountered, such as malaria, with and without complications, e.g. a lack of equipment, drug shortages, and the acquisition and maintenance of knowledge and skills of health workers. Issue 5: Inappropriate and insufficient use of health policy The assessments suggested inappropriate practices in applying for the free Maternal, Newborn, and Child Health (MNCH) program in NHI, which may have resulted in supply procurement failures due to inadequate cash flow and consequently an increase in the percentage of co-payments. Also, the evaluation showed that central government policies, guidelines, and plans had not been effectively disseminated to stakeholders at all levels. Healthcare quality improvement initiatives varied from facility to facility or service to service. Hence, national policies or guidelines are not being implemented or take a long time. Issue 6: Ethnic disparity Differences in access to health care and in health outcomes among ethnic groups, such as high adolescent pregnancy among the Hmong, have already been noted. The assessment results also showed more Hmong among the teenage patients interviewed, and differences in patient satisfaction by ethnicity. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 15 Recommended actions Recommendation: Strengthening Management at Local Level Local governments should build their own efficient and effective systems for delivering national policies, considering the geographical, ethnic, and cultural characteristics of each region. Mentorship of local managers by senior management and support from development partners in local governance and policy implementation can overcome the tendency to depend on central government. Information sharing between local and central governments should be encouraged so that on-the-ground knowledge can be accumulated and reflected in central government policies. Recommendation: Clarify the terms and conditions of the National Health Insurance The detailed descriptions of the services covered by the insurance, including diagnostic testing and medications for the services listed in the Essential Health Service Packages following the relevant service guidelines, can facilitate proper service provision and utilization. Reviewing the current insurance coverage and costs against these criteria may help identify areas for improvement. Efforts are required to secure the necessary funding for the insurance, along with continuous monitoring and analysis of the insurance utilization and health service needs from various aspects. Recommendation: Establish and implement feasible methods to collect data from existing platforms for areas lacking data, improve access to existing data, and facilitate data use Much medical information in Laos is not digitized, and its collection is time-consuming and expensive. Strengthening health information systems, including civil registration and electronic medical records, is essential. In addition, it may be possible to identify existing platforms that cover the areas to which data belongs, and to develop and implement data collection methods that leverage these platforms to alleviate the burdens and promote efficient and continuous data collection and use. Furthermore, strong cooperation with stakeholders is needed to facilitate timely data sharing. Visualizing the data in national information platforms also accelerates data utilization. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 16 Recommendation: Strengthen the public health system network by implementing a referral system One health worker or one health facility cannot alone meet the needs of a community. A robust referral system is needed to maximize fulfillment of those needs with limited resources. Infrastructure such as the internet, health information systems, roads, and transportation must be in place to make this happen. Building trust among health workers at all levels is essential to making timely referrals without hesitation. Recommendation: Incorporate existing training modules and peer training into continuing professional development schemes Improved post-graduate education and continuous professional development are needed to bridge the gaps between standard care and practice. Effective implementation of the various training programs offered by the government and development partners should be considered in the development of quality patient-centered care. A coordination mechanism is suggested to ensure that necessary training is continuously provided to those who need it. In addition, facilitating peer training may be one way to overcome the financial, human resource, and time difficulties faced by external training. Trained and experienced health workers share their learning with colleagues, strengthening and disseminating knowledge. Connection with licensing, continuous professional development, and education support could promote this action. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 17 Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 18 The Lao PDR, or Laos, is a landlocked, multi-ethnic Southeast Asian country with 70% of its land area mountainous. The estimated population in 2022 is 7.5 million, with a median age of 24.1 years1. Despite annual growth of about 7% since 2005, Laos remains one of the poorest countries in Southeast Asia, with a GDP per capita of $2,593 (current US$) in 2020 2. This economic growth has been uneven, with significant disparities in economic development between urban and rural areas. Poverty and inequality remain substantial challenges, especially in rural areas with limited access to basic services such as health care and education. In 2018 the country's poverty rate was 18.3%, with considerable variation across provinces, ranging from 5.1% in Vientiane Capital to 31.2% in Saravan 3 . In addition, the COVID-19 epidemic significantly impacted the country's economy, with GDP growth falling to 0.5% in 2020 2. A sharp decline in tourism and disruptions to global supply chains affected many sectors. Laos has made remarkable strides in improving health outcomes for the last two decades. Under-five mortality rates decreased from 107 in 2000 to 44 deaths per 1,000 live births in 20202. The maternal mortality rate decreased from 579 in 2000 to 126 deaths per 100,000 live births in 2020, the eighth largest percentage reduction in the rate over this period globally4. The incidence of communicable diseases has also declined significantly: in the last two decades, the number of confirmed malaria cases in Laos fell by 99%, from 279,903 to 3,496 in 2020 5 . The prevalence of HIV/AIDS has also remained relatively low at 0.3%, with an estimated 15,000 people living with HIV in 20216. Despite the progress, formidable challenges remain in achieving the Lao PDR's Sustainable Development Goals and UHC. The under-five mortality rate is still higher than in neighboring countries (26 in Cambodia and 21 in Vietnam2); the incidence of HIV infection declined, but only 56% of people living with HIV/AIDS receive anti-retroviral therapy7. Significant inequity remains among ethnic minorities and people living in rural areas. The percentage of deliveries assisted by skilled birth attendants was 64.4%, much lower among non-Lao-Taï ethnic groups (78.2% for Lao-Taï against 42.5% for Sino-Tibetan) and among people in rural areas without roads (34.1%)8. The latest UHC service coverage index for Laos was medium coverage of 50 in 2019; the weakest tracer indicators include health worker density, service capacity and access, and the international health regulations core capacity index9. The coverage for non- communicable diseases, a growing health concern in Laos, is not yet satisfactory either9. The Lao government has made enormous efforts, with solid partnerships with international organizations including the World Bank, the Global Fund (GF), and WHO. The Health Sector Reform Strategy (HSRS) and Framework to 2025, approved by the National Assembly in 2012, guide government activities and partner collaboration. HSRS Phase I (2013-2015) focused on achieving the Millennium Development Goals, and Phase II (2016-2020) aimed at ensuring the access and quality of primary health care. The current Phase III (2021-2025) aims to achieve UHC by strengthening primary health care, then Phase IV (2026-2030) focuses on the governance reform and enforcement of laws and regulations to achieve the health related SDG goals10. Under this guidance, various policies and systems were put in place. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 19 The Lao government is strengthening its public health service network to improve health service delivery. Public health services consist of four facility-level networks, including five central hospitals and three specialized facilities in Vientiane Capital, 17 provincial hospitals, 135 district hospitals, and 1,076 health centers (small hospitals). With the support of neighboring countries and development partners, facilities are being newly built, upgraded, and repaired at all levels to expand the number of beds and the scope of services. The COVID- 19 pandemic led to the quick placement of a range of medical equipment, including for oxygen therapy. However, shortages, inefficient allocation, and inadequate knowledge and skills in human resources for health are persistent issues. According to the latest Human Resources for Health (HRH) annual report, the total number of doctors, nurses, midwives, and medical assistants was 10,198, only 1.46 per 1,000 population in 202011, down from 12,764 and 1.88 in 201812 , and much lower than the WHO threshold of 4.45 per 1,000 population for the Sustainable Development Goals 13 . The government’s HRH reform strategy focuses on governance and management, distribution and retention of health personnel, in-service training and professional development, improved capacity of educational institutes, licensing and registration of health personnel, and accreditation of educational institutes14. As of July 2023, 7,262 health professionals were registered and licensed, and the second national qualification examinations for doctors, nurses, and midwives were completed 15. The system of continuous professional development is under development. Insufficient service availability and readiness can affect access and use of health care services and health outcomes. A Service Availability and Readiness Assessment in 2014 revealed that a lack of essential medicines, diagnostic capacity, and amenities made 60% of health centers ill-equipped to offer basic health services 16 . To address challenges in supply chain management, the Ministry of Health (MOH) introduced an electronic Logistics Management Information System using the mSupply software system at central, provincial, and district levels. Another measure is the Essential Health Services Package (EHSP), which defines a minimum set of priority public health and clinical services that must be provided at each level of healthcare facility and community, plus outreach. With EHSP, it is expected to improve efficient resource allocation and healthcare providers' awareness of service delivery, and to serve as a reference for services covered by the health insurance scheme17. To improve financial protection, one of the barriers to access to healthcare services in Laos, the government established the National Health Insurance (NHI) scheme in 2016, and also integrated free Maternal and Child Health (MCH) services along with three other health protection schemes. The NHI scheme is being implemented in 17 provinces and will soon include Vientiane Capital. It has increased its coverage of the population from 62% in 2016 to 94% in 202018. The National Health Insurance Strategy 2021–25 was endorsed in September 2022 to pursue further improvement19. In addition, to improve the quality and coverage of health services, the government has developed a policy for quality of healthcare in 201620. This "five good, one satisfaction (5G1S)" policy aims to promote quality assurance and improve healthcare services with the quality concept of “five goods” (warm welcome, cleanliness, convenience, accurate diagnosis, and timely treatment) and “one satisfaction” (patient satisfaction) . The government has translated the concept into a series of quality standards for each level of public healthcare facilities and disseminates the standards so that each healthcare facility can refer to them while conducting quality improvement activities. Many development partners committed to improving healthcare Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 20 quality, including WHO, World Bank, ADB, JICA, and KOFIH, have contributed technical and financial support to implement this policy. Maternal and child health is a priority in the health sector, with 7 of 11 national health indicators approved by National Assembly related to Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH) services. Since the first National RMNCAH Strategy 2009- 2015 was launched in 2009, it has markedly improved mother and child health in Laos. The current strategy focuses on efficient service delivery, equitable service access, and quality services with respectful care. The integrated RMNCAH Quality Assessment and Improvement Support (RMNCAH QAIS) was initiated to implement quality improvement mechanisms. The RMNCAH QAIS is a collaborative activity that works with external assessors and staff at health facilities, and includes data collection and analysis, issue identification, root cause analysis, and action plan development. This activity assesses people-centered care in RMNCAH areas and aggregates data from each facility at the sub-national and national levels to identify equity in RMNCAH services. The RMNCAH QAIS was piloted in Huaphan and Xieng Khuang provinces in 2019 and repeated in each three times. It is time to roll this out nationally as part of the final National RMNCAH Strategy 2016-2025 evaluation. The World Bank remains committed to improving Lao people’s health. Current projects include the Health and Nutrition Services Access Project (HANSA) and Programmatic Advisory Services & Analytics. HANSA, jointly funded by the World Bank, GF, and Australia, supports primary health care delivery and financing in Laos. HANSA utilizes performance-based financing to provide essential health and nutrition services in remote and ethnically diverse communities, mainly targeting poor and vulnerable groups. To enhance the quality of primary health care (PHC) services, the Ministry of Health (MOH) and the World Bank developed a Quality and Performance Scorecard (QPS) tool. This tool enables the systematic assessment of health centers, evaluating their performance based on five dimensions of health service aligned with the 5G1S policy. The implementation of the QPS was led by the Department of Healthcare and Rehabilitation (DHR) with technical support from the World Bank, and verified by an independent institution. The Programmatic Advisory Services & Analytics were implemented to complement existing health sector operations in Laos, aiming to strengthen health financing and service delivery for Universal Health Coverage (UHC). The World Bank collaborated with RMNCAH secretariats, WHO, and KOFIH to evaluate service readiness for the RMNCAH services. Using data obtained from the RMNCAH QAIS and the QPS in four northern provinces, this report analyzes readiness to provide essential health services and quality healthcare information at facilities, and discusses investment needed to improve healthcare services and strengthen the primary health care system. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 21 This report uses data from the RMNCAH QAIS and the QPS in Phongsaly, Oudomxay, Huaphan, and Xieng Khuang provinces. Each of these provinces has its own ethnic, cultural, and geographic characteristics, and all display low health outcomes and nutritional status among mothers and children. The HANSA project identified the four provinces as priority target areas, with a specific thematic focus on nutrition. Within these provinces, 12 priority districts have the highest share and absolute numbers of stunted children21. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 22 Assessment tools The tools used for the assessment were based on Early Essential Newborn Care (EENC) Module 1 22 and the Primary Health Care Quality Assessment Tools for Family Planning, Antenatal Care (ANC), and Child Health, developed by WHO Western Pacific Regional Office 23. Those tools were used for the mid-term review of the RMNCAH Strategy and Action Plan 2016- 2025, conducted in 2019. They were revised to improve data quality and to align with national standards in maternal and child health services, the evaluation and monitoring framework for the new RMNCAH Strategy and Monitoring Framework, and 5G1S standards. The assessment tools are divided into the following areas: A. Reproductive and adolescent health (RHAH) B. Maternal health (MH), including antenatal care and intrapartum care C. Newborn health (NH) D. Well child health (WH) E. Sick child health (SH) F. Essential medication and equipment G. Environmental hygiene and sanitation The assessment tool for A to E consists of three parts: service readiness, provider’s knowledge, and service provision and experienced care. The service readiness section assessed policy and guidelines, human resources, medication and equipment, and program management through direct observation and document review. Provider’s knowledge was assessed using vignettes, a tool that evaluates the knowledge of a specific service in a simulated setting. For service provision and experienced care, assessors obtained information about the quality of care by observing clinical sessions, interviewing patients and caregivers, and reviewing documents such as the MCH handbook and medical charts. Table 1 Details of the RMNCAH QAIS assessment tool Area Section Contents Methods • Policy and guideline • Human resources Direct observation Readiness • Medications and equipment (room Staff interview for family planning) • Quality assurance team Reproductive and • New contraceptive user adolescent Provider’s • Switch from short acting method to Vignette health knowledge Implant Provision or experience • Family planning counseling Exit interview of care Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 23 • Policy and guideline • Human resources • Medications and equipment (ANC Direct observation Readiness room, Delivery room) Staff interview • Quality assurance team (ANC, EmOC) • General antenatal care and anemia Maternal management health • Mild hypertension during (antenatal Provider’s pregnancy Vignette and knowledge • Intrapartum care intrapartum) • Severe pre-eclampsia • Postpartum hemorrhage • Antenatal care Direct observation Provision or • Caesarean section Exit interview experience • Severe pre-eclampsia/ eclampsia MCH handbook review of care • Postpartum hemorrhage Medical chart review • Abortion • Policy and guideline • Human resources Direct observation Readiness • Medication and equipment Staff interview (newborn care room) Newborn • Quality assurance team health Provider’s • Delivery with breathing baby Vignette knowledge • Delivery with non-breathing baby Provision or • Intrapartum and postnatal care at Exit interview experience health facility Medical chart review of care • Policy and guideline • Human resources Direct observation Readiness • Medications and equipment (well Staff interview child care ward) • Quality assurance team Well child Provider’s health • Integrated well child care Vignette knowledge • Integrated well child care (growth Provision or monitoring, nutrition screening and Exit interview experience counseling, immunization, early MCH handbook review of care childhood development) • Policy and guideline • Human resources Direct observation Readiness • Medication and equipment (OPD Staff interview and IPD for children) • Quality assurance team Sick child • Management of child with diarrhea Provider’s health • Management of child with Vignette knowledge pneumonia Exit interview Provision or • Sick child clinical session OPD logbook review experience • Outpatient management IPD medical chart of care • Inpatient management review Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 24 The target population and sample size for each checklist is shown in Table 2. Table 2 Target populations and sample size for RMNCAH QAIS tool Checklist Targets Sample size (per facility) Health workers who are constantly Vignette providing the services that are the subject 2 health workers per topic of the vignette Women in need of contraceptives who visit 10 contraceptive users RHAH exit interview a health facility on the day of the 10 women in need who do not assessment currently use contraceptives Pregnant women who visited a health ANC session direct 10 pregnant women (including facility for antenatal care on the day of the observation 5 women in third trimester) assessment ANC exit interview Pregnant women who visited a health 10 pregnant women (including MCH handbook facility for antenatal care on the day of the 5 women in third trimester) review assessment Cesareans section Women who delivered by cesarean section 10 cases chart review in the past 12 months Severe pre- Women diagnosed and treated for severe eclampsia/ preeclampsia or eclampsia in the past 12 10 cases eclampsia chart months review Postpartum Women diagnosed and treated for hemorrhage chart postpartum hemorrhage in the past 12 10 cases review months Abortion case chart Women diagnosed and treated for 10 cases review abortion in the past 12 months Women who gave birth in a health facility NH Intrapartum care on or a few days before the assessment 10 postpartum women /PNC exit interview date Intrapartum care Women who gave birth in a health facility 10 cases (including preterm/ /PNC chart review recently low birth weight baby) Children aged 0-59 months who visited a 10 children (including 5 WH exit interview health facility for well child care (any children aged 0-5 months and and MCH handbook services of well child care) on the day of 5 children aged 6 months or review the assessment older) Children aged 0-59 months with illness SH exit interview who visited a health facility on the day of 10 children aged 0-59 months the assessment Children aged 2-59 months diagnosed with SH OPD logbook diarrhea, pneumonia, upper respiratory 5 children per disease review infection, or severe acute malnutrition who visited a health facility recently Children aged 2-59 months diagnosed with SH IPD medical chart diarrhea, pneumonia, or severe acute 5 children per disease review malnutrition who were admitted to a health facility recently Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 25 Assessment tool F includes essential medication and equipment based on the EHSP and the medication lists issued by the MOH Food and Drug Department. The drug and equipment checklists in the tools for A-E assess whether those items are available in the ward where the service is provided, whereas tool F assesses the items in the pharmacy and in storage in general. Assessment tool G assesses hand hygiene facilities and waste management in the rooms where health care services are provided to patients, and toilets for patients and staff. Assessment team The assessment team was composed of individuals with sufficient experience in each area of RMNCAH and had completed assessor training. A typical assessment team consists of the following personnel. • Family planning and reproductive health provider • Antenatal care provider • Obstetrician-gynecologist neonatal care provider • Well child care provider • Pediatrician • Pharmacist • Administrative officer A central team assesses provincial hospitals, and provincial teams assess district hospitals in their jurisdiction. On-site assessment schedule The RMNCAH QAIS was implemented from January 2022 to March 2023 in collaboration with RMNCAH secretariats, RMNCAH sub-committees, WHO, KOFIH and World Bank. Table 3 Data collection schedule Province Provincial hospital Community hospital Phongsaly October 2022 January to February 2023 Oudomxay November 2022 February to March 2023 Huaphan January 2022 February to April 2022 Xieng Khuang January 2022 February to March 2022 Informed consent All patients and caregivers who participated in exit interviews provided verbal informed consent prior to their inclusion in the assessment. The consent the assessors gave included information about the assessment’s purpose, procedures, confidentiality, and their right to withdraw from the assessment at any time without penalty. The exit interview was conducted right after the patients received service at health facilities. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 26 Data processing and management In Huaphan and Xieng Khuang provinces, the collected data was entered into Excel files by the assessment teams for compilation and analysis at sub-national level. After the assessment activities in Huaphan and Xieng Khuang, the assessment tools were incorperated into the National Health Management System (HMIS), which allows assessors to enter data through the HMIS website and the District Health Information Software 2 (DHIS2) application on the Android platform. The assessment teams still used paper-based tools in Phongsaly and Oudomxay but entered the data through the application. The data for Phongsaly and Oudomxay was stored on the DHIS2 servers. To compile all data, the data in DHIS2 was extracted in Excel form and combined with those for Huaphan and Xieng Khuang for the analysis. The compiled data was stored on a password-protected computer, accessible only to authorized personnel. Access to the data was limited to the project team. The data were analyzed in aggregated form, and individual participant’s data were not disclosed in any form of dissemination. Data analysis was performed using Microsoft Excel 365. Quality checks were conducted to ensure data accuracy and completeness. Descriptive statistics, including frequencies and percentages, were calculated using Excel’s built -in functions. Assessment tools and method The Quality and Performance Scorecard (QPS) is a set of tools used to evaluate the quality of services at health centers. The assessment tools include: 1. a Quality and Performance Scorecard (QPS). 2. a list of essential equipment. 3. An agreed list of medicines and supplies. 4. Vignettes for clinical cases simulation. 5. Client interview script. The QPS covers the following aspects of quality at a health center (HC): • Structural quality (23% of the QPS) measures availability of infrastructure, essential equipment, medicine, and supplies. • Process quality (67%) measures program management assessed through direct observation, document review, and vignettes. • Outcome quality (10%) measures client satisfaction through client interviews. • Bonuses on SBCC and staff speaking prevalence dialect (6%). Structural Quality Structural quality measures health center readiness and focuses on assessment availability of basic inputs to deliver health services and their management. A list of essential equipment ▪ Agreed list of medicines and supplies is 48 in total. ▪ List of essential equipment for health centers is 49 in total. Randomization: The assessor randomly picks a number from 1–5, and then checks the items list based on the selected number. