Approved PCR G0172 G0173 30 June 2016 · PDF fileAOP – annual operational plan BemONC...

Completion Report

Project Number: 41376-022 Grant Numbers: 0172 and 0173 June 2016

Lao People’s Democratic Republic: Health Sector

Development Program This document is being disclosed to the public in accordance with ADB’s Public Communications Policy 2011.

CURRENCY EQUIVALENTS

Currency Unit – kip (KN)

At Appraisal At Program Completion 5 October 2009 30 June 2012

KN1.00 = $0,0001174743 $0.0001249668 $1.00 = KN8,512.5 KN8,002

ABBREVIATIONS

ADB – Asian Development Bank AOP – annual operational plan BemONC – basic emergency obstetric and newborn care CDTA DMF

– –

capacity development technical assistance design and monitoring framework

DHO DOF

– –

District Health Office Department of Finance

DOP – Department of Health Personnel DPF – Department of Planning and Finance DPIC – Department of Planning and International

Cooperation DTR – Department of Training and Research EPI – expanded programme on immunization GAP – gender action plan GEN – gender equity as a theme HEF – health equity fund HMIS – health management information system HRH – human resources for health IMR – infant mortality rate INGO IPD JFPR Lao PDR

– – – –

international nongovernment organization in-patient department Japan Fund for Poverty Reduction Lao People’s Democratic Republic

LSIS LWU MCH MDG

– – – –

Lao social indicator survey Lao Women’s Union maternal and child health Millennium Development Goals

MHV – model healthy village MMR – maternal mortality ratio MNCH – maternal, newborn, and child health care MOF – Ministry of Finance MOH MOU

– –

Ministry of Health memorandum of understanding

MPI MTR

– –

Ministry of Planning and Investment midterm review

O&M OPD

– –

operations and maintenance out-patient department

PCU – project coordination unit

NOTES

(i) The fiscal year (FY) of the Government of the Lao People’s Democratic Republic ends on 30 September.

(ii) In this report, "$" refers to US dollars.

Vice-President S. Groff, Operation 2 Director General J. Nugent, Southeast Asia Department (SERD) Director S. Nicoll, Lao People’s Democratic Republic Resident Mission, SERD Team leader P. Xayyavong, Project Officer, SERD Team member C. Bounnad, Associate Project Analyst, SERD

T. Saphakdy, Social and Development Officer (Gender), SERD S. Schipani, Senior Portfolio Management Specialist, SERD K. Thammalangsy, Project Analyst, SERD

In preparing any country program or strategy, financing any project, or by making any designation of or reference to a particular territory or geographic area in this document, the Asian Development Bank does not intend to make any judgments as to the legal or other status of any territory or area.

PHC – primary health care PHCCU – primary health care coordination unit PHO – Provincial Health Office SBA TA TOR UHS VHV VHW

– – – – – –

skilled birth attendant technical assistance terms of reference University of Health Sciences village health volunteer village health worker

CONTENTS

Page

BASIC DATA i

I. PROGRAM DESCRIPTION 1

II. EVALUATION OF DESIGN AND IMPLEMENTATION 1

A. Relevance of Design and Formulation 1 B. Program Outputs 2 C. Program Costs 4 D. Disbursements 4 E. Implementation Schedule 5 F. Implementation Arrangements 5 G. Conditions and Covenants 6 H. Related Technical Assistance 6 I. Consultant Recruitment and Procurement 6 J. Performance of Consultants, Contractors, and Suppliers 7 K. Performance of the Borrower and the Executing Agency 7 L. Performance of the Asian Development Bank 7

III. EVALUATION OF PERFORMANCE 8

A. Relevance 8 B. Effectiveness in Achieving Outcome 8 C. Efficiency in Achieving Outcome and Outputs 9 D. Preliminary Assessment of Sustainability 9 E. Impact 9