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 27 Process Quality – Vignette Process quality section measures clinical management of various priority programs, cleanliness and infection control, and the clinical competencies of health workers. Competencies are assessed through vignettes or standardized clinical case simulations, which measure the knowledge of health workers on diagnosing, treating and counseling patients for specific conditions. Following each assessment, health center staff will get individual feedback on his or her performance and the overall health center performance. Clinical health workers should learn from vignettes, and then study to improve their overall clinical knowledge. After each assessment, District Health Office (DHO) assessors provide a debriefing to health center staff and coach them accordingly. Randomization: The assessors drew lots to randomly select two health workers: one midwife for the MCH vignette and a nurse/medical doctor/medical assistant for the OPD vignette. The two selected health workers then have to draw two vignette tickets. If no midwife or nurse/medical doctor/medical assistant is available at the health center, the vignette will not be conducted. There are 15 vignettes in total, as follows: MCH vignette: V1: New users of family planning V2. Long-term users of family planning V3. Antenatal care with anemia V4. Antenatal care with hypertension management V5. Vaginal delivery V6. Severe pre-eclampsia management V7. Post-partum hemorrhage management V8. Early essential newborn care breathing baby V9. Early essential newborn care non-breathing baby V10. Sick child care – pneumonia V11. Sick child care – diarrhea management V12. Well child care – integrated well child care V13. Tuberculosis management V14. Non-communicable disease – hypertension management V15. Non-communicable disease – diabetes management Note: The two newborn vignettes, no.8 and no.9, are excluded due to a lack of materials. Outcome Quality Client interviews are used to assess outcome quality through telephone interviews with clients. The health center should record an accurate telephone number for each patient, on which she/he can be reached (more than one number if necessary). Each assessment includes interviews with clients who visited the health center over the previous three months. Assessors randomly select five clients from the following registers: ▪ Maternity and family planning-related cases: three from ANC, delivery, family planning. ▪ All other cases: two from among clients using vaccination or general OPD. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 28 Assessment team Two certified DHO assessors assess the performance of health centers: ▪ One clinical officer, medical doctor, or nurse. ▪ One midwife. The DHR is responsible for training and certifying all assessors for the QPS. Each district trained 4-5 assessors to ensure progress and only two assessors performed the health center assessments. On-site assessment schedule The QPS started in late 2021. The latest health centers assessment in the four target provinces was conducted October to November 2022 (third round). QPS will be conducted twice a year. Each time, the assessment will take one full day to complete one health center. Results are directly inputted to web-enabled tablets and uploaded to DHIS2. Results are presented separately for each assessment; section A describes the results from the RMNCAH QAIS at provincial and district hospitals, and section B describes the results of the QPS at health centers. This section describes the basic information for each province. The estimated population of the four provinces accounts for 15.3% of the total population in Laos. Their ethnic composition differs significantly from the nation as a whole, and there are also large differences between the provinces: for the four provinces as a whole, by using the estimated population data and the composition of ethnic groups by province as below, it is estimated that approximately 37% are Lao-Taï, 30% are Mon-Khmer, 21% are Hmong-Iumien, and 11% are Sino-Tibetan. Health indicators in Phongsaly and Oudomxay are considerably lower than the national average. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 29 Table 4 Demographics, human resources for health, and health indicators by province Phongsaly Oudomxay Huaphan Xieng Laos Khuang Estimated population24 (2022) Total 196,168 355,786 315,193 272,115 7,442,732 Live births 4,612 8,575 7,693 6,348 156,086 Children under 5 21,709 39,535 36,213 31,259 753,105 Women at 15-49 48,351 95,137 79,012 69,316 2,007,238 Ethnic group25 (2014) Lao-Taï 18.9% 20.6% 55.7% 48.0% 59.3% Mon-Khmer 20.7% 60.5% 20.3% 10.0% 26.8% Hmong-Iumien 6.1% 12.3% 23.1% 41.2% 8.2% Sino-Tibetan 53.6% 5.7% 0.0% 0.1% 4.6% Human resources (2020)21: 718 1207 1015 1333 Total Civil servant 570 879 830 986 Contract staff and volunteer 148 328 185 347 Provincial hospital 60 155 112 219 Job description 100 324 160 200 Health indicators (2017)8 Skilled birth attendant 37.3 56.1 48.8 62.1 64.4 Infant mortality rate 60 68 44 33 40 Under 5 mortality rate 68 71 44 39 46 Penta 3 coverage 36.1 43.9 67.6 68.8 60.8 Stunted (< - 2SD) 54.0 42.7 40.7 46.3 33 Wasted (-< -2 SD) 8.9 6.2 16.4 5.0 9 This section presents the results of the RMNCAH QAIS. The overall readiness is presented first, followed by the infrastructure for hand hygiene, toilets, and waste management in rooms for patients. Then, the readiness of each service is shown, along with results on quality of care. The readiness of RMNCAH services was assessed in five domains: 1) policy and guidelines, 2) human resources, 3) equipment and supplies, 4) medications, and 5) quality assurance team activities. For a detailed description of the items included in each domain per service, see Appendix 3. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 30 1) Policy and guidelines were evaluated based on whether they exist in the facility. 2) Human resources were assessed based on whether at least one physician and at least one nurse, midwife, or other professional received service-related training. 3) Equipment and supplies were evaluated based on whether they were available somewhere in the facility on the day of the assessment. Items were selected based on the EHSP, which divides equipment and medications into tracer and non-tracer items; only tracer items were included in the readiness rate calculation. Non-tracer items can be found in the tables in the appendix. Items considered critical to quality service delivery at the location where services are provided are also indicated at the end of each table in the appendix. EHSP lists diagnostic equipment for infectious diseases, such as HIV and TB, and surgical equipment as essential items for the RMNCAH services, but those are not counted in the RMNCAH section, but refer to their respective sections. 4) Medications were evaluated in the same way as equipment and supplies. 5) The quality assurance team was evaluated for its existence and activity. Readiness for communicable and non-communicable diseases, and emergency and surgical services was only assessed with the availability of equipment and medications in the same way as the RMNCAH services. The readiness rate was the number of available items divided by the total number. Each item was counted as 1 and was not weighted. The number of items for each domain is shown in parentheses after the domain name on the graph X axis. The RMNCAH QAIS collected a great deal of data on quality of services. For the purposes of this report, only the quality data considered necessary to illustrate readiness issues is presented. All assessment results will be shared in a separate report by the government. 1. Samples Sample of health facilities A total of 31 provincial and district level health facilities in the four provinces were assessed and included in the analysis. Table 5 Facilities Sample Health Facility Level Provincial District Total Phongsaly 1 6 7 Oudomxay 1 6 7 Huaphan 1 9 10 Xieng Khuang 1 6 7 Total 4 27 31 Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 31 Sample size and demographics of vignette respondents The vignette knowledge assessment targeted health workers routinely providing relevant services on the day of the assessment. For each vignette scenario, one to five health workers per facility were selected or voluntarily joined the assessment. A total of 918 healthcare professionals were evaluated. Many health workers were evaluated with several vignette scenarios in the same services. Female midwives and nurses were the primary test takers for the family planning, ANC, newborn care, and well child care vignettes, which focused on prevention, counseling, and education. Physicians were the primary test takers for vignettes focusing on treatment, such as delivery and sick child care, and more of these workers were men. Table 6 Sample size of vignettes in QAIS Phongsaly Oudomxay Huaphan Xieng Khuang Total RHAH1 new user 16 9 21 16 62 RHAH2 switch to Implant 16 9 21 16 62 ANC1 general ANC and 16 19 21 14 70 anemia ANC2 hypertension 17 18 21 14 70 Intrapartum care 18 18 28 14 78 EmOC1 severe pre-eclampsia 18 20 28 14 80 EmOC2 postpartum 19 20 28 14 81 hemorrhage NH1 delivery with a breathing 27 27 28 23 105 baby NH2 delivery with a non- 27 27 28 23 105 breathing baby WH integrated well child care 18 13 27 7 65 SH1 child with diarrhea 16 18 22 15 71 SH2 child with pneumonia 14 18 22 15 69 Total 222 216 295 185 918 Figure 1 Demographics of health workers assessed with vignettes – by profession Health workers assessed with vignette by profession 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% RHAH1 RHAH2 ANC1 ANC2 IPC EmOC1 EmOC2 NH1 NH2 WH SH1 SH2 Doctor Medical assistant Midwife Nurse Others Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 32 Sample size and demographics of interview respondents The interview samples were selected from those who visited the health facilities on the assessment days to receive the targeted services; only those who gave verbal consent were included in the survey. A total of 1,020 patients or caregivers responded to the interview questions. The sample size by service area is shown in Table 7. Table 7 Demographics of interview respondents at provincial and district level Service area Phongsaly Oudomxay Huaphan Xieng Khuang Total Family planning 66 57 58 61 242 Antenatal care 68 68 73 58 267 Postnatal/newborn 24 30 40 32 126 Well child care 46 55 65 57 223 Sick child care 38 61 34 29 162 Total 242 271 270 237 1,020 The ethnic composition of the interview respondents was consistent with the ethnic composition of each province, with clear differences across provinces (Figure 2). Province- specific differences were also observed in the availability of insurance and travel time to healthcare facilities, which is related to ethnicity. Sino-Tibetans are more likely than other ethnic groups to be uninsured and to take more than 30 minutes to get to a healthcare facility, and this is more pronounced in Phongsaly, which has a large Sino-Tibetan population. By service, half of the women who came for antenatal care were under the age of 25, 95% of postpartum mothers had insurance, and more than 95% of the children who came for vaccinations and other well child service lived within an hour of a healthcare facility (Appendix 5). Figure 2 Interview respondent's ethnicity by province Interview respondant's ethnicity by province 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Phongsaly 70 74 5 79 13 1 Oudomxay 83 152 30 2 31 Huaphan 168 40 61 1 Xieng Khuang 117 15 105 Lao-Taï Mon-Khmer Hmong-Iumien Sino-Tibetan Other Missing Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 33 Chart review sample size A retrospective chart review was conducted to evaluate case management. Efforts were made to collect the expected number of samples for each checklist retrospectively from the most recent cases, but actual sample size varies across facilities due to the number of cases detected. Table 8 Chart review sample size in RMNCAH QAIS Phongsaly Oudomxay Huaphan Xieng Khuang Total Caesarean section chart 9 17 20 41 87 review Severe pre-eclampsia/ 5 17 8 17 47 eclampsia chart review Postpartum hemorrhage 9 2 12 26 49 chart review Abortion chart review 25 56 47 63 191 Intrapartum care chart 65 72 98 92 327 review Sick child OPD logbook 110 110 71 140 431 review Sick child inpatient chart 73 76 75 53 277 review 2. Overall readiness rate A total of 285 unique criteria at provincial hospital level and 258 at district hospitals were identified as necessary to quality essential services. The overall readiness rate for the hospitals assessed was 68.8%. The readiness rates at the provincial and district levels were 76.6% and 67.5% respectively. By category, human resources for RMNCAH services was least ready, while the readiness of equipment for essential services was highest at 85%. A comparison at facility level reveals that there may be a problem with the placement of trained personnel for RMNCAH services at district hospitals. By service, the three least satisfactory services at provincial hospitals were communicable diseases at 64.5%, cervical cancer at 66.7%, and non-communicable diseases at 68.9%. At district hospitals, those were non-communicable diseases at 55.5%, newborn health at 61.6%, and communicable diseases at 62.3%. A contributing factor to the low readiness rate for communicable diseases at provincial hospitals was a lack of antiretroviral drugs, which may be because only Huaphan provincial hospital has been designated as an ART site. At the district hospitals, the lower rate for communicable diseases was caused by tuberculosis drugs. For non-communicable diseases, medications for hypertension and diabetes were often inadequate, and mental health services were completely unprepared. A lack of trained health workers was the main cause for the lower rates of newborn and well child care at district hospitals. The details are discussed in the following sections. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 34 Figure 3 Total and categorical readiness rate Total and categorical readiness rate (all hospitals assessed) 100% 85.0% 80% 68.8% 68.8% 69.0% 62.8% 60% 43.8% 40% 20% 0% Total Policy Human Medication Equipment Quality Resource Assurance Figure 4 Categorical readiness rate by facility level Categorical readiness rate by facility level Policy 100% 80% 60% 40% Quality Assurance Human Resource 20% 0% Equipment Medication Provincial hospitals District hospitals Figure 5 Readiness rate by service Readiness rate by service Reproductive and adolescent health 100% Communicable Cervical cancer diseases 80% Emergency and 60% surgical care and Safe abortion others 40% 20% Non-communicable 0% Antenatal care diseass Intrapartum care Sick child care and EmOC Well child care Newborn health Postnatal care Provincial hospitals District hospitals Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 35 3. Hygiene and sanitation infrastructure Hand hygiene equipment The RMNCAH QAIS surveyed various rooms used for patient services at provincial and district hospitals to determine the adequacy of hand hygiene facilities. An adequate sink was defined as a clean sink with clean running water, soap, and hand-drying equipment. A total of 275 rooms were assessed: 33 delivery rooms, 15 intensive care units (for general and newborn), 68 IPDs (for postnatal care (PNC) and sick children and adults), and 145 OPDs (for FP, ANC, immunization, growth monitoring, sick children and adults). Paraclinical refers to pharmacy, laboratory and so on. Table 9 Number of rooms by category Province Delivery Intensive IPD OPD Other Paraclinical Total care Phongsaly 8 4 11 30 9 62 Oudomxay 7 5 25 47 4 88 Huaphan 9 1 7 26 43 Xieng Khuang 9 5 25 42 1 82 Total 33 15 68 145 1 13 275 Of 275 rooms, 203 (73.8%) had adequate sink(s) or alcohol hand sanitizers. Compared by room type, delivery rooms and intensive care units were relatively well equipped with hand hygiene facilities, but inpatient rooms were inadequate. Regarding sinks, 134 (68.7%) of the 195 sinks were properly equipped. The sink condition in Phongsaly was significantly worse than in other provinces. A factor affecting adequacy appears to be hand-drying equipment. Figure 6 Hand hygiene equipment by room type Hand hygiene equipment by room type 100% 93.9% 93.3% 92.3% 90% 80.0% 80% 73.8% 66.7% 70% 57.6% 60% 50% 42.6% 40% 34.2% 31.0% 30% 26.5% 20% 15.4% 10% 0% Total Delivery Intensive care IPD OPD Para clinical Room with IPC poster Room with alcohol gel Room with all adequate sink(s) Room with adequate sink or alcohol gel Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 36 Figure 7 Sink condition by province Sink condition by province 100% 79.2% 76.7% 75.8% 80% 68.7% 60% 40% 32.4% 20% 0% Total Phongsaly Oudomxay Huaphan Xieng Khuang Clean With running water With soap With hand-drying equipment Adequate sink Toilets (Sanitation) For toilet facilities, the survey examined whether they are kept clean, have hand hygiene facilities nearby, and are equipped with facilities that consider the people who use them. Of the 158 toilets surveyed, 29 (18%) were female toilets and 23 (15%) were male toilets. Eight facilities were evaluated for both male and female toilets, while 15 facilities were evaluated for shared toilets only. Figure 8 Proportion of gender-separated toilets Proportion of gender-separated toilets None, 5, 3% Female, 29, 18% Male, 23, 15% For both, 101, 64% Table 10 Number of shared toilets by province Shared Male & Female & Female, male & Female Grand toilets only shared shared shared & male Total Phongsaly 3 1 3 7 Oudomxay 1 1 4 1 7 Huaphan 7 1 2 10 Xieng Khuang 4 1 1 1 7 Grand Total 15 3 5 5 3 31 Of the toilets surveyed, many were flushable, but one in five was dirty. It was also found that many restrooms were not user-friendly. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 37 Figure 9 Toilet facilities by province Toilet facilities by province 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Total Phongsaly Oudomxay Huaphan Xieng Khuang Toilet is clean Toilet is functional (flushable) Toilet has sink within 5m Disabled access Diaper change Menstrual hygiene Fewer than three-quarters of all toilets had hand hygiene facilities nearby, most of them in poor condition, and only 9.8% (11/112) of all toilets had sinks in good condition. The lack of soap placement appears to be the main reason for this. Although constituting a low percentage, staff-only toilets were in better condition than were patient-only toilets. Figure 10 Condition of sinks near toilets Condition of sinks near toilets 100% 90% 80% 70% 60% 50% 40% 30% 18.6% 20% 9.8% 10% 6.3% 3.8% 0% Total Only for client Only for staff For client and staff Sink is clean Sink has clean running water Sink has soap Sink has had-dry equipment Adequate sink Sink has a gabage bin The patient bathroom in one hospital was in shocking condition. There were four doors in the toilet wing, but three were locked and only one toilet was usable. It was a squat toilet, with a black and dirty floor. During observation, a woman had just come out after using it. She had washed her hands at the sink, but no drainpipe was connected to the sink, and the water from the faucet ran directly onto the floor. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 38 Waste containers in rooms At provincial and district levels, patient rooms were assessed to determine whether they were clean and had appropriate types of waste container. The delivery rooms and intensive care units, where treatment and procedures are performed, were equipped with three types of waste containers and the rooms were kept clean. On the other hand, sharp containers and medical waste containers were insufficient in inpatient wards and outpatient areas. Sharp containers may not necessarily be present in inpatient departments (IPD), depending on the installation of inpatient beds. However, it is alarming that more than 30% of IPDs did not have a trash can for general waste. Figure 11 Cleanliness and waste containers by room type Cleanliness and waste containers by room type 100% 80% 60% 40% 20% 0% Delivery Intensive care IPD OPD Para-clinical Clean room Room with sharp container Room with medical waste container Room with general waste container 4. Clinical service readiness Reproductive and adolescent health service A total of 33 criteria were identified as necessary for quality reproductive and adolescent health services. The overall readiness rate at provincial level was 78.8%, while at district level it was 71.2%. Figure 12 Readiness rate for reproductive and adolescent health Readiness rate for reproductive and adolescent health (Number of items) 100% 90% 78.8% 80% 71.7% 70% 60% 50% 40% 30% 20% 10% 0% Provincial hospitals District hospitals The low proportion of readiness in the policy section was due to a lack of guidelines and job aid for Adolescent and Youth Friendly Services, available at only six hospitals. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 39 Eighty-five health workers in the facilities assessed were trained in comprehensive family planning services. Most of the trained personnel were nurses and midwives, with only four physicians. About 80% of the RHAH vignette takers were nurses or midwives. This indicates that they are the primary providers of reproductive and adolescent health. The median number of trained health workers per facility was two; in one-third of the facilities, only one health worker received the training. Four facilities had five or more trained health workers. However, this number may not guarantee sufficient family planning service provision. During the field assessment, a leader of family planning services at one of the provincial hospitals stated that although there were ten people trained at her hospital, she was the only one providing family planning services and that this did not allow her enough time to provide quality counseling to women in need. In Adolescent and Youth Friendly Services, 27 people from 11 facilities have received training. Figure 13 Number of trained health workers: comprehensive family planning (left), adolescent youth friendly service Number of health workers trained in Number of health workers trained in comprehensive family planning Adolescent Youth Friendly Service 12 25 10 20 Number of heatlth facilities Number of heatlth facilities 8 15 6 10 4 5 2 0 0 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 Number of health workers trained Number of health workers trained Provincial hospital District hospital Provincial hospital District hospital Contraceptives, equipment, and drugs were relatively well stocked in the hospitals, although implants were lacking in Huaphan and Xieng Khuang provinces, as were iron-folic acid tablets for anemia prevention. Quality improvement mechanisms were absent or inadequate for Adolescent and Youth Friendly Services and in Phongsaly province. Of the 1,020 exit interview respondents, 107, or 10.5%, were teenagers. About two-thirds of them had visited healthcare facilities for perinatal services. The ethnic type of the interviewees by age shows that the younger the age, the larger the percentage of non- Lao- Taï ethnic groups. Even considering that the ethnic composition of the four northern provinces differs from that nationally, it is evident that the Hmong are more prevalent in the younger age groups. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 40 Figure 14 Percentage of services used by teenagers Percentage of services used by teenagers Sick child care, Family planning, 11, 10% 14, 13% Well child care, 15, 14% Postnatal/Newborn, 18, 17% Antenatal care, 49, 46% Figure 15 Ethnicity of interview respondents by age group Ethnicity of interview respondants by age group 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 15-19 36 29 38 3 20-24 92 85 62 32 25-29 128 71 54 19 30-34 115 56 27 19 35-39 41 28 13 6 40-44 16 5 5 3 Lao-Taï Mon-Khmer Hmong-Iumien Sino-Tibetan Cervical cancer service At provincial level, 12 criteria are recognized as necessary for the provision of quality cervical cancer services, while at district level 9 items are required. The overall readiness rate at provincial level was 66.7%, against 70.4% at district level. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 41 Figure 16 Readiness rate for cervical cancer service Readiness rate for cervical cencer service (number of items) 100% 90% 80% 70.4% 66.7% 70% 60% 50% 40% 30% 20% 10% 0% Overall (12, 9) HR doctor (1) HR nurse, midwife (1) Equipment (7, 4) Quality assurance (3) Provincial hospitals District hospitals Policies and guidelines are not included in the required items because there are no approved versions in Laos. Fifty-four health workers in four provinces were trained in cervical cancer screening and management. Eight facilities, including the Huaphan provincial hospital, had no trained health workers. Figure 17 Number of health workers trained in cervical cancer management Number of health workers trained in cervical cancer management 16 14 Number of heatlth facilities 12 10 8 6 4 2 0 0 1 2 3 4 5 6 7 8 9 10 Number of health workers trained Provincial hospital District hospital While essential equipment needed for screening was in place, the 5% acetic acid solution required for visual inspection of the cervix (VIA), although not a tracer item, could not be found in more than half of the hospitals. Cryotherapy for precancerous lesions is considered an essential service in provincial hospitals and district hospitals with trained physicians, as is the loop electrosurgical excision procedure (LEEP) in provincial hospitals. However, the assessment found that those services are not ready in the four northern provinces. Equipment for cryotherapy at the district hospital was excluded from the list in this report due to inadequate data collection. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 42 The exit interview for family planning included questions about cervical cancer. Of 242 respondents, 47.1% answered that they had heard about cervical cancer, and 40.5% knew where to get cervical cancer screening services. Differences in this knowledge were found among ethnic groups and provinces, with lower levels among the Hmong-Iumien and Huaphan provinces. Figure 18 Women's perception of cervical cancer by ethnic group Women's perception of cervical cancer by ethnic group (from family planning exit interview) 100% 90% 80% 70% 60% 56.7% 47.1% 48.9% 47.3% 45.9% 47.8% 50% 40.5% 40% 34.8% 30.9% 30% 21.8% 20% 10% 0% Grand Total Lao-Taï Mon-Khmer Hmong-Iumien Sino-Tibetan Have heard about cervical cancer Know where to get cervical cancer screening Figure 19 Women's perception of cervical cancer by province Women's perception of cervical cancer by province (from family planning exit interview) 100% 90% 80% 70% 65.2% 60.6% 60% 50.9% 47.5% 50% 43.9% 40% 32.8% 30% 22.4% 22.4% 20% 10% 0% Phongsaly Oudomxay Huaphan Xieng Khuang Have heard about cervical cancer Know where to get cervical cancer screening The MCH handbook review for the children who came to well child care, including immunization and growth monitoring, showed that only 4 of 223 mothers had cervical cancer examinations after their deliveries. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 43 Safe abortion service Essential services for safe abortion include counseling, medical and surgical abortion management, and complication management. Twenty items for the service were identified, not including equipment and medication for surgical procedures, as described in the surgical service section. The provincial hospitals were equipped with 88.8% of the items, while district hospitals had 78.3%. Figure 20 Readiness rate for safe abortion service Readiness rate for safe abortion service (number of items) 100% 90.0% 78.3% 80% 60% 40% 20% 0% Overall (20) Policy (1) IEC materials HR doctor (1) HR nurse, Equipment (3) Contraceptives Medications (1) midwives (1) (5) (8) Provincial hospitals District hospitals Guidelines on the prevention of unsafe abortion were available at 28 of 31 hospitals. Associated IEC material is needed, especially for women after induced abortion, to prevent further unintended pregnancy, but only a third of the hospitals have this. The provincial hospitals have at least one physician trained in safe abortion. The median of trained health workers per facility was two. Overall, 20% of the health workers involved in delivery were trained. Figure 21 Number of health workers trained in safe abortion Number of health workers trained in safe abortion 16 14 Number of heatlth facilities 12 10 8 6 4 2 0 0 1 2 3 4 5 6 13 20 Number of health workers trained Provincial hospital District hospital Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 44 Figure 22 Percentage of healthcare workers involved in delivery who are trained in safe abortion: Total 20% Percentage of healthcare workers involved in delivery who are trained in safe abortion Total: 20% 100.00% 90.00% 80.00% % of safe abortion-trained HWs 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 0 5 10 15 20 25 30 35 40 Number of HWs involved in delivery Provincial hospital District hospital Among equipment and medications necessary for safe abortion, misoprostol, mifepristone, and a Manual Vacuum Aspiration (MVA) kit can be the most essential. Ergometrine can be used for complicated abortions. However, about half of the hospitals assessed lacked both mifepristone and ergometrine. Of the 267 women interviewed after antenatal care sessions, 66 (22.5%) said this pregnancy was unintended. In the medical chart review of 191 abortion cases, including 59 induced abortions, curettage was used in 39 cases (20.4%), though 22 cases did not have information about the procedure. Of 59 induced abortions, only 9 cases set an appointment for family planning service. Maternal health – antenatal care Antenatal care is one of the core components of the essential service and must be provided at all levels of the health sector. Along with routine and gestational age-specific ANC services, mild complication management, including anemia, hypertension, and prevention of mother- to-child transmission (PMTCT) for syphilis, are required at the provincial and district levels. In addition, provincial hospitals should provide PMCTC for HIV and gestational diabetes management. To satisfy the provision of the services above, 43 and 33 items are identified at the provincial and district levels respectively. The readiness rate was 82.7% at provincial hospitals and 72.5% at district hospitals. One factor contributing to the low rate was a lack of medication for complications during pregnancy. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 45 Figure 23 Readiness rate for antenatal care service Readiness rate for antenatal care service (number of items) 100% 90% 82.7% 80% 72.5% 70% 60% 50% 40% 30% 20% 10% 0% Overall (42, 33) Policy (1) HR doctor (1) HR nurse, Equipment (15, Medication (20, Quality assurance midwives (1) 12) 14) (3) Provincial hospitals District hospitals The national guidelines for ANC and PNC were available at all hospitals in four provinces but five district hospitals in Oudomxay. Midwives were the primary ANC providers and active in all provincial and district hospitals. Ten obstetricians and gynecologists were assigned to three provincial hospitals and four district hospitals and provided antenatal care. 116 of the 228 ANC providers, or 51%, were trained in ANC. Four district hospitals had no ANC-trained health workers. Figure 24 Number of health workers trained in antenatal care Number of health workers trained in antenatal care 12 10 Number of heatlth facilities 8 6 4 2 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 20 Number of health workers trained Provincial hospital District hospital Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 46 Figure 25 Percentage of ANC providers trained in ANC Percentage of ANC providers trained in ANC Total: 51% 100.00% 90.00% % of ANC-trained ANC providers 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 0 5 10 15 20 25 Number of ANC providers Provincial hospital District hospital At the provincial level, ART was only available at the Huaphan provincial hospital. The district hospitals lacked equipment and medications to diagnose and treat pregnancy complications such as anemia, hypertension, and syphilis infection. As mentioned in the reproductive and adolescent health section, Iron and Folic Acid (IFA) was unavailable in many hospitals. The review of the MCH handbook on pregnant women showed that initial risk assessment of pregnancy and the general physical examinations, i.e. weight and blood pressure measurement and confirmation of fetal heartbeat and fetus position according to gestational age, were performed on almost all pregnant women. However, the performance of para- clinical examinations such as hemoglobin testing, HIV and syphilis tests, and ultrasound varied by province; 80% of pregnant women at district hospitals in Xieng Khuang received such examinations, while many in Phongsaly and Oudomxay provinces did not. It was unclear whether the availability of test kits affected the implementation of tests since availability was only evaluated on the days of the assessment. Figure 26 Percentage of tests performed during pregnancy by facility level Percentage of tests performed during pregnancy by facility level 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Phongsaly Oudomxay Huaphan Xieng Khuang Phongsaly Oudomxay Huaphan Xieng Khuang Provincial level Hb test HIV test Syphilis test Ultrasound District level Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 47 While the rate of Hb testing was not high, 26 of the 267 cases of pregnant women reviewed were found to have mild anemia. Among them, 17 (65.4%) women with mild anemia received a double dose of IFA as treatment. Four cases of hypertension risk and two cases of mild hypertension were found during the review, but no treatment was recorded. In the chart review of 47 cases of eclampsia and severe preeclampsia, no patients were treated with aspirin for risk management. During the vignette assessment, ANC providers were evaluated for their ANC knowledge under two scenarios, general ANC with mild anemia and hypertension during pregnancy. The results indicated a weakness in complication assessment: the scoring rates for the assessment of anemia and hypertension were 40% and 61% respectively. Figure 27 Sectional scoring rate vignette ANC1 General ANC and anemia management Sectional scoring rate Vignette ANC1 General ANC and anemia management 100% 90% 90% 84% 83% 80% 75% 70% 70% 71% 70% 64% 60% 52% 50% 40% 40% 30% 20% 10% 0% Total Section 1: Section 2: Section 3: Section 4: Section 5: Section 6: Section 7: Section 8: Section 9: Introduce Danger sign Review Physical Assessment Diagnosis of Treatment for Counseling on Counseling in oneself assessment provious ANC assessment for anemia anemia mild anemia anemia 3rd Trimester Figure 28 Sectional scoring rate of vignette ANC2 mild hypertension during pregnancy Sectional scoring rate Vignette ANC2 Mild hypertension during pregnancy 100% 90% 90% 85% 83% 78% 80% 71% 70% 70% 65% 61% 59% 60% 50% 40% 30% 20% 10% 0% Total Section 1: Section 2: Section 3: Section 4: Section 5: Section 6: Section 7: Section 8: Introduce Danger sign Review previous Physical Examination for Diagnosis Counseling Referral oneself assessment ANC examination hypertension Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 48 Meaningful discussions during the assessment are noted here. This survey showed that 2 provincial and 16 district hospitals lacked daily IFA tablets on the assessment day. However, the MCH Handbook review confirmed that iron tablets were prescribed to 85% of pregnant women. The assessors witnessed IFA prescriptions to more than 90% of pregnant women during ANC sessions. In addition, almost all pregnant women indicated that they were taking or had been prescribed IFA. This inconsistency was discussed during the data analysis session at the on-site assessments. According to several health workers at the facilities, the prescription itself does not guarantee that the iron pills are reaching the pregnant woman. Due to high drug prices and limited support from the National Health Insurance, the supply of IFA is unstable. When a hospital cannot provide the tablets to pregnant women for free, they write a prescription and have them purchase it at their own expense at a pharmacy. Another relevant conversation with health workers at the facilities was about HIV testing. HIV testing during pregnancy is covered by the National Health Insurance because it is recommended and directed by the national ANC and PNC guidelines. However, health workers sometimes demand testing fees from pregnant women, saying that it is the woman's request, not the health worker's instruction, which may be the reason why they do not test. Maternal health- intrapartum care Pre-labor and intrapartum care include a range of services from normal vaginal delivery to maternal complications requiring emergency surgery. Surgical services should be available at the provincial and type A district hospitals, while type B district hospitals should provide assisted vaginal deliveries and preterm labor management. Besides the equipment and medication necessary for surgical service, 30 items are identified as essential to providing above adequate services at both facility levels. The provincial and district hospitals showed relatively high levels of readiness, at 92.5% and 83.2% respectively. The policy and guidelines for intrapartum care are detailed in the pocketbook on essential care for childbirth and maternal complications, describing the indications and procedures for maternal complications, and on the intrapartum care /EmOC algorithm poster, which allows health workers to follow the guidelines easily in case a maternal complication happens. The posters were visible at all but one district hospital, while the pocketbook existed at two-thirds of hospitals. Figure 29 Readiness rate for intrapartum care Readiness rate for intrapartum care (number of items) 100% 92.5% 84.0% 80% 60% 40% 20% 0% Overall (30) Policy (2) HR doctor (1) HR nurse, Equipment (9) Medication (13) Quality midwife (1) assurance (4) Provincial hospital District hospital All hospitals had at least two health workers trained in CARE/EmOC package, although the percentage of trained staff among those involved in delivery service was not high, at 34%. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 49 Figure 30 Number of trained health workers in EmOC Number of health workers trained in EmOC/CARE Package 12 10 Number of heatlth facilities 8 6 4 2 0 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Number of health workers trained Provincial hospital District hospital Figure 31 Percentage of health workers involved in delivery trained in EmOC/CARE Percentage of health workers involved in delivery who are trained in EmOC/CARE Total: 34% 100.00% 90.00% 80.00% % of EmOC/CARE-trained HWs 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 0 5 10 15 20 25 30 35 40 Number of health workers involved in delivery Provincial hospital District hospital Like antenatal care services, the readiness for maternal complications seems problematic. Vacuum extractors to deal with prolonged labor and fetal distress, and ergometrine and tranexamic acid to treat postpartum hemorrhage, were less available at the district level. A quality improvement mechanism was functional, including maternal death review. The vignette results showed that although appropriate treatment can be selected based on diagnosis, there is room for improvement in assessing and monitoring signs and symptoms. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 50 Figure 32 Sectional scoring rate of vignette EmOC1 severe pre-eclampsia Sectional scoring rate Vignette EmOC1 severe pre-eclampsia 100% 90% 87% 90% 79% 79% 80% 73% 73% 68% 70% 63% 61% 60% 50% 40% 30% 20% 10% 0% Total Section 1: Seciont 2: Initial Section 3: Section 4: Section 5: Initial Section 6: Section 7: Re- Section 8: Identify assessment Diagnosis Assessment of treatment Monitoring evaluation and Delivery hypertension labor stage treatment decision Figure 33 Sectional scoring rate of vignette EmOC2 postpartum hemorrhage Sectional scoring rate Vignette EmOC2 postpartum hemorrhage 99% 100% 92% 90% 82% 80% 74% 72% 67% 70% 57% 60% 50% 40% 30% 20% 10% 0% Total Section 1: Section 2: PPH Section 3: Initial vital Section 4: Initial Section 5: Cause Section 6: Treatment Postpartum Detection assessment treatment detection monitoring Newborn care There are 34 criteria for provincial hospitals and 32 for district hospitals for providing routine newborn care (e.g. skin-to-skin contact, early exclusive breastfeeding, and immunization) and neonatal resuscitation at provincial and district levels. In addition, kangaroo mother care and complication management are required in provincial hospitals. The readiness rate for newborn care was 81.3% and 61.6% at the provincial and district hospitals respectively. As can be seen from the graph, there is a large gap in the human resources area. Policy and guidelines included in newborn health are the EENC pocketbook, the breastfeeding reference book ,and breastfeeding promotion policy. While the EENC pocketbook is available at about 70% of health facilities, breastfeeding policy and guidelines were unavailable in many hospitals. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 51 Figure 34 Readiness rate for newborn care Readiness rate for newborn care (number of items) 100% 81.3% 80% 61.9% 60% 40% 20% 0% Overall (36,34) Policy (3) HR doctor (3) HR nurse, midwife Equipment (9, 7) Medication (12) Quality assurance (3) (8) Provincial hospital District hospital EENC is at the core of neonatal care training, with 326 (60.8%) of the 536 health workers providing neonatal care at the 31 facilities receiving EENC training. However, only 15 received training in kangaroo mother care for vulnerable preterm low-birthweight infants, and 17 in breastfeeding, essential for the nutritional management of newborns. Figure 35 Number of trained health workers on EENC Number of health workers trained in EENC 6 Number of heatlth facilities 5 4 3 2 1 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 20 23 26 54 Number of health workers trained Provincial hospital District hospital Figure 36 Percentage of health workers in newborn care trained in EENC: Total 61% Percentage of health workers in newborn care trained in EENC Total: 61% 100.00% 90.00% 80.00% % of EENC-trained HWs 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 0 10 20 30 40 50 60 Number of health workers involved in Newborn care Provincial hospital Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 52 Tracer equipment and medications for newborn care were well-stocked at the hospital assessed; non-tracer items for complications were not. Although not mentioned in the data, it is worth noting that one hospital had three incubators, none of which were in use on the assessment date. One was donated two years ago but had not yet been opened. Although the EENC module requires establishment of a quality assurance team, quality improvement mechanisms for newborn care were not visible at district hospitals in Phongsaly and Oudomxay provinces. This has led to low readiness rates. The vignette assessed health workers caring for newborns on their delivery skills, routine newborn care, and neonatal resuscitation. Health workers demonstrated neonatal resuscitation using a baby manikin, but the scoring rate in this section was only 54%, indicating a need for improvement. Figure 37 Vignette sectional scoring rate of NH1 breathing baby, NH2 non-breathing baby Sectional scoring rate Vignette NH1 breathing baby, NH2 non-breathing baby 90% 80% 80% 74% 73% 73% 71% 67% 65% 65% 70% 63% 60% 54% 50% 40% 30% 20% 10% 0% Total Section 1: Section 2: Section 3: Total Seciont 1: Section 2: Section 3: Section 4: Section 5: Preparation Routine care Breatfeeding Preparation Routine care Resuscitation Routine care Breatfeeding counseling 1 (before 2 (after counsleing detection) resuscitation) NH1 Breathing baby NH2 Non-breathing baby During the exit interview, postpartum mothers were asked if they applied skin-to-skin contact, i.e. putting babies on their bare chests immediately after delivery for more than 90 minutes with first breastfeeding. There was a considerable difference in skin-to-skin contact between provinces. Figure 38 Application of skin-to-skin contact by province Application of skin to skin contact by province 100% 80% 60% 40% 20% 0% Phongsaly Oudomxay Huaphan Xieng Khuang Applied any skin to skin contact Started skin to skin contact immediately after delivery Lasted more than 90 min Given first breastfeeding during skin to skin contact Complete skin to skin contact (all elements) Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 53 Postnatal care Postnatal care services are the least equipment-dependent services, requiring nine items. The readiness rate was 97.2% for provincial hospitals and 80.7% for district hospitals. The national ANC/PNC guidelines govern postnatal care. Figure 39 Readiness rate for postnatal care Readiness rate for postnatal care (number of items) 100.0% 100.0% 100.0% 100.0% 99.3% 97.2% 100% 90% 80.7% 81.5% 80% 75.0% 70% 63.0% 60% 50% 44.4% 40.7% 40% 30% 20% 10% 0% Overall (9) Policy (1) HR doctor (1) HR nurse, midwife (1) Equipment (5) Medication (1) Provincial hospital District hospital Among health workers involved in delivery services, 30% were trained in PNC. One fifth of the hospitals did not have PNC-trained health workers. All health workers involved in delivery services in three provincial hospitals were trained in PNC. Figure 40 Number of health workers trained in PNC Number of health workers trained in PNC 7 6 Number of heatlth facilities 5 4 3 2 1 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Number of health workers trained Provincial hospital District hospital Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 54 Figure 41 Percentage of health workers in delivery trained in PNC. Total 30% Percentage of health workers in delivery trained in PNC Total: 30% 100.00% 90.00% 80.00% 70.00% % of PNC-trained HWs 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 0 5 10 15 20 25 30 35 40 Number of health workers involved in delivery Provincial hospital District hospital Only general equipment is needed for PNC, such as a sphygmomanometer, stethoscope, and weight and length measures, and these were available at all hospitals. The issue is, again, IFA for mothers to prevent anemia. Postpartum care begins immediately after delivery. During hospitalization, postpartum women are expected to receive counseling and health education. Similar to skin-to-skin contact for newborns, provisions for counseling were higher in Huaphan and Xieng Khuang provinces than in the other provinces. A stay of more than 24 hours after delivery at a healthcare facility is recommended to ensure adequate time for postpartum monitoring, counseling and health education. The review of postpartum women's medical records showed that 54% of women with normal deliveries stayed for more than 24 hours, while 14% were discharged within 12 hours of delivery. Figure 42 Provision of counseling in postnatal period Provision of counseling in postnatal period (From exit interview with postpartum mothers, n=126) 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Phongsaly Oudomxay Huaphan Xieng Khuang Breastfeeding Length of stay PNC Family planning Nutrition Immunization for newborn Mother danger signs Newborn danger signs Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 55 Figure 43 Length of stay after normal delivery Length of stay after normal delivery (Normal vaginal deliery with term and normal birth weight) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Phongsaly 15 38 2 Oudomxay 13 32 1 5 Huaphan 90 1 Xieng Khuang 20 38 24 hours or more Less than 24 hours Not discharged Not recorded The survey examined PNC records in the MCH handbook for children who came for vaccinations and growth checks. The MCH handbook has a section for recording four PNC sessions, with 12 and 19 checklist items for mother and child respectively. Figure 44 shows the percentage of mothers and children with more than 80% of items recorded for each session. It indicates that PNC services were not being provided, were not being used, or were of inadequate quality. Figure 44 Record of PNC in MCH handbook Record of PNC in MCH handbook 100% 90% 80% 70% 60% 50% 40% 31% 30% 17% 20% 10% 10% 5% 1% 1% 1% 2% 0% Mother Newborn Mother Newborn Mother Newborn Mother Newborn PNC1: Within 1 day PNC2: Days 2-3 PNC3: Days 7-14 PNC4: 6 weeks Well child care Well child services predominantly focus on immunization. To demonstrate people-centered care, other services, such as growth monitoring, screening and counseling for nutrition, and childhood development, should be provided simultaneously. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 56 There are 44 criteria for well child care at provincial and district hospitals. Overall readiness rates for the provincial and district hospitals were 73.9% and 67.4% respectively. The lack of policy, guidelines, and trained health workers contributed to the lower rates. The Integrated Well Child Care Standard Operating Procedure (SOP) details the steps for providing necessary services at a well child clinic. However, the detailed guidelines and training materials have not been released. Reference to various policies and guidelines is required, but no hospital had all of these in place. Figure 45 Readiness rate for well child care Readiness rate for well child care (number of items) 100% 90% 80% 73.9% 67.4% 70% 60% 50% 40% 30% 20% 10% 0% Overall (44) Policy (8) HR doctor (5) HR nurse, Equipment (8) Medication (12) Quality midwife (5) assurance (6) Provincial hospital District hospital The primary providers of well child care were midwives or nurses, and in more than half of the district hospitals, physicians were not involved. In Phongsaly and Oudomxay, there were two to four staff working in well-child care, while Huaphan and Xieng Khuang had 4 to 11 people working per hospital. Immunization training was relatively common, while nutrition and childhood development training were not widespread. Figure 46 Number of health workers trained in EPI Number of health workers trained in EPI 10 9 8 Number of heatlth facilities 7 6 5 4 3 2 1 0 0 1 2 3 4 5 6 7 8 9 10 11 Number of health workers trained Provincial hospital District hospital Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 57 Figure 47 Percentage of healthcare workers in well child care trained in immunization Percentage of healthcare workers in well child care trained in immunization Total: 47% 100.00% 90.00% % of Immunization -trained HWs 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 0 5 10 15 20 25 Number of health workers in well child care Provincial hospital District hospital Figure 48 Number of health workers trained in infant and young child feeding (IYCF), nutrition and early childhood development Number of health Number of health Number of health workers workers trained workers trained trained in Early in IYCF in nutrition Childhood Development 18 12 25 16 Number of heatlth facilities Number of heatlth facilities Number of heatlth facilities 10 14 20 12 8 10 15 8 6 6 10 4 4 2 5 2 0 0 1 2 3 4 0 0 0 1 2 3 4 5 0 1 2 3 4 5 Number of health workers trained in IYCF Number of health workers trained Number of health workers trained in ECD Provincial hospital District hospital Provincial hospital District hospital Provincial hospital District hospital The availability of equipment and medication was almost total at the provincial hospitals, but some district hospitals had issues with polio, Japanese encephalitis, and tetanus vaccines. Regional and facility-level differences were also apparent in quality assurance activities. The well child vignette is structured to ask if well child care providers have the knowledge to practice integrated well child care. The graph below shows the percentage scores for the total and for each section; while health staff scored well in the growth monitoring and immunization sections, scores in the rest of the sections were low. In the counseling section, which asked what type of counseling was to be provided based on the assessment results, the average scoring rate was 25%, indicating that both assessment and counseling skills need improvement. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 58 Figure 49 Sectional scoring rate of vignette WH1 integrated well child care Sectional scoring rate Vignette WH1 integrated well child care 100% 94% 90% 85% 82% 80% 70% 63% 64% 59% 60% 60% 50% 40% 40% 33% 30% 25% 20% 10% 0% Total Section 1: Section 2: Section 3: Section 4: Section 5: Section 6: Section 7: Section 8: Section 9: Introduce Growth Development Feeding/ Counseling on Vaccination Vaccine Danger sign Next oneself monitoring check Nutrition Issues counseling administration counseling appointment situation In addition, the integrated well child care SOP recommends that the MCH handbook be used for counseling. This is because the MCH handbook provides comprehensive information on the services to be provided and is concise with illustrations and photographs. The well child exit interview asked caregivers if health care providers used the handbook during counseling, but the use rate was not high. Figure 50 Use of MCH handbook during counseling Use of MCH handbook during counseling 94% 100% 90% 80% 73% 70% 64% 61% 58% 56% 58% 60% 50% 50% 43% 40% 28% 27% 30% 30% 25% 26% 23% 16% 20% 10% 0% Phongsaly Oudomxay Huaphan Xieng Khuang Exclusive breastfeeding (less than 6 months) Complementary feeding (6 months or older) Vaccination Development Sick child care Sick child care involves managing various diseases and requires a range of equipment and medications. Since diarrhea, pneumonia, and malnutrition are the focus diseases for children in Laos, the equipment and medications needed to manage these diseases are listed as the main tracer items in the readiness assessment. Medication and equipment for malaria and tuberculosis were excluded from the list for sick children; these were listed in their respective sections. Sixty-one items were identified, 92.2% available at the provincial hospitals and 80.1% at the district hospitals. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 59 Figure 51 Readiness rate for sick child care Readiness rate for sick child care (number of Items) 100% 92.3% 90% 80.3% 80% 70% 60% 50% 40% 30% 20% 10% 0% Overall (61) Policy (3) HR doctor (3) HR nurse, midwife Equipment (21) Medication (29) Quality assurance (3) (2) Provincial hospitals District hospitals Three guidelines, Integrated Management of Newborn and Childhood Illnesses (IMNCI), Integrated Management of Acute Malnutrition (IMAM), and a pocketbook of hospital care for children have been adopted in Laos, and training for health workers follows these texts. The IMNCI chartbook and the pocketbook were available at more than 90% of the hospitals in the four provinces. Regarding staffing, all but three hospitals had physicians providing care for sick children. Three provincial hospitals and two district hospitals had pediatricians. Medical assistants provided the services at the three hospitals without physicians serving sick child care. The number of health workers involved in sick child care ranges from 2 to 27, with a median of 8. IMNCI-trained health workers accounted for 27% of sick child care providers. Physicians mainly received training in caring for sick children, and a third of hospitals had midwives and nurses trained in IMNCI. 