IV. OVERALL ASSESSMENT AND RECOMMENDATIONS 11

A. Overall Assessment 11 B. Lessons 11 C. Recommendations 12

APPENDIXES

1. Compliance with Policy Actions 14 2. Design and Monitoring Framework Targets and Achievements 18 3. Training Programs Provided 21 4. Implementation Schedule 23 5. Compliance with Grant Covenants 26 6. Summary of Gender Equality Results and Achievements 32 7. Annual Allocation of Program Funds by Province from 2010 to 2015 48 8. Calculation of Overall Program Rating 49 9. Contribution to the ADB Results Framework 50

BASIC DATA A. Grant Identification 1. Country 2. Grant Numbers 3. Project Title 4. Recipient

5. Executing Agency 6. Amount of Grant 7. Project Completion Report Number

Lao People’s Democratic Republic 0172 and 0173 Health Sector Development Program Government of the Lao People's Democratic Republic Ministry of Health $20,000,000 (Asian Development Fund) PCR:LAO 1568

B. Grant Data 1. Appraisal – Date Started – Date Completed 2. Grant Negotiations – Date Started – Date Completed 3. Date of Board Approval 4. Date of Grant Agreement 5. Date of Grant Effectiveness – In Grant Agreement – Actual – Number of Extensions

6. Closing Date of Program Grant (G0172) – In Grant Agreement – Actual – Number of Extensions 7. Closing Date of Project Grant (G0173) – In Grant Agreement – Actual – Number of Extensions

3 August 2009 11 August 2009

1 October 2009 2 October 2009 10 November 2009

23 November 2009

17 December 2009 17 December 2009 0

30 June 2012 31 August 2012 0

30 June 2014 30 June 2015 1

8. Disbursements

a. Dates:

1. Program Grant (G0172)

Initial Disbursement

14 January 2009

Final Disbursement

6 March 2012

Time Interval

38 months

Effective Date

17 December 2009

Original Closing Date

30 June 2012

Time Interval

30 months

ii

2. Project Grant (G0173)

Initial Disbursement

10 February 2010

Final Disbursement

30 October 2015

Time Interval

69 months

Effective Date

17 December 2009

Original Closing Date

30 June 2014

Time Interval

54 months

b. Amount ($):

1. Program Grant (G0172)

Tranche No. Date Disbursed Amount Tranche 1 14 January 2010 5,000,000 Tranche 2 6 March 2012 5,000,000 Total 10,000,000

2. Project Grant (G0173)

Category No.

Category Names Original Allocation

Last Revised Allocation

Amount Disbursed

Undisbursed Balance

a

3101 Consulting Services

1,240,000 1,718,910

1,712,867

6,043

3201 Civil Works

2,347,200 1,863,597 1,863,571

26

3501 Staff Development

1,875,000

1,714,537 1,686,558

27,979

3601 Equipment and Vehicles

548,000

2,684,370 2,716,119

(31,749)

3801 Workshops, Studies, System Development

977,000

259,370 252,739

6,631

3901 Project Management

982,800

1,053,000 1,051,588

1,412

3902 Operation and Maintenance

1,350,000

681,797 713,424

(31,627)

4901 Unallocated

680,000 24,419

-

24,419

Total (US$) 10,000,000 10,000,000 9,996,866 3,134

( ) = negative. a

cancelled on 30 October 2015.

C. Program Data

1. Financing Plan ($ million)

Cost Appraisal Estimate Actual Implementation Costs Recipient-Financed 0.80 1.57

a

ADB- Program Grant (ADF) 10.00 10.00 ADB- Project Grant (ADF) 10.00 9.99 Total 20.80 21.57 ADB = Asian Development Bank, ADF = Asian Development Fund. a

Government contributions are $1,574,240 ($1,219,167 million for taxes and duties and $355,037 contribution for construction of Bounnuea hospital in Phongsaly province: land leveling, access road, water supply and electricity connection).