16% of the health workers serving sick child care at the provincial and district hospitals have received IMAM training. Of 101 physicians, 46 have received pocketbook training. Figure 52 Number of trained health workers in IMNCI Number of health workers trained ion IMNCI 12 10 Number of heatlth facilities 8 6 4 2 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Number of health workers trained Provincial hospital District hospital Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 60 Figure 53 Percentage of health workers involved in sick child care trained in IMNCI Percentage of healthcare workers in sick child care trained in IMNCI: Total: 27% 100.00% 90.00% 80.00% % of IMNCI-trained HWs 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 0 5 10 15 20 25 30 Number of health workers in sick child care Provincial hospital District hospital Figure 54 Number of healthcare workers trained in IMAM and Child Illness Pocketbook Number of healthcare workers Number of physicians trained in trained in IMAM Child Illness Pocketbook 16 16 14 14 Number of heatlth facilities Number of heatlth facilities 12 12 10 10 8 8 6 6 4 4 2 2 0 0 0 1 2 3 4 5 6 15 0 1 2 3 4 5 6 7 8 9 10 11 Number of healthcare workers trained Number of physicians trained Provincial hospital District hospital Proivncial hospital District hospital Overall, the equipment and medications necessary for caring for sick children were well maintained. However, it should be noted that among the tracer devices and medications, those with less than 50% availability were lumbar puncture needles, Ready to Use Therapeutic Food (RUFT), ReSoMal, F75/F100, and gentian violet; three malnutrition-related supplies are included. The survey showed that measurement devices were well stocked at all but a few district hospitals. However, the outpatient logbook review revealed that not all sick children were assessed for their nutrition status, in contrast with at the well child clinics, where most children were checked for height and weight. For sick children, weight was measured, probably because it is necessary for medications. However, height was not measured in about half of the children; therefore, weight for height, an indicator of severe acute malnutrition, was not determined. If height measurement is unavailable, Mid-Upper Arm Circumference (MUAC) can be an alternative, but only 3.7 % of the children were measured with MUAC. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 61 Figure 55 Weight and height measurement at well child clinic Weight and height measurement at well child clinic 98% 98% 98% 100% 96% 94% 94% 95% 91% 91% 90% 84% 80% 80% 80% 70% 60% 50% 40% 30% 20% 10% 0% Phongsaly Oudomxay Huaphan Xieng Khuang Weight Height Weight for height Figure 56 Weight and height measurement at sick child clinic Weight and height measurement at sick child clinic 99% 99% 99% 100% 90% 79% 80% 72% 70% 67% 60% 51% 49% 50% 44% 45% 40% 30% 20% 10% 6% 1% 0% Phongsaly Oudomxay Huaphan Xieng Khuang Weight Height Weight for height Of the 431 sick children evaluated in the OPD logbook review of this assessment, 248 with known height, weight, age, and sex were reassessed for their weight for height, and 16 or 9% were determined to have severe acute malnutrition. None of these were diagnosed with severe acute malnutrition in the logbook and opportunities for treatment were missed. Three- quarters of these cases were recorded in Phongsaly and Oudomxay provinces. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 62 Figure 57 Re-evaluation of weight for height Re-evaluation of weight for height: Number and percentage of recorded cases by nutrition status Severe acute Obesity, malnutrition, 16, Overweight, 12, 5% 14, 6% 6% Moderate acute malnutrition, 22, 9% No malnutrition, 184, 74% In the facility-based survey, antibiotics were prescribed to 99% of children under five years old who had been diagnosed with pneumonia at an outpatient visit. In contrast, 50.4% or 63 out of 125 children under five years of age presented at the outpatient clinic with diarrhea, were prescribed oral rehydration salts and zinc. Non-communicable diseases Among non-communicable diseases, the EHSP focuses on cardiovascular disease, diabetes, chronic respiratory disease, cancer care, and mental health. Health education and promotion address tobacco cessation, alcohol abuse, regular exercise, low salt intake, and basic rehabilitation. Of the 41 items in provincial hospitals, 68.9% were available; of the 36 items in district hospitals, 55.5% were available. Figure 58 Readiness rate for non-communicable diseases Readiness rate for non-communicable diseases (number of itemd) 100%100% 100% 90% 85.4% 83.3% 81.8% 80.9% 80% 75.0% 68.9% 67.3% 67.0% 70% 60% 55.5% 52.5% 50% 40% 30% 18.2% 20% 8.3% 10% 0% Overall (41, 36) NCD General (4) Cardiovascular Diabetes (11, 6) Chronic Cancer care (5) Mental (3) diseasesl (12, 12) respiratory diseases (6) Provincial hospitals District hospitals Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 63 Essential equipment (weight and height scales, blood pressure monitors, stethoscopes, etc.) for assessing the risk of cardiovascular disease and diabetes was available at all levels of facilities. Hypertension medications were relatively well maintained, but the readiness for hyperlipidemia management and diabetic complications was limited. As for chronic respiratory disease, the readiness for complicated cases was not yet ready. For cancer care, the EHSP included only palliative care using opioids for pain management. Regarding narcotics, injectable opioids were available at the provincial and type-A district hospitals as analgesics during surgery. Oral opioid tamaradol tablets were deployed in half of the hospitals. The RMNCAH QAIS assessed nine antipsychotic and mental health-related medications in the provincial and district hospitals. Most were not available at any facility. A few facilities had chlorpromazine or amitriptyline. Emergency and surgical care Basic emergency service at three facility levels includes basic resuscitation and management of poisoning, injury, acute respiratory failure, and shock. Fourteen tracer items were identified; the readiness rate for basic emergency care at the provincial hospitals was 96.4%, while that at district hospitals was 87.8%. Surgical operation service is provided in the central, provincial, and type A district hospitals. Of 135 district hospitals nationwide, 32 currently provide surgical services, including one hospital in Phongsaly and Oudomxay provinces and three in Huaphan and Xieng Khuang. Twenty-five items in four categories, anesthesia equipment, anesthesia medication, operation equipment, and blood transfusion equipment, were included as tracer items for basic surgical operation service. Anesthetics were evaluated according to their pharmaceutical effects. Atropin, neostigumin, and epinephrine were excluded due to data quality issues. Overall readiness at provincial hospitals was 93.0%, and 91.5% at district hospitals. As far as the survey shows, emergency supplies and the necessary equipment for surgical procedures appear to be in place. Regarding transfusion readiness, blood coagulation testing was not available at three-quarters of the facilities. It is noted that the preparation of blood products may have been underestimated because some facilities outsource the preparation of blood products. Human resources for surgical service were not assessed in the RMNCAH QAIS, but it was witnessed that during the assessment in Phongsaly province, an obstetrician-gynecologist participating in the survey as an assessor had to be taken by ambulance to her provincial hospital after receiving an urgent call. Dental and eye services are listed in EHSP, but no specific equipment nor medications were listed. The reason for the low readiness rate for dental service was a lack of augmentin and azithromycin. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 64 Figure 59 Readiness rate for emergency care and surgical services Readiness rate for emergency care and surgical services (number of items) 97.9% 100.0% 100.0% 100.0% 96.4% 93.0% 91.5% 93.8% 97.9% 100% 87.5% 87.8% 85.2% 90% 75.0% 81.3% 80% 70.0% 70% 63.0% 60% 50% 40% 30% 20% 10% 0% Basic Surgical care: Anesthesia Anesthesia Surgical Blood (5) Basic dental Basic eye care emergency overall (25) equipment (12) medication (6) equipment (2) care (4) (2) service (14) Provincial hospitals District hospitals Communicable diseases The EHSP lists the following communicable diseases as essential: sexually transmitted diseases, specifically syphilis and HIV/AIDS, malaria, and TB. For communicable diseases, the readiness of necessary medical equipment and medication was not high. The EHSP stipulates that district hospitals should have diagnostic capacity for communicable diseases. For malaria and tuberculosis, they should provide standard treatments. However, some hospitals lack rapid diagnostic kits and are not well stocked with initial treatment medications. Figure 60 Readiness rate for communicable diseases Readiness rate for communicable diseases (number of items) 95.8% 100% 90% 80% 71.9% 71.0% 75.0% 76.3% 75.4% 70% 62.8% 55.8% 60% 50% 38.3% 38.4% 40% 30% 20% 10% 0% STI (8, 6) HIV (15, 2) Malaria (7) TB (13) Other CD (12) Provincial hospitals District hospitals The Lao government has designated 11 ART hub hospitals for specialized treatment in eight provinces and six service base hospitals for guiding compliance and prescription in the provision of HIV and AIDS services. Huaphan provincial hospital is an ART hospital, and Xieng Khuang and Oudomxay provincial hospitals are the service base hospitals. There is no HIV facility in Phongsaly province. The survey looked at diagnostic equipment and therapeutic drugs: HIV rapid diagnostic test kits, a necessary item for HIV screening of all pregnant women, were missing from six district hospitals. Equipment for definitive diagnosis was relatively well stocked at provincial hospitals, but treatment drugs were found only at Huaphan hospital. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 65 5. Patient satisfaction During exit interviews in the RMNCAH QAIS, the assessors asked patients and caregivers who visited health facilities for maternal and child health services if they were satisfied with the service and how they perceived the health workers' performance. The questions included waiting time, privacy, explanation and informed consent, communication, and overall satisfaction. Responses were given on a 3-point scale: yes, partially, or no. Overall patient satisfaction was very high, with 94% of the patients and caregivers interviewed saying they were satisfied with the service. More than 90% of the interview respondents waited for less than 30 minutes to see their health workers. On the other hand, one in five respondents was less comfortable with the explanation they received from their health workers. Figure 61 Patient satisfaction from exit interviews in RMNCAH QAIS Patient satisfaction from exit interviews in RMNCAH QAIS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Overall satisfaction Satisfied with waiting time Privacy was protected Received all necessary care HWs explained procedures HWs asked permission for procedure Comfortable asking questions HWs gave all information needed HWs spoke in understandable language Yes Partially No Missing There was a detectable difference in satisfaction with information given by health workers between the provinces. Further analysis also showed a clear difference between ethnic groups; Mon-Khmer and Sino-Tibetan people were less satisfied with the explanation and information from health workers than the Lao-Taï and Hmong-lumien groups. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 66 Figure 62 Satisfaction with information given by health workers Satisfaction with information given by health workers 94% 97% 94% 95% 95% 100% 93% 88% 82% 74% 77% 79% 80% 72% 71% 66% 57% 60% 51% 40% 20% 0% Provincial District Provincial District Provincial District Provincial District Phongsaly Oudomxay Huaphan Xieng Khuang HW explained procedure HW gave all information I wanted Figure 63 Satisfaction with information given by healthcare workers by ethnicity Satisfaction with information given by healthcare workers by ethnicity 100% 89.6% 85.6% 86.1% 86.6% 79.3% 80% 72.2% 72.0% 64.4% 60% 40% 20% 0% Lai-Tai Mon-Khmer Hmong-Iumien Sino-Tibetan HW explained procedure HW gave all information I wanted *Excluding other ethnic group and missing data Several users left comments: some of the comments were positive, some gave suggestions for improvement, such as more attention to patients and not being late for treatment. There were also suggestions regarding the lack of human resources, medical equipment, consumable items (e.g. soap, paper napkins, clean towels), expansion of treatment rooms, and dirty toilets. This section presents the results from the QPS at health center level. Unlike the RMNCAH QAIS, the QPS evaluated services in the health centers holistically, not by service area. The results include various aspects of administration and management, including infrastructure, human resources, financial management, health insurance, essential equipment and medication, staff knowledge of clinical services, and patient satisfaction. Only selected data are presented in this report to complement the findings of the RMNCHA QAIS. The comprehensive results of the QPS will be detailed in separate reports prepared by the government through the HANSA project. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 67 1. Samples The QPS assessed 234 HC across four provinces in the north. Table 11 Sample of facilities at health center level Health facility Level Health centers Phongsaly 50 Oudomxay 53 Huaphan 75 Xieng Khuang 56 Total 234 Sample size and demographics of vignette respondents QPS uses vignettes of a relatively similar design to those in the RMNCAH QAIS, with the same procedure for conducting them, but with the addition of randomization for selecting health workers and topics. For some topics, such as EmOC, the referral system is emphasized as it is only available at the upper level. A total of 929 health workers were assessed, with the majority of staff who went through maternal and child topics being midwives, while nurses, medical assistants, and general doctors were assessed for OPD topics such as tuberculosis and non-communicable diseases. Table 12 Sample size of vignettes in QPS Phongsaly Oudomxay Huaphan Xieng Khuang Total V1: Reproductive health: new 10 12 19 11 52 user of contraceptive V2: Reproductive health: 4 4 13 9 30 introduction of long-acting reversible contraceptive V3: ANC: routine ANC and 12 10 19 20 61 anemia management V4: ANC: hypertension 10 15 19 17 61 management V5: Intrapartum care: vaginal 17 25 28 16 86 delivery V6: EmOC: severe pre-eclampsia 8 7 9 9 33 management V7: EmOC: PPH postpartum 14 16 22 24 76 hemorrhage management V10: Sick child care: pneumonia 7 7 9 0 23 management V11: Sick child care: diarrhea 10 6 7 0 23 management V12: Well child care: integrated 8 5 4 4 21 well child care V13: Tuberculosis TB 30 35 51 34 150 management V14: NCD: hypertension 40 43 60 46 189 V15: NCD: diabetes 28 28 36 32 124 Total 198 213 296 222 929 Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 68 Figure 64 Health workers assessed with vignette by profession Health workers assessed with vignette by profession 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% V1 V2 V3 V4 V5 V6 V7 V10 V11 V12 V13 V14 V15 General doctor Medical assistant Midwife Nurse Other Client satisfaction interview At health center level, QPS uses a systematic random selection of client feedback interviews, ideally aiming for three MCH cases and two OPD cases. A total of 662 patients or caregivers from RMNCAH areas participated in the exit interview via phone calls. Table 13 Demographics of interview respondents at the health center level Service area Phongsaly Oudomxay Huaphan Xieng Khuang Total Family planning 10 20 28 7 65 Antenatal care 13 43 46 22 126 Delivery 15 52 43 12 122 Well child care 12 30 58 21 130 Sick child care 44 75 99 45 219 Total 94 220 274 107 662 The highest level of education in most respondents is primary school, for those aged 30 and over, while among the 15–29 age range many have completed lower secondary level. Figure 65 Education level by age range Education level by age range 0 0 0 1 0 0 100% 1 2 1 1 9 3 9 3 1 14 45 5 11 8 80% 52 21 7 13 60% 41 66 28 60 24 40% 13 29 20% 49 38 21 50 9 3 8 4 5 3 2 0% 15-19 20-24 25-29 30-34 35-39 40-44 45 or above None Primary (primary 1-5 years) Lower secondary (secondary 1-4 years) Upper secondary (secondary 5-7 years) Post-secondary and non-tertiary (13-15 years) Tertiary (associate and higher) Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 69 More health center users were aged in their 20s, but it is important to note that these data were captured through systematic sampling, which may introduce some bias into the sample. Nonetheless, this information provides valuable insights on how health centers should adopt a patient-centered approach when engaging with their users. Figure 66 Service used by age range Service used by age range 200 180 160 46 37 140 120 37 55 100 39 80 15 42 60 29 14 16 40 25 15 31 44 35 1 3 0 19 7 1 36 20 22 15 17 3 7 1 15 4 2 3 0 5 10 11 15-19 20-24 25-29 30-34 35-39 40-44 45 or above Family planning ANC Delivery Child vaccination Sick child OPD 2. Health center infrastructure The health center is the closest health station to the community, designated as the first station for providing timely health services to the population, especially in underserved areas. One indication of readiness requiring attention is the condition of the buildings. According to the QPS results, nearly 90% of HC have a surrounding wall or fence in Phongsaly and Huaphan, against only 62% of health centers in Oudomxay. When looking inside the buildings, almost all health centers in Phongsaly have separate rooms for OPD, delivery, and ANC services, while in Oudomxay and Xieng Khuang the figure is below 80%. Regarding energy source for the facility, Huaphan seems to be the least ready for electricity shortages, followed by Xieng Khuang. Additionally, almost all HC in the four provinces have waiting areas with seating. Figure 67 Infrastructure at health center level Infrastructure at health center level 0% 20% 40% 60% 80% 100% Health centre has surrounding wall or fence Phongsaly Health centre has at least one room for each of: (a) OPD consultation (b) delivery room (c) Oudomxay ANC check-up Solar light, battery light or generator back-up available Huaphan Waiting area with seats for patients and companions, with drinking water Xieng Khuang Feedback box to collect comments from patients Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 70 Hygiene and sanitation infrastructure For OPD room, ANC room and delivery room, the QPS investigated those rooms’ conditions, whether those are kept clean with an adequate hand washing facility. The results show that OPD rooms at some health centers in particular districts, such as Xai and La districts of Oudomxay and in Mok and Phoukout districts of Xieng Khuang, were in poor condition, lacking consumable items like soap, paper napkins, or clean towels. Most of those health centers did not have three separate rooms, raising concerns on basic infrastructure. Figure 68 OPD Room by province OPD Room by Province 100.00% 50.00% 0.00% 02 Phongsaly 04 Oudomxay 07 Huaphan 09 Xieng Khuang Total Health Facility OPD ward has general waste bin, not full (more can be added without spilling over) Running water or alcohol hand-rub available Soap available (no detergent) at every hand-washing station Paper or clean towels for drying hands near every hand-washing station For ANC rooms, Phongsaly performed better than the other provinces, with all indicators above 80%. In the other provinces, around 20% of health centers did not have running water or alcohol gel, nor soap nor hygiene items in the ANC rooms, particularly in Xai, La, Beng district (Oudomxay), and in Phoukout district (Xieng Khuang). Figure 69 ANC Room status by province ANC Room status by province 100.00% 80.00% 60.00% 40.00% 20.00% 0.00% 02 Phongsaly 04 Oudomxay 07 Huaphan 09 Xieng Khuang Total Health Facility OPD ward has general waste bin, not full (more can be added without spilling over) Running water or alcohol hand-rub available Soap available (no detergent) at every hand-washing station Paper or clean towels for drying hands near every hand-washing station Most health centers seem to pay attention to the hygiene of delivery room; all indicators are above 80%. However, some health centers in Oudomxay still lack consumables. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 71 Figure 70 Delivery room Delivery room 100% 80% 60% 40% 20% 0% Phongsaly Oudomxay Huaphan Xieng Khuang OPD ward has general waste bin, not full (more can be added without spilling over) Running water or alcohol hand-rub available Soap available (no detergent) at every hand-washing station Paper or clean towels for drying hands near every hand-washing station More than 90% of the health centers have functional toilets. However, toilet problems such as lack of sinks, running water, and lighting are common in all four provinces. Approximately 14% of health centers in Phongsaly, including Phongsaly, Khoua, Samphan, and Bountai districts, have lighting problems. Figure 71 Toilet functionality by province Toilet Functionality by province 75% 80% 85% 90% 95% 100% At least one toilet is available for use by patient or… Toilet has a door and is lockable from the inside Toilet has running water or container with water and… Toilet has functional place to wash hands with running… Toilet has a functional light Toilet has no visible waste No flies or foul smell Phongsaly Oudomxay Huaphan Xieng Khuang Medical waste handling and disposal Health centers in Phongsaly province show remarkable performance in waste management, surpassing 90% in all indicators. However, several health centers in Houamuang, Xam Tay, Kouan, and Xon districts in Huaphan province, are short of staff trained in water and sanitation as well as waste management. Furthermore, in Oudomxay, Huaphan, and Xieng Khuang, approximately 20% of health centers have inadequate waste triage practices. Disturbingly, in Xieng Khuang, around 20% of health centers fail to dispose of sharps and needles in designated safety boxes. Although more than 95% of health centers in the four provinces store infectious waste and safety boxes in temporary safe storage areas with proper labeling, roughly 17% of health centers in Oudomxay and Huaphan do not securely store liquid chemicals in sealed containers. When it comes to the final destination of waste, pits or incinerators are available in the majority of health centers in four provinces (94% on average). Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 72 Figure 72 Medical waste handling and disposal Medical Waste Handling & disposal 100% HC has at least one staff trained in water and sanitation, and waste management 90% 80% Waste is collected separately in colour coded bins. General waste in black container, infectious 70% waste in yellow container 60% Sharps and needles disposed in Safety Box (yellow sharps container) 50% Infectious waste and Safety Box are stored 40% temporarily in safe, protected area in labelled 30% container prior to disposal Liquid chemical waste is safely stored in labelled 20% and sealed container before disposal 10% There is a pit or incinerator for infectious waste 0% and sharps Phongsaly Oudomxay Huaphan Xieng Khuang 3. Human resources The QPS data shows the number of each type of health center assessed, and the availability of essential health care workers in the four provinces. The majority of health centers are type B (88%), which have limited resources and facilities compared to type A facilities. Table 14 Type of health center by province Province No. of type A HC No. of type B HC HC - missing information of type identification Phongsaly 1 43 6 Oudomxay 3 49 1 Huaphan 2 71 2 Xieng Khuang 8 44 4 Table 15 Estimated number of health worker at health center level26 Phongsaly Oudomxay Huaphan Xieng Khuang Type A Type B Type A Type B Type A Type B Type A Type B Number of HC 1 43 3 49 2 71 8 44 Number of health workers* Medical assistant/high 0 31 4 27 1 49 4 19 diploma PHC Low/midlevel PHC 0 4 1 22 0 11 7 12 High-level nurse 1 9 0 12 0 14 3 11 Technical nurse 0 26 5 54 2 34 3 41 Midlevel midwife 1 36 4 56 3 52 10 57 Low-level nurse/midwife 0 10 2 15 0 11 2 8 General doctor 0 34 5 30 1 50 6 26 (Bachelor’s Degree) Total 2 150 21 216 7 221 35 174 Source: Distribution of Health Worker in Lao PDR, DHP, MOH, 2021 *Note: number of health workers excludes medical doctor with specialization, interns, pharmacists, pharmacist assistants, high level health management, lab assistants, rehabilitation staff and hygiene practitioners. Data for volunteers and private health sector staff not available. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 73 Given that most of the health centers assessed are type B, the number of health workers is 2-4 individuals on average per health center. This does not meet the stipulations of MOH Decree 0447 on establishing a health center, 12 March 2019 (page 4), which specify • Health center A: 5-7 individuals • Health center B: 3-4 individuals The availability of staff was checked by reviewing the daily staff attendance register over the previous three months. Overall, 84.6% (198/234) had health workers from three categories. 94% (221/234) of health centers had at least one clinical health worker (medical assistant, medical doctor, primary healthcare high level, specialist, family medicine). In Oudomxay, all health centers have a 100% presence, while Phongsaly and Huaphan have over 95% coverage. Xieng Khuang has the lowest coverage at 88%. Specifically, the health centers in Pek, Khoun, and Phoukout districts are short of clinical health workers. 95% (223/234) of health centers had at least one midwife. As above, Oudomxay has 100% coverage, while the other provinces show over 90% coverage. 