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2. Cost Breakdown by Project Components ($ million) Component Appraisal

Estimates Actual

Component 1: Strengthen Planning and Financing 3.40 3.67

Sub-component 1: Enhanced Planning and Financing Capacity 2.60 1.19 Sub-component 2: Efficient Program Administration and Coordination 0.80 2.48

Component 2: Increase Access to Maternal, Newborn, and Child Health Care 4.10 4.53

Sub-component 1: Upgrades Hospitals and Health Centers 3.40 3.44

Sub-component 2: Expanded Model Healthy Villages 0.70 1.09 Component 3: Improve Quality of Human Resources for Health 2.50 1.79

Sub-component 1: Training to Decrease Maternal Mortality 1.20 1.21

Sub-component 2: Improving Quality of Pre-service Training and Education Institutions 1.30 0.58

Total 10.00 9.99

3. Project Schedule

Items

Appraisal Estimate

Actual

Component 1: Strengthened Planning and Financing

1.1 Enhanced Planning and Financing Capacity Strengthen planning division of MOH January 2010 January 2010 Create internal financial control unit April 2010 April 2010 Train provinces on program approach April 2010 October 2010 Train districts on program approach October 2010 October 2010 HEF provincial capacity building April 2010 April 2011 Consulting Services January 2010 January 2010 1.2 Efficient Program Administration and Coordination

Program coordination and monitoring January 2010 January 2010 Component 2: Increased Access to MNCH care

2.1 Upgraded Hospitals and Health Centers National strategy for MNCH December 2009 December 2009 Guidelines for PH and DH October 2010 October 2010 District roll out of mother and child MNCH package October 2010 October 2010 Improve district hospitals October 2010 July 2011 Improve health centers October 2010 April 2011 Assess equipment needs January 2010 January 2010 Replace MNCH equipment October 2010 October 2011 Ambulances for district hospitals January 2010 July 2011 Motorcycles for health centers January 2010 April 2011

2.2 Expanded Model Healthy Villages Guidelines and strategic plan December 2009 December 2009 Provincial and district capacity building January 2010 January 2010 Village capacity building and monitoring October 2011 October 2010

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Component 3: Improved Quality of Human Resources for Health

2.1 Trained Skilled Birth Attendants Upgrade staff to SBA April 2010 October 2010 Upgrade PHC workers to mid-level April 2010 October 2011 Train high level PHC doctors April 2010 October 2011

2.2 Improved Quality of Pre-service Education Institutional development plans April 2010 July 2010 Upgrade faculty April 2010 January 2011 Consulting services October 2010 January 2011 Teaching and curriculum improvement July 2011 October 2010 HRMIS update October 2010 October 2010 DOP capacity building January 2010 January 2010

DH = district hospital, DOP = Department of Organization and Personnel, HC = health center, HEF = health equity fund, HRH = human resources for health, HRMIS = human resource management information system, MNCH = maternal, newborn, and child health, MOH = Ministry of Health, PH = provincial hospital, PHC = primary health care, SBA = skilled birth attendant.

4. Project Performance Report Ratings

Implementation Period

Ratingsa

Development Objectives

Implementation Progress

From January 2010 to December 2010 Satisfactory Satisfactory From January 2011 to May 2011 Satisfactory Satisfactory From June 2011 to December 2011 On track On track From January 2012 to December 2012 On track On track From January 2013 to December 2013 On track On track From January 2014 to December 2014 On track On track From January 2015 to June 2015 On track On track a New project performance rating system was applied beginning June 2011.