92.7% (217/234) of health centers had at least one nurse. Oudomxay has the top score with 100% coverage. Huaphan has the lowest score, with 12% of health centers facing a shortage of nurses, as cited in Xam Neua, Xiangkhor, Xam Tay and Sobao districts. Around 93% (218/234) of health centers have at least one clinical health worker who can speak the prevailing language spoken by the catchment population. Oudomxay has 100% coverage, whereas 17% of health centers in Xieng Khuang lack ethnic language speaking staff, as seen in Pek, Kham and Phoukout districts. Figure 73 Human resource situation at health center level Human resource situation at health center level 0% 20% 40% 60% 80% 100% Phongsaly HC has at least one clinical health worker (medical assistant, medical doctor, high- level PHC, specialist, family medicine) HC has at least one midwife Oudomxay HC has at least one nurse Huaphan At least one health worker can speak the local language Xieng Khuang Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 74 4. Financial management QPS also conducted an examination of financial management at health center level. It was found that all health centers in the four target provinces maintain daily bookkeeping records. However, when reviewing the quarterly financial income-expense report for the last quarter, it became evident that Oudomxay province faced the most significant challenges in accurately preparing and submitting financial reports to the DHO, with 32% of health centers accomplishing these tasks. No health centers in Xai and Pakbeng districts completed the tasks. Additionally, it was observed that around 20% of health centers in other provinces faced similar challenges, as cited in Boun Tay district (Phongsaly), plus Houamuang (Huaphanh) and Kham districts (Xieng Khuang). Figure 74 Financial record at health center level Financial record at health center level 100% 50% 0% Phongsaly Oudomxay Huaphan Xieng Khuang Daily bookkeeping register is available HC has quarterly financial income-expense report in last quarter, submitted to District Health Office Quarterly income expense reports are accurate 5. Health insurance Based on the QPS data for checking patient records, it appears that many respondents have access to free healthcare services, which is particularly beneficial for pregnant women and children under the age of 5 who need essential healthcare services. The Lao exemption policy is specifically designed to provide vulnerable populations with access to these services without financial burden. Figure 75 Number of patients by payment type and services Number of patients by payment type and service 250 0 200 73 150 2 1 0 46 100 0 94 94 116 50 100 55 9 12 6 21 7 0 15 7 4 Family planning ANC Delivery Child vaccination Sick hhild OPD Health Equity Fund Health insurance Exemption Self-pay Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 75 Results from a randomized selection of respondents show a positive trend in that the exemption scheme has been reaching vulnerable people, with 432 out of 662 respondents accessing this payment type. Regular health insurance seems to be less commonly used in this region, potentially because it is not always necessary when the basic healthcare package is provided for free. According to the current study, health insurance usage was low in Oudomxay (5%), Huaphan (10%), and Xieng Khuang (8%), while it was more commonly used in Phongsaly (47%). Figure 76 Health insurance management at health center by province Health Insurance Management at Health Centre by Province 100% List of people classified as poor in health centre 90% catchment area exists 80% 70% Records of co-payments by users maintained in 60% Contribution Book 50% 40% Information posted clearly in Lao showing all free of charge health services, including free package 30% of MCH services 20% Poor, pregnant women and children under 5 not 10% charged for using OPD or IPD services 0% Phongsaly Oudomxay Huaphan Xieng Khuang The graph above shows that nearly all health centers face delays in claim processing by the National Health Insurance Bureau. The percentage of recorded co-payments by users in the contribution books and number of prescriptions filled matching the number of patients in the logbook is above 80% in all four provinces. In Huaphan, where more people use standard health insurance than in the other three provinces, the figure reaches 100%. About 80% of all health centers in the four provinces have records of people classified as poor, making them eligible for exemption from healthcare fees. However, in four provinces, the vast majority of pregnant women and children under 5 years old were charged for utilizing OPD or IPD. Specifically, the percentage of those who were not charged is nearly zero in Phongsaly, while it is completely zero in the other three provinces. Figure 77 Number of clients from vulnerable groups - additional payments at healthcenters Number of clients from vulnerable groups - additional payments at health centers 45 40 35 30 25 20 15 10 5 0 FP ANC Delivery Well Sick child OPD Did the nurse/doctor prescribe drugs that you had to purchase in a pharmacy? Did you pay additional money under the table? Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 76 When conducting client exit interviews to assess out-of-pocket practices, it was found that approximately 37% of patients (158/432) who received maternal and child health services had to purchase drugs from a pharmacy, despite the exemption scheme. Additionally, it was found that 25% of patients (107/432) had to pay an additional amount "under the table" for all services. Looking at the findings in more detail, of the women who visited health centers for antenatal care and delivery, 35.7% (45/126) and 35.2% (43/122) respectively had to purchase prescribed medications at their own expense at pharmacies. This happened more in Phongsaly and Oudomxay than in Huaphan and Xieng Khuang. Figure 78 Nurse/doctor prescribed drugs you had to purchase in a pharmacy. Health center level Nurse/doctor prescribed drugs you had to purchase in a pharmacy.Health center level 100% 79% 80% 60% 51% 52% 47% 40% 21% 21% 20% 9% 0% 0% Phongsaly Oudomxay Huaphanh Xieng Khuang ANC Delivery 6. Quality of communicable disease management Tuberculosis The QPS survey results for TB services indicate that of the total number, 122 health centers across four provinces had accurately recorded presumptive TB cases in the previous six months, and all collected sputum had test results available within 15 days of collection. Only 80 health centers found positive cases and correctly documented the treatment for TB- positive patients. Figure 79 Quality of TB management Quality of TB management 100% 80% Presumptive TB cases are accurately 60% recorded and results noted 40% Positive TB cases are put on treatment 20% 0% Phongsaly Oudomxay Huaphan Xieng Khuang Of these 80 health centers, 54 facilities conducted screening for children under 5 years old who live in the same household as someone identified as TB positive or receiving tuberculosis preventive treatment if TB was excluded: Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 77 • Phongsaly: 69% of health centers (18/26) • Oudomxay: 64% of health centers (23/36) • Huaphan: 73% of health centers (8/11) • Xieng Khuang: 71% of health centers (5/7) There are several scenarios in which the remaining health centers did not meet the quality of management based on the QPS TB indicators. For instance, some were unable to prepare accurate records of presumptive TB cases every month for six months. In some months during the previous six months, there were no reported cases. Furthermore, not all positive cases received treatment, and even in cases where treatment was provided, there was a lack of accurate record-keeping. Although, the number of TB cases found is low, the evaluation of health worker knowledge on TB management showed a good average vignette score of 89%. Figure 80 Sectoral scoring rate: Tuberculosis management vignette Sectoral scoring rate: Tuberculosis management vignette 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Total Section 1: Medical Section 2: Physical Section 3: Section 4: Section 5: Section 6: history exam Identification of Paraclinical tests Treatment Counseling: presumptive TB initiation Patient management HIV services for ANC1 The percentage of HIV tests performed during pregnancy at health center level is even more worrying, especially in Oudomxay, Huaphan and Xieng Khuang which show results of below 15%, while Phongsaly is at 30%. Based on additional comments in the data server from the DHO assessors, the main reason for not conducting HIV tests is a lack of HIV tests and reagents. Figure 81 Pregnant women undergoing HIV rapid tests at health center level by province All pregnant women have undergone HIV rapid test (ANC 1st) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Phongsaly Oudomxay Huaphan Xieng Khuang Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 78 Malaria The QPS checked the malaria testing report for the previous six months and found that 97% of health centers (227/234) had conducted one test or more in each month. Figure 82 Malaria management Malaria management 100% 80% 60% 40% 20% 0% Phongsaly Oudomxay Huaphan Xieng Khuang One or more malaria tests conducted every month Positive malaria cases were found in only 26 health centers — 9 in Phongsaly, 11 in Oudomxay, 5 in Huaphan, and 1 in Xieng Khuang —and all positive cases were given first line treatment. 7. Essential equipment and medications Medical supply management On average, more than 95% of health centers manage their equipment and medication well in terms of recording and storage. The pharmacy is managed by assigned staff who print monthly reports in the format outlined in the guideline for management of medicines and supplies for health centers. Daily dispensing and received quantities are recorded in Excel or on paper for the previous seven days. Monthly reports of the previous six months are reviewed to ensure that all items in the agreed list of medicines and supplies have sufficient stock quantity for at least 30 days. Oudomxay is behind the other provinces in this regard, with health centers in La, Nga, and Beng districts experiencing stock shortages. Unfortunately, detailed stock availability results are not available for all health centers due to the randomization method. Figure 83 Management of medications and commodities Management of medications and commodities 100% HC has assigned staff responsible for 80% pharmacy 60% Print-out of monthly report of medicines and commodities is available 40% HC maintains daily stock of drugs and commodities 20% Medicdines and supplies in the Agreed List 0% have stock quantities higher than 30-days Phongsaly Oudomxay Huaphan Xieng Khuang Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 79 Essential equipment A total of 49 essential devices based on the EHSP 2018 list were evaluated in 234 health centers. The average possession rate of these devices in each health center was 86.8%, with a low of 63.3% and a median of 87.8%. Only two health centers had all the equipment, namely Ounua health center in Nyot Ou district, Phongsaly and Latsen health center in Phaxay district, Xieng Khuang. The least available pieces of equipment were the vacuum extractor used for assisted delivery (13.3% in 31 facilities), followed by the neonatal resuscitation trolley (22.7%). Oxygen and oxygen masks were also missing in about half of the facilities. It appears that over 95% of health centers adequately store immunization vaccines in cold-chain boxes, with health workers monitoring the temperature over the previous six months. Each vaccine has a logbook that records the supply on a weekly basis for the previous six months. Essential medication Of the 48 drugs listed, 10 drugs were systematically selected and evaluated per health center. 43 of the 48 drugs were available in more than 90% of the health centers surveyed, with primaquine, an antimalarial drug, and zinc, an essential drug for treating diarrhea, available in fewer centers (87.3% and 85.2% respectively). 8. Patient satisfaction When examining the client experience after receiving healthcare services at the health center level in the four provinces, it is encouraging to note that over 90% of health workers provided explanations to patients of diagnosis or prevention measures, provided detailed information on how to use medicines, and allowed adequate time for clients to ask questions. Furthermore, up to 90% of clients reported being satisfied with the friendliness of staff and the waiting time from their arrival until receiving consultation. This is particularly high for family planning services. Figure 84 Client experience through healthcare services at health center Client experience through healthcare services at health centre 100% Did health staff explain about diagnosis or prevention measures? 80% Did health staff explain about how to use medicines? 60% Did health staff provide time to ask questions? To what extent are you satisfied with staff friendliness? 40% To what extent are you satisfied with waiting time, from arrival until receiving consultation from health staff? 20% Family planning ANC Delivery Well child care Sick child care Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 80 This section discusses issues with service readiness using results from the two assessments, available service utilization data, health outcomes, and other data, documents, and literature. The results of the two assessments point to various hospital infrastructure deficiencies. These deficiencies would affect service delivery, service quality, and patient satisfaction. The problem could be broken down into two barriers: tangible and intangible. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 81 The QPS found that 15% of health centers do not have a separate OPD, ANC, or delivery room. If the problem lies with the structure of the building itself, this is due to design and authorization when the health center was established, which raises the question of whether the administrative office in charge approved the structure according to the standards with which it should comply. As for management issues, one might consider how the rooms are assigned. About half of the health centers have fewer than 25 deliveries per year so if a delivery room is used only once every two weeks, it might also be used as an ANC room. Since the ultimate goal is to provide quality services, such an arrangement may not be a particular problem if basic facilities such as electricity and the necessary supplies for each service are organized, and staff are clear on how to deal with simultaneous demand for services. Inadequate hand hygiene facilities highlight management issues. With the COVID-19 epidemic, infection control measures were implemented. The WASH IPC survey, which was conducted at 1,225 healthcare facilities nationwide in 2021, found that only 16% of healthcare facilities had basic hand hygiene services, i.e. water and soap or alcohol- based gel, within 5 meters of a care point or toilet. The situation in the four provinces surveyed in this report was no exception, with poor practices observed (Table 16). Table 16 Results of the WASH survey in four provinces Total Basic water Basic sanitation Basic hygiene Basic waste health service service services management facilities services Phongsaly 57 29 50.9% 1 1.8% 3 5.3% 1 1.8% Oudomxay 60 45 75.0% 15 25.0% 6 10.0% 10 16.7% Huaphan 85 12 14.1% 39 45.9% 0 0.0% 25 29.4% Xieng Khuang 63 16 25.4% 15 23.8% 0 0.0% 22 34.9% Source: National Health Statistics 202127 The RMNCAH QAIS and QPS were conducted after the WASH survey. Because of the different survey methods, a simple before/after comparison cannot be made, it cannot derive evidence that there has been improvement since the WASH survey however, the problem continues. Potential root causes of this persistent issue can include a lack of awareness, issue prioritization, and financial constraints. Approaching the root causes is necessary to find concrete solutions. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 82 The QPS results highlighted inaccurate financial reports at health center level. Such issues could also occur at higher levels. Inaccurate reports impact healthcare facility operations and overall effectiveness in health service delivery. For instance, inaccurate reports lead to incorrect estimates and resource allocation decisions, resulting in inefficient procurement of medical supplies, inadequate staffing, and insufficient equipment and facilities maintenance. Moreover, inaccurate financial reporting creates opportunities for financial mismanagement, including fraud, embezzlement, and misappropriation of funds. Without accurate records, discrepancies and irregularities in financial transactions are difficult to identify, undermining the integrity of financial management systems and compromising the overall financial health of facilities. Improving financial records at health centers and higher levels can be challenging and requires the leadership and involvement of high-ranking officials. The existing system is often complex, requiring management of multiple records. To address this, simplifying and transitioning to electronic records can facilitate processes and minimize discrepancies in expenses and incomes. Such an ideal approach, however, would need a long-term plan. By providing training focused on enhancing financial record-keeping, health workers should be able to adhere to standardized procedures, meticulously record transactions, prioritize timely and accurate data entry, regularly reconcile financial data, seek guidance when needed, and actively participate in training opportunities. These practices promote accuracy, consistency, and transparency in financial management, ensuring reliable records and supporting overall financial integrity within health centers. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 83 The QPS results showed that the introduction of the exemption scheme demonstrates great potential as it is more accessible for vulnerable groups. However, there are gaps between the NHI’s intention and the real practice. At health centers in the four target provinces, one-third of MCH service recipients were instructed to purchase drugs at their own expense, and one in five had made an under-table payment. The QPS data also indicated deficiencies in insurance claims, co-payment records, etc. Although the RMNCHA QAIS did not collect data on insurance usage, discussions with health staff suggest that insurance and self-payment issues were related to the quality of services. The National Health Insurance system is important for improving access to health care for the Lao population. Several factors hinder its utilization. A lack of knowledge about service costs and insurance schemes among patients and healthcare providers has resulted in inappropriate use or non-use of insurance. It is clear that the NHI is underfunded, and cash flow challenges at facility level due to inadequate financing and delays in claims processing may directly affect requests for equipment and drug replenishment and co-payments. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 84 The shortage of health workers is a persistent problem, and although measures are being taken, annual trends in the number of health workers have fluctuated and have not yet reached a full-fledged increase11, 12. All health facilities in Laos rely on volunteers and contractors while waiting for civil service quotas 28 Educational institutes also depend on volunteers for teaching positions. The situation becomes demoralizing for volunteers, leading to high staff turnover and inconsistent allocation of resources. Additionally, skilled health workers are often promoted to administrative and managerial roles, resulting in a shortage of clinical health workers at facilities. Staffing of health centers, particularly for midwives, appears to be progressing well, as evidenced by the QPS results. The RMNCAH QAIS looked at the number of health workers engaged in each RMNCAH service, but found a large gap in the number of health workers between service areas and between hospitals. This may be due to whether the health workers are dedicated or dual-engaged in services, or it may also be due to respondents' perceptions. In addition, not all health workers providing a service at a health facility are trained in that service. Many facilities have only two or three people trained on a single topic. This may reflect how training is commonly conducted, as the central government invites a few people from each district to train at provincial hospitals. Furthermore, as a health worker who participated in the RMNCAH QAIS stated, even if someone is trained in a service, that does not necessarily mean he or she is providing that service. They may have already left that appointment or even never served in it. Planning for appropriate staffing will require consideration of the professions, work patterns, and skill sets of healthcare workers, along with the service demands of the community. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 85 Reproductive and adolescent health The four northern provinces covered in this survey have the highest rates of adolescent birth nationally, followed by Xaysomboun province. Compared to among the Lao-Taï ethnic group, the rate is about twice as high for Mon-Khmer, and three times as high among Sino-Tibetans and Hmong-Iumien8. Many women and youth lack access to comprehensive sexual and reproductive services due to limited resources, healthcare infrastructure, and cultural barriers. Figure 85 Adolescent birth rate per 1,000 women aged 15-198 Adolescent birth rate per 1,000 women aged 15-19 250 192 200 136 150 113 105 105 105 99 100 83 54 50 0 Hmong-lumien Huaphan Mon-Khmer Oudomxay Xieng Khuang Lao-Tai National Sino-Tibetan Phongsaly Province Ethnicity Source: LSIS II 2017 The National Adolescent and Youth Friendly Services Guideline was launched on February 16, 2018, with UNFPA support 29 , aiming to build and strengthen the capacity of healthcare providers to address the needs of young people, especially in sexual and reproductive health, and is expected to reduce early pregnancies. However, the policy has not been fully communicated to health facilities, which may hinder achievement of goals. To further augment the effectiveness of this initiative, comprehensive sex education programs are needed to reach young people both in and out of school. These programs can help to enhance awareness and knowledge about sexual and reproductive health, thereby empowering young individuals to make informed decisions about their health and well-being. By adopting a multi-faceted approach encompassing youth-friendly healthcare services and comprehensive sex education, a more supportive and enabling environment can be created to help young people thrive. Most health facilities are well equipped with modern contraceptive methods. However, a lack of implants was noted in Huaphan and Xieng Khuang, which may be a result of the COVID-19 pandemic. During the pandemic, the MOH recommended the promotion of long-lasting reversible contraceptives, especially implants 30 . According to DHIS2, the number of new implant users increased sharply in August 2022 in Xieng Khuang province and declined in all four provinces in the following few months. These changes imply that the lack of implants may have happened in all provinces at that time, and a rise in offers that followed this recommendation may have led to that situation. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 86 Figure 86 Trend of the number of new implant users Trend of the number of new implant users 400 350 300 250 200 150 100 50 0 January October January October January February July February July February April April April August September August March March September March May May May June December June December November November 2021 2022 2023 Phongsaly Oudomxay Huaphan Xieng Khuang Source: DHIS2 Cervical cancer service Cervical cancer is the third leading cause of death among women ages 15 to 44, with an estimated 191 deaths and 371 cases annually 31 . Despite this the cervical cancer lifetime screening uptake rate is very low at 4% 31. The MOH is implementing a screening campaign and the Maternal and Child Health Center has started collecting the number of cervical cancer screenings performed at a health facility within routine monthly reports. Although this has not been rolled out in all provinces, the 2022 data from Vientiane Capital and nine provinces, including Huaphan and Xieng Khuang, is available in DHIS2. According to this, all provincial and district hospitals in Huaphan and Xieng Khuang provided cervical cancer screening services. Of 1,455 screenings in the two provinces, 17 were found VIA positive. Further treatment information is not available so far. There are no reports from Phongsaly or Oudomxay in DHIS2 as yet. The utilization of cervical cancer screening is expected to increase and could be monitored through the national HMIS. Increased use of the service will naturally lead to more positive patients detected. The RMNCAH QAIS indicates that provincial hospitals need to improve their readiness regarding personnel and equipment to treat positive cases, including by following up and treating cervical intraepithelial neoplasia. Furthermore, since cancer treatment services have not yet spread to the regional level and are dependent on hospitals in the capital or overseas, it is necessary to establish a pathway that will enable the implementation of continuous and appropriate management from diagnosis to treatment for cervical cancer. Information from interviews suggests a need to raise awareness among the target population to increase the use of this service. The role of primary care providers should incorporate the sharing of information on cervical cancer as one of the elements in people-centered care, so that the target population does not miss the opportunity for cancer screening when accessing health facilities. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 87 Safe abortion service The Unsafe Abortion Prevention and Care Practical Guidelines for Health Workers defines safe abortion as "a process to terminate a pregnancy by skillful health personnel, in a standard health facility and with the woman's consent". It is illegal to perform induced abortions in Laos, except in special cases. In the case of an unlawful act, the woman, the healthcare provider, and anyone who assists her can be charged with a crime32. This situation has led to many unsafe abortions, using traditional herbs, dangerous medications, or self-induced abortions. According to LSIS II in 2017, the general induced abortion rate was 6.5 per 1,000 women aged 15-498. An apparent disparity in induced abortion rate as a pregnancy outcome was seen according to ethnic group and education level. The Lao-Taï group and women with higher education had more induced abortions than others. Figure 87 Induced abortion rate and unmet need Induced abortion rate and unmet need 120 25% 106 Unmet need (%) among 15-49 years old women Induced abortion ratio per 1,000 live births 21% 104 103 100 20% 85 16% 16% 16% 80 15% 15% 14% 14% 63 14% 66 64 14% 13% 14% 15% 60 11% 47 47 45 39 10% 34 7% 40 5% 22 18 5% 20 12 0 0% Primary Oudomxay Mon-Khmer None or ECE Hmong-Iumien Xieng Khuang Higher Lao-Taï Huaphan National Sino-Tibetan Upper secondary Phongsaly Lower secondary Post secondary/ Non tertiary National Province Ethnicity Education Induced abortion Unmet need Source: LSIS II 2017 Safe abortion should be considered in conjunction with family planning and contraception as abortion could result from unmet needs. Approaches to preventing unwanted pregnancies are discussed in the section on reproductive and adolescent health, so how to terminate an unwanted pregnancy is discussed here. The decision on how to terminate an unwanted pregnancy may be related to a variety of factors, including knowledge about pregnancy and abortion, social and cultural perceptions, including stigma against abortion, and access to abortion services. A recent study of teenagers in two Lao provinces found that only one-third of the participants were aware of induced abortion, on which they had limited knowledge and negative impressions33. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 88 While the readiness for safe abortion at the provincial and district hospitals in four provinces is not poor compared to other services, management of the equipment and medications for safe abortions in each facility need to be improved. The readiness of abortion services in health centers is not known as the assessment was not included. According to the EHSP, counseling and medical treatment for abortions are essential only in health centers with trained staff. However, when abortion is perceived as a stigma, people may not want to access and obtain treatment in the community to which they belong. Therefore, the provision of services must consider not only needs but also people's behavior in consuming services. Maternal health – antenatal care Antenatal care is an activity to confirm the normal course of pregnancy, assess the risk of complications, and detect pregnancy abnormalities early, facilitating appropriate treatment and safe delivery for mother and child. Antenatal care services are available at all levels of the Lao health sector. A dramatic improvement has been seen in the percentage of pregnant women who received at least one antenatal care session from a healthcare professional, from 56% in 2011 to 81.5 % in 2017. Further improvement is expected in the next LSIS based on the ANC 1 coverage data in DHIS2. Issues with antenatal care seem to concern managing pregnancy complications. About 40% of Lao women of reproductive age (15-49 years old) have anemia, a risk factor for preterm birth8. It is estimated that 0.3% of women of reproductive age are infected with HIV, according to the Joint United Nations Program on HIV/AIDS (UNAIDS)34. WHO estimated the maternal syphilis prevalence in 2016 was 0.05% 35 . Although those numbers are lower than in neighboring countries, vertical transmission of HIV and syphilis remains a public health issue. According to a 2013 cross-sectional survey, the prevalence of hypertension among women aged 18-44 years is as high as 16%. Pregnancy-induced hypertension is the second leading cause of perinatal mortality after postpartum hemorrhage. While no information was found on gestational diabetes, the prevalence of gestational diabetes is 12-13% in Thailand, where the age-adjusted comparative prevalence of diabetes in adults aged 20-79 years in 2019 is 7%, close to the Lao rate of at 6.3%36 . It is therefore likely that the prevalence of gestational diabetes in Laos is also considerable. However, the assessments reveal that the above complications have not yet been adequately assessed and managed. While training for healthcare providers is needed to improve complication management, availability of reliable information on the incidence of pregnancy complications would also contribute. Information on morbidity suggests how much attention health workers should pay to pregnancy complications in their clinical practice. Greater awareness would help identify more complications, and more frequent encounters will strengthen knowledge and skills. At health center level, it is recommended that knowledge of the referral system for pregnant women with complications be improved, especially in Oudomxay. Maternal health – intrapartum care Despite dramatic improvements in ANC 1 coverage, approximately one third of all deliveries in Laos are still performed at home8. There is a clear difference in facility delivery rate between provinces (Figure 84). Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 89 Figure 88 Place of delivery Place of delivery 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% National 64.6 34.5 1.0 Phongsaly 38.3 61.7 0 Oudomxay 58.7 40.3 1.1 Huaphan 55.8 43.8 0.4 Xieng Khuang 67.1 32.6 0.4 Facility delivery Home Other Source: LSIS II 2017 Home birth without a skilled birth attendant increases the risk of maternal and neonatal complications and death. However, cultural beliefs and practices, as well as limited access to and use of healthcare facilities, favor home births among rural populations37. Increasing the number of births at health facilities is a critical public health goal, as such deliveries are safer and also offer the chance to provide education on issues such as postnatal care, promotion of exclusive breastfeeding, hepatitis B vaccination at birth, and family planning counseling. Regarding the utilization of delivery services, DHIS2 data shows that deliveries in the four target provinces are almost evenly distributed among the three levels of facilities. Half of the health centers had fewer than 25 deliveries in 2022, corresponding to an average of one delivery every two weeks. At health center level, insufficient readiness for perinatal complications was observed, such as lack of Kiwi ventouse, adult oxygen masks, and newborn resuscitation trollies. Low levels of experience in delivery among health center staff raise concerns about the readiness for and quality of deliveries, and the management of delivery complications. Figure 89 Number of deliveries by facility level in the four target provinces Number of deliveries by facility level in four target provinces Provincial hospital, Health center, 6345, 29% 7024, 32% District hospital, 8345, 39% Health center District hospital Provincial hospital Source: DHIS2 Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 90 Figure 90 Number of deliveries (facility delivery/outreach in 2022 from HMIS) Number of deliveries (facility delivery/outreach in 2022 from HMIS) 140 121 120 100 80 66 60 40 2 19 20 1 7 38 3 6 3 0 0-25 26-100 101-500 501-1000 1001-2000 2001- No data Health center District hospital Provincial hospital Source: DHIS2 Newborn care Early Essential Newborn Care (EENC), developed by WHO Western Pacific Regional Office, is a set of evidence-based interventions designed to improve newborn care and reduce neonatal mortality. In Laos, EENC has been adopted and implemented nationwide since 2016. This module is the basis of the RMNCAH QAIS. In Huaphan and Xieng Khuang provinces, the RMNCHA QAIS has been implemented three times, approximately once a year. Quality improvement plans have been developed and implemented each time. Although the EENC training had been previously conducted in Phongsaly and Oudomxay, this was the first RMNCA QAIS in those two provinces. Comparison in skin-to-skin contact practices between the four provinces suggests that the quality improvement actions taken in newborn care are having a positive impact. However, concerns remain about health workers’ ability to care for complicated newborn cases, as observed in antenatal care and intrapartum care. Postnatal care The national guidelines for ANC and PNC recommend that a woman receives four postnatal care sessions, within 24 hours of birth, on day 3 (48-72 hours), after 7 -14 days, and after 6 weeks. Factors contributing to the lack of uptake of postnatal care include the fact that it has not yet been fully integrated into the services, the lack of a clear platform for providing the service, and a lack of awareness about its importance. It is not well defined where and by whom this care should be provided to be efficient and effective, especially as regards PNC2 and PNC3. As mentioned above, PNC1 coverage could be improved with increased facility deliveries. The postnatal stay is a valuable time to receive care and education from healthcare providers and a minimum stay of 24 hours is recommended. However, the survey found that only about half of postpartum mothers stayed in the hospital for more than 24 hours, and approximately one in seven left hospitals within 12 hours. Reasons for early discharge may overlap with those for not choosing to deliver at a facility, such as inaccessibility to relatives and other visitors, and the inability to implement cultural practices such as hot beds37. For the same reasons, and considering Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 91 that cultural practices dictate postpartum behavior, a community-based platform should be considered to encourage PNC2 and PNC3 consultations. Discussions are needed about existing service platforms and providers' knowledge and capacity. PNC4, polio, penta1, and PCV1 immunizations are recommended at six weeks of age. The national average immunization rate for penta1 is 72.5%, according to LSIS II 2017 8. As discussed below, incorporating PNC4 into the integrated well child care service can improve PNC4 coverage. Well child health The national RMNCAH strategy and action plans 2021 to 2025 focus on people-centered care, shifting the perspective of service delivery from what programs need to provide, to what users need to receive38. Reflecting this perception in well child care means that immunization, nutrition, growth and development, and disease prevention services should be offered as a comprehensive package on one platform. In addition, the services for the child's caregivers, who are often mothers at reproductive age, should be provided at the same time. Those services include family planning, nutritional guidance for adults, and immunization. Measures facilitating service integration include the development of SOP in the well child clinic, and use of the MCH handbook. These are currently not well utilized at field level. Actions are needed to raise their visibility, plus awareness of their usefulness, among both healthcare professionals and service recipients. At provincial and district hospitals the number of staff committed to well child care is not as large as for delivery and newborn care. Staffing constraints are becoming increasingly apparent in health centers, with only 61% of the staff receiving training based on vignette demographic data. The services to be provided in an integrated well child service require more time spent per child, as there is significantly more to do and communicate than in the case of vaccination service alone. To provide quality well child services efficiently, it is necessary to consider how the facility will be staffed, who will provide what, and where. For example, management must decide whether a single health worker should provide all services in one booth, or if separate staff should be assigned to services such as nutrition counseling, childhood development check, vaccination, etc., with patients rotating through each. The government can provide some options, and each facility must find its own optimal solution, considering the number of patients, staffing and capabilities, clinic schedules, room availability, and other factors. In addition, the proportion of service recipients who traveled less than 30 minutes to reach a health facility is higher in well child clinics than for the other services, suggesting that proximity of services may be important for well child care. If so, it would seem important to enhance integrated well child care in more health centers. Sick child health Although the absolute numbers are declining, pneumonia and diarrhea are still the leading causes of death among children under five, excepting prematurity and birth disorders 39. The prevalence of malnutrition, which increases vulnerability to and the severity of diseases, remains higher than the regional average of 2.2%. According to LSIS II 8, the highest prevalence of severe malnutrition in the country is in Huaphan, where it is 8.3%, followed by in Phongsaly, at 4.5%. In Laos, the IMNCI and the Pocketbook have been adopted as guides for sick child care. The national RMNCAH strategy sets criteria for managing child cases of pneumonia, diarrhea, and severe acute malnutrition, with these guides as strategy evaluation indicators38. The results of the RMNCAH QAIS show that the approach to malnutrition remains inadequate. Some malnourished patients leave health facilities without being diagnosed with malnutrition. This may be due to lack of skills and awareness among health workers, or a lack of necessary Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 92 ready-to-use therapeutic food. The Pocketbook and IMNCI advise on the management of malnutrition, while the National Guidelines for the Integrated Management of Acute Malnutrition (IMAM), published in 2018 with support from UNICEF and other partners, are specific to malnutrition. While guidelines are already in place, they are not being fully utilized in the field, and there may be a need to revisit causes for this and effective interventions. For pneumonia, according to the RMNCAH QAIS commonly used oral antibiotics for children were available in all facilities assessed, and most children under five years old diagnosed with pneumonia were treated with antibiotics during outpatient visits. However, on a population basis, only 45% of children under the age of 5 who present symptoms of acute respiratory infection receive antibiotics8. This low percentage may be caused by access to health facilities and care-seeking behavior, rather than service quality. Essential interventions for diarrhea include prevention or correction of dehydration with oral rehydration salts and zinc administration to reduce the duration and frequency of diarrhea. In the mid-term review of the RMNCAH Strategy, among 20 healthcare facilities in the four provinces, the availability of oral rehydration salts and zinc were 85% and 35% respectively. In the current survey, both are above 90%, indicating improvement. However, due to a lack of zinc prescriptions, actual treatment quality for children with diarrhea has not shown the same improvement. Increased awareness among healthcare providers of the benefits and need for zinc for children with diarrhea appear to be required. Non-communicable diseases As mentioned in the methodology section, the RMNCAH QAIS survey focused on RMNCAH services, assessing only equipment and medication related to services for non-communicable diseases, communicable diseases, and emergency and surgical services. According to the EHSP, the role of primary health care in these services is mainly to provide education and counseling on disease prevention and health promotion, initial diagnosis and appropriate referral to higher-level healthcare facilities, and follow up of stable patients. For many years, recorded deaths have been predominantly related to maternal and child disorders and communicable diseases, but the picture has changed since around 2015. Cardiovascular diseases have become the leading cause of death, accounting for more than a third of deaths in Laos 40 . Diabetes is also a growing concern, as in other neighboring countries. The national survey conducted in 2013 calculated that 5.7% of the population had diabetes, while only 14% of the sampled population had ever had their blood glucose checked by a health worker41. The Lao government has adopted the WHO's Package of Essential Non- Communicable Disease Intervention (Lao PEN) — its implementation in primary health care is still underway. Given the shift in disease burdens in Laos, it may be time to move focus to non-communicable diseases, especially cardiovascular and lifestyle diseases, and prioritize them over communicable diseases. Because available data for non-communicable diseases is limited, old or refers to neighboring countries, this should start with a detailed surveillance and situation analysis to understand the current state of diseases. The government's priority 5G1S policy incorporates standards for non-communicable diseases as part of two quality aspects for accurate diagnosis and timely treatment. The government encourages healthcare facilities to use these standards to self-evaluate their services and run a quality improvement cycle. The assessment results are expected to provide some clues for the future. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 93 For cancer services, the Global Cancer Observatory estimates that there were approximately 9,000 new cases of cancer in Laos in 2020, but as there is no information available in country, this was calculated by applying averages from neighboring countries such as Thailand and Vietnam to the Lao population42. While cancer care is available at hospitals in Vientiane, the capacity is still limited and those cancer patients that can afford it tend to seek treatment in neighboring countries. The EHSP includes only health education and cancer screening promotion at all levels, plus pain management for palliative care at provincial and district levels. As for cancer treatment, the government has begun screening and managing positive cases of cervical cancer. This could begin the expansion of cancer services through the training of specialized doctors and nurses. Many low- and middle-income countries have not yet incorporated palliative care into their health systems due to a lack of priorities and funds43. In Laos, it is not clear if such services are available at public hospitals. An NGO hospital affiliated with a public hospital outside Vientiane Capital provides palliative care for children suffering from cancers, cerebral palsy, and muscular dystrophy. Foreign experts constantly support the hospital staff, who provide care to ease symptoms and psychological hardships for both patients and their families by visiting children's houses in rural areas. They are closely communicating with their families or neighbors, and asking nearby healthcare facilities for daily support, including opioid management. This is labor intensive and expensive and its introduction as a public service would require a lot of financial, ethical, and cultural consideration. A holistic approach and oral opioids require a high level of ethics, sensitivity, communication skills, and knowledge of palliative care. Without these, negative consequences may occur, including opioid abuse. Mental health services are significantly under-served in Laos. The prevalence of mental health disorders has not yet been fully investigated, but a cross-sectional survey conducted in Vientiane Capital in 2016 reported that the estimated age- and sex-standardized current prevalence of any disorder was 15.2% 44 . The COVID-19 pandemic stimulated the improvement of mental health services availability and utilization; the Ministry of Health identified strengthening the capacity of the current workforce in primary health care as a core strategy 45. Interpersonal skills are essential to preventing and managing non-communicable diseases, along with solid knowledge of the diseases and scientific evidence. Effective communication helps health workers engage with patients and the community, understand the risks associated with unhealthy behavior, and provides them with the information and tools they need to make positive changes. With strong interpersonal skills, healthcare professionals are well-suited to build trusting relationships and creating a supportive environment where patients feel comfortable discussing their health concerns and goals. The central government will need to implement mechanisms to ensure that front-line health workers are constantly updated with such knowledge and skills. Emergency and surgical care In the four target provinces, the number of surgical operations and cesarean sections performed increased from 2018 to 202224. According to the HRH 2019-20 Annual Report, Phongsaly has only one surgeon and one anesthesiologist, Oudomxay has four of each, Huaphan has three surgeons and one anesthesiologist, and Xieng Khuang has five surgeons with two anesthesiologists11. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 94 Figure 91 Surgery trends in the four target provinces 2018-2224 Number of surgeries over 5 years in four target provinces 2500 2000 1500 1000 500 0 2018 2019 2020 2021 2022 2018 2019 2020 2021 2022 2018 2019 2020 2021 2022 2018 2019 2020 2021 2022 Phongsaly Oudomxay Huaphan Xieng Khuang IPD large surgery IPD medium surgery Source: DHIS2 Figure 92 Cesarean section trend in the four target provinces 2018-2224 Number of caesaran sections over 5 years in four target provinces 1000 774 762 800 658 639 573 599 537 545 600 469 469 445 367 400 279 219 221 130 165 149 200 34 47 0 2018 2019 2020 2021 2022 2018 2019 2020 2021 2022 2018 2019 2020 2021 2022 2018 2019 2020 2021 2022 Phongsaly Oudomxay Huaphan Xieng Khuang Source: DHIS2 According to DHIS2, 1,337 cesarean sections were performed in 2022 nationwide, accounting for 8.6% of estimated live births. The number of operations performed at public health facilities in 2022 was 645 per 100,000 of population, far lower than the target of 5,000 procedures set by the Lancet Commission on Global Surgery46. A preliminary study conducted with the Lao Society of Anesthesiology proved the shortage of the anesthesia workforce, showing that there were 244 anesthesia providers in Laos, including 64 anesthesiologists and 26 nurse anesthetists, for a population of 7.5 million. Surgical demands have been increasing in Laos. In response, the government plans to increase the number of type A district hospitals to 40 by 2030. While progress is being made in training physicians with specialized skills through residency and other programs, there is a need to plan how many surgeons, anesthesiologists, circulation nurses, surgical technicians, and other surgical personnel will be needed in the future and how they will be secured. Communicable diseases With strong government leadership and partner support in strategy development and implementation, Laos has made significant progress in addressing communicable diseases in recent years. The prevalence of HIV among adults aged 15-49 years has been kept low at an Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 95 estimated 0.3%6 The incidence of tuberculosis is constantly falling 47 (Global TB Report 20210), while malaria prevalence has seen a 99% reduction in the last two decades5 . Some issues with these services persist. Among 15,000 people living with HIV in Laos, just over half are on treatment (UNADIS)6. The TB incidence is still high, with an estimated 149 new cases per 100,000 people 47. Only 74% of estimated TB cases are registered, meaning unregistered people with TB may not receive adequate treatment. Service readiness for communicable diseases at provincial and district hospitals is limited. Several reasons can be considered. The first is designation as a treatment facility by the government. Among the provincial hospitals surveyed, only Huaphan provincial hospital is an HIV ART facility, and is the only one with ART drugs. The second is the low number of cases. Malaria is almost eradicated in the northern provinces. Three malaria drugs were counted as essential drugs in this survey; four facilities had no malaria drugs at all, while the rest had at least one malaria drug. How much attention should be given to covering rare diseases needs to be considered from the aspect of limited resource availability. The third also concerns type of drugs. There are many types of TB drugs, including single-agent, fixed-dose, first-line, and second-line drugs, and selection depends on the patient's background and treatment situation. Not all facilities have all these drugs. These factors all contribute to the low readiness rate. Patient satisfaction When assessing healthcare system performance, patient satisfaction is essential. It offers insight into the effectiveness and quality of healthcare services from the patient's perspective. The 5G1S policy clearly indicates that patient satisfaction is a quality criterion in Laos. The results of the RMNCAH QAIS and QPS assessments show satisfaction with the services received at all levels of health facility. While people were generally satisfied, some people in specific regions were not happy with the explanations and information provided by health workers. Given the vignette results show lower average scoring rates for counseling sections than other sections, it seems that healthcare providers' knowledge and communication skills may need improvement. This is relevant to all health workers regardless of specialty or work location, since they are all responsible for providing health education and promotion as essential services. Quality care results in the RMNCAH QAIS were not always good, and improvements are needed in many areas, but patient satisfaction was high. Some caution may be necessary in interpreting these results. Firstly, the population is skewed because only patients and caregivers who came to the facility were surveyed, and those who were not satisfied with the facility's services may not have come to the facility in the first place. Secondly, because respondents answered the questions listed in the questionnaire on a three-point scale of "yes", "partially", or "no" and were not asked why or how they were satisfied, it is possible that different respondents may have different levels of satisfaction even though they gave the same answers. In addition, since the RMNCAH QAIS interviews were conducted immediately after consultations, it is possible that respondents did not answer the questions sincerely, because they wanted to finish the interview as soon as possible or because they were concerned about the presence of the facility staff. The QPS customer satisfaction interviews were conducted by telephone, with clients who had visited the health centers in the past three months for evaluation, so there may be recall bias. It is also possible that questions were not properly understood by some respondents due to language issues. Use of health services is influenced not only by level of readiness on the supply side but also by care-seeking behavior on the demand side. How the quality of service affects patient satisfaction and care-seeking behavior was unclear from the RMNCAH QAIS. Detailed research is needed to better understand these relationships and then optimize service delivery. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 96 Issue 1: Quantity, quality, and deployment of human resources for health The quantity, quality, and deployment of human resources in health forms a major obstacle to providing quality essential services in Laos. The human resources available in the health system are clearly inadequate against the recommended WHO human resources ratio needed to achieve UHC. One in seven people working in the health sector are volunteers. Meanwhile, not all graduates from health science schools can get a job as a health worker. Local governments consistently raise the issue of staff shortages. This is an issue not only in the health sector but in all public services and is closely related to the financial situation. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 97 There are also concerns about the quality of health workers, i.e., knowledge, skills and attitudes. Pre-service education curriculums have been revised to be aligned with national guidelines, and a health professional licensing scheme has been implemented. Yet, the gaps between the current practice at ground level and standard practice exist. Post-graduate training offered by the government and development partners has faced challenges in its implementation. There was variation among facilities in the number of people they claim to be engaged in a service. High caseloads may compromise the quality of service and exhaust health workers. However, infrequent encounter to a particular disease or health condition also raises concerns about the quality of services and the retention of knowledge and skills of health workers. Inadequate information on community demand and service utilization precludes appropriate staffing and allocation. Issue 2: Lack of essential equipment and medication The assessment indicated a lack of essential equipment and medicines to provide essential health services at each facility level. The most likely factor is financial difficulty in procurement, hampered by limited health insurance disbursement and reimbursement, delays in claims processing, and the impact of the overall economic situation. Other factors include the low priority given to purchasing certain equipment and medication due to less frequent use or no intention to provide services under tight financing. Suboptimal allocation of available funding is another issue. For example, while 392 of 461million USD (85%) costed for the National Strategy and Action Plan on RMNCAH accounts for intervention cost, most external supports are concentrated on programmatic cost, which is costed as 69 million USD (15%). Besides the financial issues, one question arose from the observations made during the assessment. While infrastructure development and purchase of supplies are easy-to- understand outputs, their development does not guarantee service delivery or quality. How is the effectiveness of support for infrastructure and equipment from development partners being assessed? These assessments did not collect such information systematically, only episodic information, and this needs to be evaluated in terms of the effective use of resources. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 98 Issue 3: Underserviced essential services The assessment results and additional data and information indicate that some essential health services, such as non-communicable diseases, cancer and palliative care, surgical care, and mental health, are not adequately provided or are inadequately prepared to be provided. Some data indicate that these diseases are a burden in Laos, and the importance attached to each service in public health has been called into question. However, because of the lack of detailed and nationwide data, current service demand is still not fully understood. There is insufficient evidence to say that these services should be prioritized over current priority diseases. Multifaceted data, not only on mortality and morbidity but also on people's knowledge and perception of conditions, is necessary to the design of service delivery. Issue 4: Imbalance between demand and availability of essential services The interrelationship between service provision, demand, and utilization may shape inadequate service readiness for some services. The low frequency of encounters with Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 99 particular diseases or conditions such as malaria and deliveries, with and without complications, raises concerns about preparedness for these, e.g. lack of equipment, drug shortages, and the acquisition and maintenance of required knowledge and skills among health workers. The discrepancy in the data seen in malaria cases at health center level, though it may be related to data quality issues, raises questions about whether health workers respond appropriately to suspected malaria cases. Based on the low coverage of facility delivery, the demand for deliveries at health center level can be assumed to exceed current utilization. There can be many reasons for underutilization. It cannot be ruled out that the quality of care and trust in healthcare may influence patients’ care-seeking behavior. Since this survey was conducted at facilities, the thinking of those who do not use healthcare needs to be investigated separately. Issue 5: Inappropriate and insufficient use of health policy The assessments suggest inappropriate practices in applying for the free MNCH program National Health Insurance. Inaccurate financial reporting and delays in submitting insurance claims, as observed at health center level, may have resulted in supply procurement failures due to inadequate cash flow, consequently increasing the percentage of co-payments. In addition, discussions at district level over iron folic acid prescriptions and HIV testing during antenatal care suggest that patients and health workers do not have sufficient insurance knowledge, partly due to a lack of clarity on covered services. Also, the evaluation shows that central government's policies, guidelines, and plans, such as the Adolescent and Youth-Friendly Service Guidelines, have not been effectively disseminated to stakeholders at all levels. Healthcare quality improvement initiatives vary from facility to facility or service to service. Hence, national policies or guidelines are not being implemented or take a long time. Implementing the guidelines usually involves training, which may face budget and human resource constraints. It may also be that administration at the local level does not have sufficient capacity to interpret and implement the policies. Issue 6: Ethnic disparities Differences in access to health care and health outcomes among ethnic groups have already been noted. Pregnancy and childbirth among young people are higher among the Hmong, with higher unmet needs but lower induced abortion, suggesting barriers to knowledge about pregnancy and access to contraceptive methods. The RMNCAH QAIS results also show more Hmong among the teenage patients interviewed, and differences in patient satisfaction by ethnicity. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 100 Including the four main linguistic groups, Laos is home to nearly 50 ethnic groups. With their different languages, cultures, and beliefs, it is unlikely that the same approach will work for all. Hence, approaches need to be small scale, based on the characteristics of each ethnic group, and in cooperation with local government and health workers or village health volunteers from ethnic groups. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 101 Addressing every healthcare issue in Laos will require a drastic improvement in healthcare financing. The central government needs to secure adequate financial resources for healthcare, which in turn will ensure the proper operation of healthcare insurance and healthcare personnel. However, this report does not address financing issues, which were already apparent before these assessments were conducted, and which lie out of the scope of the assessments. While the results of these assessments may not be unique, based on the data and experience gathered in the field, the following recommendations are made. Recommendation: Strengthen management at the local level In terms of policy implementation, Laos, a multi-ethnic country with rich regional characteristics, needs to strengthen local government. Local administrations must consider the appropriate and effective use of their financial, physical, and human resources. They need to build their own efficient and effective systems, taking into account the geographical, ethnic, and cultural characteristics of each region and the policies developed by the central government. Local governments tend to be dependent on the central government. They face difficulties with interpreting policies, developing concrete implementation steps, and budgeting, so policies are poorly implemented locally. To support local government health policy implementation, senior management mentorship and support is needed for local managers, along with comprehensive management support from development partners, in line with their own programs. This would help local government managers build their capacity while engaging in practical work. In addition, encouraging information sharing between local and central governments would help accumulate on-the-ground knowledge that could be reflected in central government policies. Central government policies should guide local governments by setting clear directions and standards of practice, while allowing interpretation to reflect regional characteristics better. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 102 Recommendation: Clarify the terms and conditions of the National Health Insurance One of the reasons for low health service utilization is financial burden. Due to lack of knowledge of the insurance system among patients and front-line health workers, the free MCH financial protection scheme for mothers and children is not used appropriately. The EHSP is a service provided to everyone in Laos. To ensure quality of services, the provision of each service must follow the relevant service guidelines. The NHI scheme should include the services listed in the EHSP to enhance their availability and utilization. Services must be enumerated and clearly described in detail, such as diagnostic tests and medications: what tests will be covered and how often, what medications will be covered and in what quantities, etc. Such descriptions can give patients and healthcare providers clear expectations about the services to be provided and their costs. Reviewing the current insurance coverage and costs against these criteria may help identify areas needing improvement. However, such clarification may also lead to an increase in the necessary budget for the NHI. Efforts are required to secure the necessary funding for the insurance, along with continuous monitoring and analysis of insurance utilization and health service needs across various aspects. Allocation of available funding should be discussed. While external funding is concentrated on programmatic costs for quality improvement, domestic funding is insufficient to cover intervention costs to delivery services. Use of flexible funds such as loans for intervention cost might be an option for consideration. In this light, effectiveness of result-based payment, as opposed to input- based payment to directly improve availability of essential equipment and medicines, needs to be rigorously assessed. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 103 Recommendation: Establish and implement feasible methods to collect data from existing platforms for areas lacking data; improve access to existing data, and facilitate data use In some areas, information is lacking, and the current situation and needs are not fully understood. Much medical information is not digitized, and its collection is time-consuming and expensive. In some cases, the information itself may be outside the health sector. It is necessary to determine if existing platforms cover the area to which the data belongs and if so, to develop and implement data collection methods that leverage these platforms to promote efficient and continuous data collection and use. This information will help answer questions on what level of facilities are needed, where, and at what scale. Multiple surveys conducted to measure gaps in the delivery and preparation of healthcare services show similar trends. However, some of these data sources are retained and underused by stakeholders. An environment needs to be created in which data is shared and visualized to improve access and to link its use to the development and implementation of timely improvement measures. A dedicated dashboard section on the HMIS website could ensure effective dissemination of survey results. This dashboard should visualize the data in graphs, charts, or tables and should be updated regularly based on the frequency of each data source. In addition, user accounts should be provided, so relevant stakeholders can access the data and be informed about ongoing efforts. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 104 Recommendation: Strengthen the network of the public health system by implementing a referral system To provide efficient and safe healthcare services with limited resources, it may be necessary to reorganize the location, volume, and extent of services based on data. However, while this work may make services more accessible or safe for many, it may also place new burdens on those who have not been inconvenienced in the past. A strong referral system that vertically links healthcare facilities at all levels is essential to bridge this gap. To make it work, infrastructure such as internet, health information systems, roads, and transportation must be developed. In addition, building trust among health workers at all levels is essential for timely referrals. Developing face-to-face relationships through supportive supervision and exchange projects may help lower- level health workers contact their counterparts in referral hospitals without hesitation. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 105 Recommendation: Incorporate existing training modules and peer training into continuing professional development schemes Improved pre-graduate education and health professional licensing systems are already in practice as a quality assurance for healthcare professionals. In addition, improved post- graduate education and continuous professional development are needed to bridge the gaps between standard care and current practice. Effective implementation of the various training programs offered by the government and development partners should be considered so that patient-centered care can be practiced with quality. A coordination mechanism would help ensure that necessary training is continuously provided to those who need it. In addition to external training, bottom-up initiatives such educational opportunities within health facilities are recommended. Peer education offers one way of overcoming the financial, human resource, and time difficulties associated with external training. Trained and experienced health workers share their learning with colleagues, strengthening and disseminating knowledge. Peer education may require skills that health workers learn independently, but such skills may not be inherent in health workers. Pre-service and external training should include content that raises awareness of the importance of self- and peer education. In addition, modifications to existing training modules might make these training modules more accessible to health workers as a resource. Partnerships between healthcare facilities and educational institutions will also facilitate education in health facilities. It contributes to create opportunities to learn teaching methods, mentoring, coaching, use of communication systems, and obtaining expert support. Incentives may be needed to motivate both staff and healthcare facility managers to promote peer education in health facilities. One approach would be incorporating peer training into a continuous professional education system — one of the human resource management priorities in HSRS 2021-2023. For instance, if training is properly conducted under certain conditions, it can be recognized as a learning outcome and used to maintain or renew licenses. Alternatively, evidence of peer training at health facilities could be considered when accrediting hospitals under the 5G1S policy. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 106 Since the RMNCAH QAIS focuses on maternal and child health services, other clinical services are evaluated only with respect to the availability of equipment and drugs in accordance with the EHSP. Therefore, it does not cover all service readiness elements to be provided at each facility level. In addition, hospital operations, such as finance, inventory control, and human resource management, which are the foundation of clinical service delivery, were not included in the assessment. Unfortunately, the QPS results could not provide sufficient findings on essential medicine and equipment due to the randomization method — not all item lists were checked in each health center during the assessment. Due to various project impediments, including the COVID-19 epidemic, the RMNCAH QAIS was limited to the four target provinces, so this data cannot be applied nationally. However, with their particular ethnic composition and sets of problems, these four provinces provide many insights, including on the disparities in healthcare service quality experienced by ethnic groups. A time gap of about one year exists between the assessments in Huaphan and Xieng Khuang, and those in Phongsaly and Oudomxay, while this was the third RMNCAH QAIS in the first two provinces and the first survey in the latter two. This situation may cast questions on whether it is appropriate to consolidate or compare the results. However, the comparison does suggest the effectiveness of the QAIS activities. Finally, validation of the data was limited since data collection and entry were performed by provincial assessors and access to the original data was limited for project teams. However, local members of the project teams frequently approached the assessment teams by telephone calls and SMS to verify any suspicious data in an effort to ensure data quality. Objectives The objectives of the RMNCAH QAIS are: 1) To identify strengths and weaknesses of quality of care in RMNCAH service 2) To provide on-site technical supervision (individual-level improvement) 3) To develop action plans to improve RMNCAH services (facility-level improvement) 4) To collect data for national/sub-national data-based planning (national/subnational- level improvement) 5) To report the data to the 5G1S Standard Assessment. Activities On-site assessment schedule An example of the 4.5-day on-site assessment schedule at a provincial hospital is shown in table 2. The assessment at district hospitals followed this schedule, too. Facility-Based Service Readiness Assessment in Four Northern Provinces of the Lao PDR | 107 Table 17 The on-site assessment schedule for RMNCAH QAIS at provincial hospital Day 1 Content Responsibility 9:00-9:30 Session 1: Meet with the director of the hospital All central team members 9:30-16:00 Session 2: Data collection All central team The central team conducts assessment/data collection at the members provincial hospital in their area of expertise Clinical wards - Direct observation of clinical sessions - Exit interview of patients after their clinical sessions - Chart review - Vignette and debriefing (at least to 2 doctors) Administrative section - Check the availability of medicines and medical equipment - Examine the management of the health system (manuals, policies, standards, personnel, environment) Day 2 Content Responsibility 08: 30-16: 00 Continue session 2 Central team Day 3 Content Responsibility 08: 30-16: 00 Continue session 2 All central members 12: 00-13: 30 Lunch break 13: 30-16: 00 Continue session 2 (if still not done yet) Central member and Session 3: Data analysis and action planning provincial focal point - Analyze data and fill the flipcharts in the service areas - Prioritiz issues and discuss root causes - Develop action plans Day 4 Content Responsibility 08: 30-16: 00 Continue session 3 Central member and provincial focal point in the service areas Day 5 Content Responsibility 08: 30-12:00 Session 4: Result presentation Central member and Present the action plans in each area to: provincial focal point The director of Provincial Health Department in the service areas The director of the provincial hospital Leaders Relevant staff at the provincial hospital Staff in relevant areas 12: 00-12: 30 Closing session Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 108 On-site feedback and technical support During the assessment, especially after the vignette assessment and direct observation of the clinical sessions, the health workers received immediate feedback and had a debriefing session with assessors. The assessors used structured questions (a debriefing tool) to facilitate the health workers’ reflection on their experiences. Based on their reflections and the assessors' observations, the health workers identified their strengths and weaknesses. They discussed together what they could do to overcome their weaknesses. In addition, a mini lecture was held to supplement the health workers’ knowledge. On-site data analysis Immediately after data collection, the assessment team reviewed the collected data and summarized them on flipcharts. The flipcharts consist of tables, bar graphs, and pie charts and allow the data to be visualized through writing the results. In addition, areas that fall under the 5G1S standards are highlighted to facilitate the prioritization. This work was jointly done with the assessment team and the facility team for each service. Action plan development Based on the visualized data, the facility team, with the assessment team’s support, identified areas where their services were good and areas for improvement and compared them with the results of the previous year if available. The assessment team asked questions that encouraged facility staff to think, helped them explore the root causes of the problems, and helped them develop action plans to address those causes. The assessment results and action plans were presented by the facility team at the post-assessment meeting to share and arrange the resources necessary to implement action plans. Sub-national planning workshop After the field activities were completed at the provincial hospital and all district hospitals in the province, the data collected were compiled and displayed on flipcharts as provincial results. Provincial assessors presented the data and their interpretations, along with health outcome and coverage indicators from DHIS2, and Lao Social Indicator Survey II 2017 (LSIS II), to stakeholders such as directors of provincial and district health offices, technical and clinical staff from health offices and hospitals, and central RMNCAH assessors. All participants discussed the problems and what possible solutions to the problems could be at each level, also referring to the action plans developed at the facility level. Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 109 Example of vignette – ANC2 hypertension management during pregnancy Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 110 Example of vignette – ANC2 hypertension management during pregnancy Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 111 Example of vignette – ANC2 hypertension management during pregnancy Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 112 Example of vignette – ANC2 hypertension management during pregnancy Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 113 Example of vignette – ANC2 hypertension management during pregnancy Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 114 Objectives The objective of QPS is: - To strengthen accountability for results and improves efficiency and quality of public expenditure to obtain better outputs and outcomes by employing a performance- based fund transfer directly to the HC level which are proportionate to their QPS scores - To provide flexible resources to spend on small investment and operational expenses for improving PHC service delivery QPS indicators Table list of indicators: ID Indicator 1.1.1 Infrastructure 1.1.1.1 health center has a surrounding wall or fence 1.1.1.2 health center has at least one room each: (a) OPD consultation (b) delivery room (c) ANC check-up 1.1.1.3 Solar light, battery light or generator back-up is available 1.1.1.4 There is a waiting area with seating for patients and patient-parties and drinking water 1.1.1.5 There is at least 1 feedback box to collect comments from patients 1.1.2 Displays for clients 1.1.2.1 A display board at the main entrance is clearly marked with health centre name in Lao 1.1.2.2 Information is posted clearly in Lao showing all “free of charge” health services, including free package of MCH services 1.1.2.3 Weekly staff duty roster is posted identifying names of health workers 1.1.3 Equipment 1.1.3.1 Essential equipment and supplies are available and in working condition to deliver Essential Health Service Package 1.2 Health facility management 1.2.1 Financial management 1.2.1.1. Daily bookkeeping 1. Daily bookkeeping register is available 2. Entries are made by HC within at least 7 days 3. Health center has a safety box and a bank account 1.2.1.2 Validation of continue use of budget 1. There were disbursements from the account in the past 1 month 2. Randomly assess 1 disbursement for accurate and complete supporting documents 1.2.1.3 Quarterly income-expense report 1. HC has quarterly financial income-expense report in the last quarter and submitted to the District Health Office 2. Quarterly income-expense reports are accurate 1.2.2 Human resources 1.2.2.1 Staff Management Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 115 1. HC has job descriptions for all staff which identifies their responsibilities and tasks are assigned based on decree role and function 2. HCs maintain daily staff attendance register 3. HC has at least one clinical health worker (medical assistant, medical doctor, primary health care high level, specialist, family medicine) 4. HC has at least one midwife 5. HC has at least one nurse 6. At least one clinical health worker can speak the prevailing ethnic dialect spoken by the catchment population 7. Health center has at least one patient in 70% of the day is open in previous 3 months 8. Names and contact details of duty staff available for emergencies outside working hours is displayed in front of hC 1.2.3 Individual performance evaluations 1.2.3.1 Results of latest performance evaluations are used to allocate individual performance bonuses 1.2.3.2 Individual performance bonus distributed is up-to 15% of the bonus received 1.2.3.3 Random staff member interviewed knows (a) her bonus received and (b) her/his last individual performance evaluation score and (c) can explain how her individual performance evaluation led to her bonus earning 1.2.4 Medical supply management 1.2.4.1 Medicines and supplies are adequately stocked 1) HC has assigned a staff responsible for pharmacy 2) Print-out of monthly report of medicines and commodities is available 3) HC maintains daily stock of drugs and commodities 4) Medicines and supplies in the Agreed List have stock quantities higher than 30-day stock quantities 1.2.4.2 Medicines are kept according to good storage practices 1) Medicines and supplies are stored in clean cupboard(s) with labelled shelves 2) First Expiry, First Out (FEFO) system is used to manage stock 3) Drugs and commodities are stored according to treatment group (e.g. antibiotic, analgesic, vitamin) and dosage form (e.g. pill, syrup, injections) 4) Expired medicines are not in the cupboard and are removed 1.2.4.3 Immunizations are adequately stored in a cold-chain box 1) HC has a functioning cold-chain box and accurately maintains a record of temperature 2) Log book for each vaccine is maintained (BCG, Tetanus, Penta-3) 2.1.1 Health insurance 2.1.1.1 A list of the people classified as ‘poor’ in health cent er catchment area exists 2.1.1.2 Records of co-payment paid by users is maintained in the contribution Book 2.1.1.3 Poor, pregnant women and children less than 5 years old were not charged for using OPD or IPD health services 2.1.1.4 Number of prescriptions filled matches the number of patients in the Logbook 2.1.1.5 Claims were completed on time, signed and dated as per guideline (15th of following month) 2.1.2 Outreach Services 2.1.2.1 A catchment map is prepared by the health center identifying zones 2 and 3 2.1.2.2 A catchment map is prepared by the health center identifying ethnic populations Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 116 2.1.2.3 Annual micro-plan for outreach activities plan exists, signed and dated by District Health Office 2.1.3 Social Behaviour Change Communication (only in 4 convergence provinces) 1. HC has supply of IEC forms and Job Aide for SBCC 2. Monthly Village Facilitator Reports is compiled by the health center for previous month (previous 2 months) signed and stamp with village chief and village facilitator 3. HC has record of allowances paid to village facilitators for each month 4. Home-visits to monitor and provide counseling to all wasting and stunting children are made by each village facilitator 2.2 Infection control, hygiene and medical waste disposal 2.2.1 Cleanliness of HC premises 1. Premises does not have discarded waste in its premises 2. There is a visible garbage bin nearby patient area for patients 2.2.2 Cleanliness of rooms 1. the floor, ceiling, wall contain no visible leaks, or holes through concrete (OPD) 2. the ward smells of disinfectant (OPD) 3. the ward has at least one general waste garbage bin, which is not full (more can still be added without spilling over). (OPD) 1. the floor, ceiling, wall contain no visible leaks, or holes through concrete (ANC) 2. the ward smells of disinfectant (ANC) 3. the ward has at least one general waste garbage bin, which is not full (more can still be added without spilling over). (ANC) 1. the floor, ceiling, wall contain no visible leaks, or holes through concrete (Delivery) 2. the ward smells of disinfectant (Delivery) 3. the ward has at least one general waste garbage bin, which is not full (more can still be added without spilling over). (Delivery) 2.2.3 Hand washing 1. Running water, storage tank with water or alcohol hand-rub is available in all wards (OPD) 2. Soap is available (no detergent) at every station for washing hands (OPD) 3. Paper napkins or clean cloth is available to dry hands nearby every station for washing hands (OPD) 1. Running water, storage tank with water or alcohol hand-rub is available in all wards (ANC) 2. Soap is available (no detergent) at every station for washing hands (ANC) 3. Paper napkins or clean cloth is available to dry hands nearby every station for washing hands (ANC) 1. Running water, storage tank with water or alcohol hand-rub is available in all wards (Delivery) 2. Soap is available (no detergent) at every station for washing hands (Delivery) 3. Paper napkins or clean cloth is available to dry hands nearby every station for washing hands (Delivery) 2.2.4 Toilet facilities 1. At least one toilet is available for use by patient or patient family 2. Toilet has a door and is lockable from the inside Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 117 3. Toilet has running water or container with water with a ladle for flushing the toilet 4. Toilet has a place to wash hands with running water - or a water container with functioning tap containing water-paper napkins and soap 5. Toilet has a functional light 6. Toilet has no visible waste 7. There are no flies or foul smell 2.2.5 Bathing Facilities 1) At least one bathing facility with running water or water container with water and ladle containing water 2) the room is lockable from the inside, and the lock is functional and the room cannot be locked from the outside 3) bathroom has an exhaust fan or ventilation through tiles 2.2.6 Medical Waste Handling & disposal 1) HC has at least one staff trained in water and sanitation, and waste management 2) Waste is collected separately in colour coded bins for waste disposal (general, infectious). General waste is in black container, infectious waste is in yellow container 3) Sharps and needs are disposed in a safety box (yellow sharps container) 4) Infectious waste and safety box are stored temporarily in a safe, protected storage area in a labelled containers prior to disposal 5) Liquid chemical waste is safely stored in a labelled and sealed container temporarily for disposal 6) There is a pit to buy infectious waste and sharps or send to incinerator 2.4.1 TB Services 1) Presumptive TB cases are accurately recorded, and results noted 2) Positive TB cases are put on treatment 3) Children under 5 years of age living in the same household as TB patients were screened for TB and received IPT if TB was excluded 2.4.2 HIV Services 1) All pregnant women have undergone HIV rapid test (ANC 1st) 2.4.3 Malaria Services 1) One or more malaria tests conducted every month 2) All malaria positive cases are treated with first line treatment Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 118 Selection criteria: based on EHSP 2018 and 2022 • Tracer items (from EHSP 2018 and 2022) ○ Tracer item (for policy and training) Health services Policy/ Guideline Training Equipment Diagnostics Medication and commodities Maternal and child health Reproductive and o Family planning A o Family planning • Uterine sound • Condom adolescent health GLOBAL HANDBOOK comprehensive • Vaginal speculum • Implant FOR PROVIDER 2018 training (e.g. • Examination light • IUD Contraceptive EDITION counseling, IUD, • Minor surgery equipment set • Levonorgestrel methods o National adolescent and Implant • Babcock forceps (progestin-only pill) - Short acting youth friendly service insertion and • Refrigerator • Ethinylestradiol + - Emergency o Job aid of adolescent removal) levonorgestrel Alligator forceps - Long acting youth friendly service o Adolescent youth- (combined pill) - Permanent o IEC materials friendly service Blade holder • Depot Medroxyprogesterone (PH & DHA) - Family planning training acetate (DMPA) (Progestin- Blade leaflet only injectable) Tetanus vaccine - Simulation tool for Cooper surgical scissors straight • Lidocaine 2% Iron and folic acid family planning • Paracetamol Cup guideline • Amoxycillin - Leaflet for pregnant Forceps mosquitos • Tetanus vaccine and sexual • Iron (60mg) folic acid Forceps sponge preventing for youth (400 microg) Instrumental tray Sedative drug (PH & DH) Kelly forceps Ibuprofen Kidney basin Antiseptic solution (Polyvidone Scissors iodine) Tenaculum Ferrous salt Folic acid Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 119 Health services Policy/ Guideline Training Equipment Diagnostics Medication and commodities Cervical cancer o Cervical cancer • Examination table screening and • Examination light Screening management • Vaginal speculum Treatment • Sponge forceps (Cryotherapy) (PH & • Cryosurgery unit DH with trained • Electrosurgical generator doctor) • Wire electrodes Treatment Acetic acid 5% (LEEP) (PH) Coagulating/Ball electrode Cotton ball Suction equipment Prevention of Safe o Prevention of unsafe o Safe abortion and • MVA or EVA • Pregnancy urine • Contraceptives (see family abortion abortion guideline postabortion care • CBC/ hemoglobinometer rapid test planning) o IEC material for safe training • Urine dipstick • Oxytocin Counseling (Equipment for advanced abortion • Methergine complication is equivalent to Medical abortion • Misoprostol surgical service. See surgical management • Mifepristone service section) • Ampicillin Surgical abortion • Gentamicin management (PH, • Ceftriaxone DHA, DHB with • Metronidazole trained doctor) Normal saline Complication management Ringer lactate Advanced (Medications for advanced complication complication is equivalent to management surgical service. See surgical (PH, DHA) service section) Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 120 Health services Policy/ Guideline Training Equipment Diagnostics Medication and commodities Antenatal care o National guideline of o General antenatal • Adult sphygmomanometer • CBC/ • Iron (6omg) folic acid Antenatal care and care training • Adult stethoscope Hemoglobin (400microg) Routine antenatal Postnatal care • Fetus stethoscope/ testing • Calcium supplement care Traube/ doppler • Rapid diagnostic • Tetanus vaccine Gestational age • Weighing scale for adult test for HIV • Mebendazole or Albendazole specific service • Mother and Child Handbook • Rapid diagnostic • Antihypertension drugs • Refrigerator test for Syphilis ▪ Hydralazine, Anemia • Thermometer • RPR (Rapid ▪ Nifedipine, management Plasma ▪ Methyldopa Measurement tape for uterine Hypertension Reagin)/VDRL • Low dose aspirin (81mg) fundal height management (Venereal • Antibiotics Pregnancy due date disease research ▪ Aqueous benzylpenicillin Low dose aspirin calculator wheel laboratory) test ▪ Procaine benzylpenicillin prophylaxis kit (PH) Benzathine PMTCT for Syphilis • TPPT benzylpenicillin (Treponema ▪ Ceftriaxone PMTCT for HIV (only pallidum, ▪ Azithromycin ART site, PH) particle ▪ Erythromycin Gestational agglutination • Antiretroviral drugs diabetes assay/ TPHA o Zidovudine (AZT) management (PH) (Treponema, o Nevirapine (NVP) Pallidium (See communicable disease Hemagglutinatio section) n assay test) kit (PH) • Metoformin (PH) • Ultrasound • Humulin R (PH) • Rapid Glucose • Intermediate acting insulin test kit (PH) (PH) • Urine dipstick • 75gOGTT (PH) Pre-labour and o Pocketbook on o EmOC/CARE • Full delivery kit • Oxytocin Intrapartum care Essential Care for package • Delivery bed • Misoprostol Childbirth and • Delivery table or trolley • Methergine Routine Maternal Complication • Adult sphygmomanometer • Dexamethasone intrapartum care • Adult stethoscope • Magnesium sulfate Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 121 Health services Policy/ Guideline Training Equipment Diagnostics Medication and commodities Assisted vaginal o Intrapartum care • Thermometer • Antibiotics delivery /EmOC Algorithm • Vacuum extractor (Kiwi o Ampicillin ventose) o Gentamicin Preterm labor • MVA or EVA • Antihypertension drugs management • Urine catheter/urine bag o Hydralazine (injection, Induction of labor • IV cannulas (16/18G) oral) o Nifedipine Augmentation for Partograph • Tranexamic acid prolonged labor Scissors for episiotomy • Calcium gluconate Manual removal of • Metronidazole (Equipment for management of placenta maternal complication is (Medications for management Basic emergency equivalent to surgical service. of maternal complication are obstetric care See surgical service section) equivalent to surgical service. See surgical service section) Management of maternal complications (Comprehensive Emergency obstetric care) Newborn care o Early essential o Early essential • Refrigerator/Vaccine carrier • CBC/ • Tetracycline eye ointment newborn care newborn care (cold box) Hemoglobinome • Hepatitis B vaccine Routine newborn pocketbook training ter • BCG vaccine care (EENC and Resuscitation area o Kangaroo Mother care o Kangaroo Mother • Vitamin K1 immunization) pocketbook care training Trolley for resuscitation area • Antibiotics Neonatal o National o Breastfeeding o Ampicillin • Newborn bag and mask resuscitation Breastfeeding training o Cloxacillin reference Newborn stethoscope o Gentamicin Kangaroo Mother • Midazolam (PH, DHA) Care for preterm Suction bulb • Aminophylline and low-birth Thermometer • Glucose solution weight infants (PH, DHA) • Oxygen Phenobarbital • Nasogastric tube • Incubator/ radiant warmer Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 122 Health services Policy/ Guideline Training Equipment Diagnostics Medication and commodities Management of • Light therapy lamp (PH) (Medications for delivery are newborn with • Binder for KMC (PH, DHA) listed to Intrapartum care complication • CPAP (PH) section) (PH and DH with • Weighing scale for newborn trained doctor) Monitor Neonatal Clean cup for cup feeding respiratory distress syndrome (Delivery equipment is listed to management (PH) Intrapartum care section) Postpartum and o National guideline of o Postnatal care • Adult stethoscope • Iron (60mg) folic acid (400 early postnatal care Antenatal care and training • Adult sphygmomanometer microg) for mother and Postnatal care • Weighing scale for newborn Vitamin B1 newborn • Height scale for newborn • MCH handbook Routine PNC for mother and baby Newborn stethoscope Thermometer Well child care o Integrated well-child o Nutrition • Refrigerator/ Vaccine carrier • BCG vaccine service SOP o Immunization (cold box) • DPT-HepB-Hib vaccine Routine o Infant and Young Child o Infant and Young • Weighing scale (standing, non- • Polio (IPV) immunization Feeding guideline Child Feeding standing) • Polio (OPV) Vitamin A and o National guideline for o Early childhood • Height scale (standing, non- • Measles-Rubella deworming breastfeeding development standing) • PCV o National guideline for o Injury prevention • Child stethoscope • Japanese encephalitis Screening and complementary • MCH handbook • Vitamin A counseling on feeding • MUAC tape • Mebendazole/ Albendazole feeding o National micronutrient Screening and guideline counseling on early o Medical officer childhood handbook on development immunization Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 123 Health services Policy/ Guideline Training Equipment Diagnostics Medication and commodities Growth monitoring o Early childhood and counseling development guideline o IEC materials for growth monitoring Sick child care o IMNCI Chart book o IMAM • Oxygen • CBC/ • Ampicillin o IMNCI Supervision o IMNCI • Oxygen mask or nasal cannula Hemoglobin • Amoxicillin Primary care for guideline o Pocket book for (newborn and child) testing • Gentamicin sick child o Pocket book of child illness • Weighing scale (standing, non- • Rapid blood • Cloxacillin - Growth hospital care for standing) glucose test kit • Ciprofloxacin assessment/ children • Height scale (standing, non- • Rapid diagnostic • Albendazole nutrition status standing) test for Dengue • Mebendazole assessment • MUAC tape • Rapid diagnostic • Aminophylline - Basic • Adult and child stethoscope test for HIV • Azithromycin complication • Aural speculum • Rapid diagnostic • Erythromycin management • Thermometer test for malaria • Tetanus vaccine - Health education • CPAP • Urine dipstick • Tetracycline eye ointment on danger signs, • RUTF 1% Bilirubin checker/ nutrition, • Newborn bag valve mask test kit Vitamin B1 immunization, • Child and adult bag valve mask child • Inhaler/ Nebulizer Blood culture Benzathine benzylpenicillin development • Lumbar puncture needle equipment (PH) Cefalexin • F75/F100 Advanced sick Urine culture • ReSoMaL Ceftriaxone child care equipment (PH) • Microscope Chloramphenicol - Advanced • Nasogastric tube emergency care Chlorpromazine Intra-osseous needle - Severe Mefloquine respiratory Intubation tube diseases Primaquine Laryngoscope - Severe Quinine dehydration Oximeters and probes - Severe fever and Sulfamethoxazole + Suction equipment infection Trimethoprim (Cotrimoxazole) Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 124 Health services Policy/ Guideline Training Equipment Diagnostics Medication and commodities - Severe acute Morphine (PH, DHA) malnutrition with Naloxone (PH, DHA) complication - Injury • Metronidazole • Gentian violet • Magnesium sulfate • Glucose solution Normal saline Ringer lactate Ofloxacin 2% eye drop • Paracetamol • Prednisolone • ORS • Zinc • Vitamin A • Salbutamol for nebulizer • Salbutamol sulfate • Diazepam (PH, DHA) Digoxin Epinephrine Ferrous salt Furosemide (Medications for child’s TB cases is listed in TB section) Non-communicable diseases Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 125 Health services Policy/ Guideline Training Equipment Diagnostics Medication and commodities General • Adult sphygmomanometer • Adult stethoscope Health promotion • Weighting scale for adult and education, including tobacco Measuring tape for abdominal cessation, exercise, circumference salt intake, nutrition Risk factor screening Counseling on lifestyle Basic rehabilitation Cardio vascular • Adult sphygmomanometer • Cholesterol test • ACE inhibitor diseases • Adult stethoscope kit o Enalapril • Oxygen • Electrocardiogra • Beta blocker Hypertension • Ultrasound phy (EKG) (PH) o Atenolol Acute myocardial • Ca blocker infarction o Nifedipine o Amlodipine Cardiac failure • Aspirin 81 mg Stroke • Furosemide • Bestatin (PH, DHA) Hypercholesteremia • Atrovastatin (PH, DHA) (PH, DHA) Diabetes mellitus • Weighing scale for adult • Rapid blood • Metformin • Height measure for adult glucose test • Glibenclamide (Sulfonylurea) Screening • Slit microscope (PH) • Urine dipstick • Humulin R Diagnosis • Ophthalmoscope (PH) • Intermediate-acting insulin • Hammer patella (PH) (PH, DH with trained staff) Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 126 Health services Policy/ Guideline Training Equipment Diagnostics Medication and commodities Counseling • Tuning fork (PH) • Mydriatic eye drop • Atropine eye drop 0.5-1% Oral treatment • Homatropine eye drop Insulin injection 1%/2% (PH) (PH, DH with trained staff} Complication management (PH) Chronic respiratory • Inhaler/ Nebulizer • Salbutamol for nebulizer diseases • Oxygen • Salbutamol sulfate • Adult oxygen mask or nasal • Budesonide Bronchial Asthma cannula • Long-acting bronchodilators Chronic obstructive pulmonary disease Cancer • Opioid  Fentanyl (PH, DHA) Health education  Morphine (PH, DHA) and promotion of  Pethidine (PH, DHA) cancer screening  Tramadol Pain control and palliative care Mental Health • Antidepressants • Antipsychotic Treatment for depression, psychoses Basic emergency • Oxygen • Cloxacillin care • Oxygen mask or nasal cannula • Salbutamol for nebulizer for adult • Normal saline Basic life support • Bag valve mask for newborn, resuscitation Ringer lactate child, and adult • Oropharyngeal airway Polyvidone iodine Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 127 Health services Policy/ Guideline Training Equipment Diagnostics Medication and commodities Intoxication/ • Surgical suture poisoning • IV catheter • Nasogastric tube Injury and fracture • Inhaler/Nebulizer Acute respiratory Bandage failure Sling Shock Splint Basic surgical • Anesthesia equipment • Pre-operation • General anesthesia operation o Anesthesia machine routine medicines o Suction machine and tube examination o Ringer lactate Appendectomy o Spinal needle equipment o Normal saline Hernia repair o Bag valve mask for child o CBC/ o Ketamine/ Propofol/ and adult Hemoglobino Thiopental Repair for o Oxygen meter o Isoflurane/ Sevoflurane perforation o Intubation tube o ABC blood o Suxamethonium/ Peritonitis o Laryngoscope type test kit Pancratium/ Vecuronium o Airway o Bleeding test o Morphine/ Fentanyl Abdominal o IV catheter kit • Operation medicines hemorrhage o Urine catheter and bag o Blood clot o Polyvidone iodine Urinary obstruction • Minor surgery equipment set test kit o Ceftriaxone or stone • Basic surgical equipment o Metronidazole • Surgical equipment o Gentamicin Colostomy • Orthopedic surgery equipment • Blood transfusion Tracheostomy Internal fixation for bone fracture Basic dental care • Paracetamol • Amoxycillin Pain and infection • Augmentin (PH, DHA) control • Azithromycin Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 128 Health services Policy/ Guideline Training Equipment Diagnostics Medication and commodities Basic eye care • Antibiotics eye drop  Chloramphenicol 0.5% Red eyes eye drop (conjunctivitis,  Tetracycline eye injury and referral) ointment 1% Communicable diseases General • Thermometer Rick communication and health education/ promotion on communicable diseases Detection, investigation, and reporting of clusters of acute illness Screening for fever and respiratory symptoms HIV/STI • Reagent (KOH 10%) • Rapid diagnostic • Condom • Sputum cup test for Syphilis • Doxycycline Peer education • Ziehl-Neelsen stain • RPR/VDRL test • Ceftriaxone service to improve • Microscope kit (PH) • Azithromycin access to HIV • TPPH/TPHA test • Erythromycin service Microscope slide kit (PH) Benzathine benzylpenicillin HIV transmission Bunsen burner • Rapid diagnostic prevention test for HIV Procaine benzylpenicillin Vortex mixer • SD Bioline for Cefixime • Staining kit HIV (test 2) Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 129 Health services Policy/ Guideline Training Equipment Diagnostics Medication and commodities STI management • DOTs • HIV 1/2 Stat-Pak Ofloxacin (Syphilis, (test 3) (PH) • Antiretroviral drugs (only Gonorrhea, • FACSCount CD4 ART site) Chlamydia) (PH, analyzer  Zidovudine (AZT) DHA) • GeneXpert  Nevirapine HIV counseling and  Abacavir (ABC) testing  ABC/Lamivudine (3TC)  Atazanavir/Ritonavir (r) Antiretroviral  Efavirenz (EFV) therapy (Only  3TC/AZT ART site)  Lopinavir/r CD4 cell count (PH  Nevirapine ART site)  Tenofovir disoproxil fumarate (TDF) TB testing for  TDF/3TC People living  TDF/3TC/EFV with HIV  TDF/3TC/Dolutegravir Malaria • Microscope • Rapid diagnostic • Antimalaria drugs test for Malaria  Artemether + Microscope slide • Staining kit for Lumefantrine (Coaterm) malaria  Primaquine • Rapid diagnostic  Artesunate test G6PD/G6PD Quinine (Sick child) quantitative test Mefloquine (Sick child) Tuberculosis • Sputum cup GeneXpert • Tb drugs • Ziehl-Neelsen stain  Ethambutol (E) Identification of • Rapid diagnostic • DOTs kit  E/ Isoniazid (INH) presumptive TB test for HIV • Oxygen  Isoniazid • SD Bioline for Investigation with  Pyrazinamide (Z) Microscope slide HIV (test 2) bacteriological  Rifampicin (R) • HIV 1/2 Stat-Pak examination Vortex mixer  R/INH (test 3) (PH) Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 130 Health services Policy/ Guideline Training Equipment Diagnostics Medication and commodities Free HIV testing Monitor  R/INH/Z  R/INH/Z/E Standardized short- course TB treatment TB prophylaxis for children TB complication (PH) Other • Oxygen • Rapid diagnostic • Praziquantel communicable • Oxygen mask or nasal cannula test for dengue • Mebendazole diseases for adult • CBC/ • Paracetamol • Throat swab Hemoglobinome • Oseltamivir Parasitic disease • Inhaler/ Nebulizer ter • Ceftriaxone Dengue fever • Salbutamol for nebulizer Bunsen burner • Oral rehydration salt (ORS) Acute respiratory • Azithromycin infection • Dexamethasone Diarrhea • Fluoroquinolone Unknown fever Flu-like illness COVID-19 Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 131 List of equipment 1 Capital Equipment 1 1.1 Delivery bed 2 1.2 Refrigerator 3 1.3 Vaccine carriers/ cold box 4 1.4 Autoclave 5 1.5 Sharps box / safety box 6 1.6 Oxygen (cylinder) 2 Consumables 7 2.1 IV catheter 8 2.3 Child and Adult oxygen mask or nasal cannula 9 2.4 Surgical suture 3 Examination equipment 10 3.1 Weighing scale for adult 11 3.2 Weight scale for newborn 12 3.3 Height measure -standing 13 3.4 Height measuring tape - lying down 14 3.5 Measurement tape for uterine fundal height 16 3.6 MUAC measure tape 17 3.7 stethoscope 18 3.8 Newborn stethoscope 19 3.9 Fetus stethoscope / traube / Soniquete 20 3.1 sphygmomanometer 21 3.11 Thermometer 22 3.12 Aural speculum / Auriscope 23 3.13 Light for procedure 24 3.14 Pregnancy due date calculator wheel 25 3.15 Speculum 26 3.16 Tenaculum 27 3.17 Uterine sound 28 3.18 Urine test (dipstick) 29 3.19 Rapid blood glucose test kit and equipment 4 Treatment equipment 30 4.1 Self-inflating bag and mask (size 0 and 1) 31 4.2 Self-inflating bag and mask (child / adult) 32 4.3 Suction bulb 33 4.4 Inhaler / nebulizer 34 4.5 Full delivery set (sponge forceps, scissors, needle holder, vaginal speculum, artery forceps and clamp, clean sheet, dissecting forceps, sanitary pads, cord clamp, iodin cup and kidney tray) 35 4.6 Delivery table or trolley for setting up delivery sets & resuscitation areas 36 4.7 Table or trolley for newborn resuscitation 37 4.8 Single-use towels 38 4.9 Vacuum extractor 5 Surgical instruments and Equipment 39 5.1 Clamp cord, umbilical clamps 40 5.2 Kidney bowl / basin 41 5.3 Cup 42 5.4 Lancet / Scalpel / blade 43 5.5 Scalpel / blade holder Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 132 44 5.6 Cooper surgical scissors, straight 45 5.7 Needle holder straight 46 5.8 Forceps, sponge straight 47 5.9 Alligator forceps 48 5.1 Forceps, artery, mosquito curved 49 5.11 Instrument tray List of drugs 1. Painkillers, antipyretics, and non-steroidal anti-inflammatory drugs 1 Diclofenac sodium tablet 50mg 2 Paracetamol tablet 500mg 3 Paracetamol injection 300mg / 2ml 4 Paracetamol syrup 120mg / 5ml 2. Antidepressants and allergens 5 Chlorpheniramine tablet 4mg 6 Chlorpheniramine syrup 2mg / 5ml 3. Deworming 7 Mebendazole tablet 500mg 4. Antibiotics 4.1 Beta Lactam medicines 8 Amoxicillin capsule 250mg, 500mg (Anhydrous) 9 Amoxicillin Syrup 125mg / 5ml, 250mg / ml 10 Ampicillin capsule 250mg, 500mg 11 Ampicillin Syrup 125mg / 5ml, 250mg / ml 12 Phenoxymethylpenicillin (Penicillin V) tablet 400,000 IU 4.2 Sulfonamides 13 Co-Trimoxazole (Sulfamethoxazole + Trimethoprim) tablet 400mg + 80mg, 14 Co-Trimoxazole (Sulfamethoxazole + Trimethoprim) suspension 200mg + 40mg / 5 ml 4.3 Malaria medicine 15 Artemether + Lumefantrine tablet 20mg + 120mg 16 Primaquine 7.5mg / 15mg 4.4 Malaria test kits 17 Malaria Rapid Diagnostic Test 5. Medications for anemia 18 Ferrous sulfate + folic acid tablet 200mg + 0.4mg, 6. Anticoagulant 19 Phytomenadione (Vitamin K1) injection 1mg / ml 7. Antihypertensive drugs 20 Enalapril tablet 5mg, 20mg 8. Antacids and stomach ulcers 21 Aluminum hydroxide tablet 500mg 22 Cimetidine tablet 200mg, 400mg 23 Omeprazole tablet 10mg, 20mg 9. Anticonvulsants 24 Hyoscine (Scopolamine) tablet 10mg 10. Diarrhea medicine 25 Zinc sulfate tablet 20mg 11. Contraceptive products 11.1 Birth control pills Combination pills (Ethinylestradiol + levonorgestrel 30mg / 150mcg (Combined Pills, BL / 26 28 tablet)) 27 tablet 30mcg (Mini pills, BL / 35tablet) Contraceptive injection (Medroxy progesterone acetate injection 150mg / ml (Depo- 28 Provera)) Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 133 11.2 Contraceptive devices 29 Condoms Vaccination (for small schools with vaccine storage cabinets) Penta (DPT-Hep B-Hib vaccine (Diphtheria, Tetanus, whole-cell Pertussis (DTP), Hepatitis 30 B and Haemophiles influenza type B)) 31 BCG vaccine 13. Ointments and stimulants for uterine contractions 32 Chloramphenicol Eye drops 0.5% 33 Tetracycline Eye ointment 1% 34 Oxytocin Injection 10 IU in 1ml 14. Medications used in the respiratory tract 35 Salbutamol tablet 2mg 15. Substitute water, minerals, and balance 15.1. Oral medicine 36 Oral rehydration salt Powder for dilution 15.2. Injections 37 Glucose Injectable solution 5% in 500-1000ml 16. Medicines for vitamins and minerals 40 Ascorbic acid (Vitamin C) tablet 50mg, 100mg 41 Retinol (Vitamin A) Soft capsule 100,000 IU 42 Retinol (Vitamin A) Soft capsule 200,000 IU 43 Thiamine (Vitamin B1) tablet 50 mg, 100mg, 250mg 17. Antiseptics 44 Alcohol 70%, 90% 45 Polyvidone iodine Solution 10% 18. Other equipment 46 Syringe 1.0 ml 47 MCH handbook 48 Sputum cups Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 134 FAMILY PLANNING AND YOUTH FRIENDLY SERVICE Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 135 Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 136 CERVICAL CANCER SERVICE Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 137 SAFE ABORTION SERVICE Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 138 ANTENATAL CARE Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 139 Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 140 INTRAPARTUM CARE Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 141 NEWBORN CARE Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 142 Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 143 POSTNATAL CARE Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 144 WELL CHILD CARE Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 145 Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 146 SICK CHILD CARE Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 147 Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 148 NON-COMMUNICABLE DISEASES Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 149 BASIC EMERGENCY CARE OTHER SERVICE Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 150 BASIC SURGICAL SERVICE Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 151 COMMUNICABLE DISEASES Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 152 Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 153 ESSENTIAL EQUIPMENT AT HEALTH CENTER LEVEL Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 154 ESSENTIAL MEDICATION AT HEALTH CENTER LEVEL Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 155 Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 156 Number of health High Low/ High-level Technical Midlevel Low-level General worker at Health diploma Midlevel nurse nurse Midwife nurse/ Doctor Center level PHC PHC midwife Phongsaly 34 4 11 28 38 12 37 0201 Phongsaly 4 1 2 5 6 4 4 0202 Mai 3 2 2 5 9 0 3 0203 Khoua 5 0 1 2 5 3 5 0204 Samphan 7 0 4 3 6 1 8 0205 Bounnua 3 0 0 1 1 0 3 0206 Nyot Ou 5 1 0 7 3 3 6 0207 Bountai 7 0 2 5 8 1 8 Oudomxay 31 23 12 59 60 17 35 0401 Xai 4 7 3 10 8 2 4 0402 La 3 2 2 6 6 3 3 0403 Namoh 3 4 5 7 9 5 4 0404 Nga 9 0 1 5 10 3 10 0405 Beng 0 2 0 11 8 2 0 0406 Houn 9 4 1 13 15 2 10 0407 Pakbeng 3 4 0 7 4 0 4 Huaphan 51 11 15 36 57 12 52 0701 Xam Neua 5 1 3 4 6 5 6 0702 Xiangkhoh 5 2 2 2 5 3 5 0703 Hiam 3 0 1 0 3 0 3 0704 Viangxai 8 1 1 7 8 1 8 0705 Houamuang 4 2 3 10 5 0 4 0706 Xam Tay 5 4 2 0 6 1 5 0707 Sopbao 2 1 0 4 5 2 2 0708 Et 7 0 2 2 7 0 7 0709 Kouan 6 0 0 5 6 0 6 0710 Xon 6 0 1 2 6 0 6 Xieng Khuang 23 21 16 46 71 11 32 0901 Pek 0 3 1 5 7 2 1 0902 Kham 6 5 1 2 8 4 9 0903 Nonghet 10 4 6 8 19 1 12 0904 Khoun 5 2 1 10 13 2 5 0905 Mok 1 3 0 4 4 0 3 0906 Phoukout 1 3 6 13 14 2 2 0907 Phaxay 0 1 1 4 6 0 0 Grand Total 139 59 54 169 226 52 156 Facility based Service Readiness Assessment In four northern provinces in Lao PDR | 157 1 United Nations, Department of Economic and Social Affairs, Population Division (2022). 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