D. Data on Asian Development Bank Missions

Name of Mission Date No. of

Persons No. of

Person-Days Specialization of Members

a

1. Fact Finding Mission 1 June 2009 2 12 a, c 2. Appraisal Mission 3 August 2009 4 36 a, f, c, h 3. Grant Negotiation Mission 1 October 2009 3 6 a, c, e 4. Inception Mission 1 February 2010 5 20 a, b, c, e, f 5. Review Mission 1 23 March 2011 4 36 a, b, d, e 6. Review Mission 2 17 September 2012 4 20 a, c, e, f 7. Midterm Review Mission 18 May 2012 5 30 a, c, d, e, j 8. Review Mission 3 25 March 2013 3 15 c, e, i 9. Review Mission 4 7 October 2013 3 18 c, d, e 10. Review Mission 5 23 March 2014 3 18 d, e, i 11. Review Mission 6 1 December 2014 3 15 d, i, e 12. Project Completion Review 4 December 2015 3 21 d, e, i a a = lead health specialist, b = senior health specialist, c = social sector specialist, d = project officer, e = project

analyst, f = project analyst, g = portfolio management specialist, h = counsel, i = social and development officer (Gender), j = principal country economist. Note: Grant administration was delegated to the Lao PDR Resident Mission in April 2013.

I. PROGRAM DESCRIPTION

1. The Asian Development Bank (ADB) approved the Health Sector Development Program on 10 November 2009. It was financed with a $10 million program grant and $10 million project grant, which became effective on 17 December 2009. The program grant (G0172) supported policy reforms to improve the quality of health services, while counterpart funds were earmarked to support an increase in non-wage recurrent budget. The project grant (G0173) supported capacity building for implementation of reforms and selective investments to improve access to health services. 1 The program grant was completed as scheduled on 31 August 2012. The completion date of the project grant was extended once from 30 June 2014 to 30 June 2015. 2. The program impact was to reduce maternal and child mortality and malnutrition by 2015. The expected outcome was improved use of health services, in particular for the poor, women and ethnic groups; and a contribution to achieving the Millennium Development Goals (MDGs) on maternal and child health and malnutrition. The program outputs were (i) strengthened planning and financing; (ii) increased access to maternal, newborn, and child health care (MNCH); and (iii) improved quality of human resources for health.

II. EVALUATION OF DESIGN AND IMPLEMENTATION

A. Relevance of Design and Formulation

3. The program design was highly relevant and remains relevant to the country’s needs and government policy. At the time of formulation, the program was aligned with government policies on poverty reduction, rural development, and gender and ethnic inclusion as articulated in the Sixth National Socio-Economic Development Plan (2006-2010). 2 Application of a sector development program modality was based on the 2006 Vientiane Declaration on Aid Effectiveness.3 It supported implementation of government priorities and strategies outlined in the Seventh Health Sector Development Plan (2011-2015), 4 which stipulated the need to implement a national health sector program approach to improve health sector performance. 4. The program design and objectives were fully in line with ADB’s long-term strategic framework and consistent with the ADB Country Strategy and Program Update for Lao People’s Democratic Republic (Lao PDR) (2006-2008).5 These emphasized poverty reduction through inclusive economic growth and greater emphasis on human resource development, with focus Lao PDR’s underserved northern provinces.

5. Program design followed a comprehensive needs assessment, community consultations and lessons from five previous ADB-supported health projects in Lao PDR. The use of capacity development technical assistance (CDTA) to support the preparation and implementation of a sector development program was appropriate, considering this was Lao PDR’s first health sector development program.6 The modality allowed the Ministry of Health (MOH) to directly address constraints in the health system through a comprehensive set of policy actions and

1 ADB. 2009. Report and Recommendation of the President on a Proposed Health Sector Development Program. Manila.

2 Committee for Planning and Investment. 2006. The Sixth Five Year National Socio-Economic Development Plan (2006-2010). Vientiane.

3 Government of the Lao People’s Democratic Republic. 2006. Vientiane Declaration on Aid Effectiveness. Vientiane.

4 MOH. 2011. The Seventh Five Year Health Sector Development Plan. Vientiane.

5 ADB. 2005. Country Strategy and Program Update for Lao People’s Democratic Republic. Manila.

6 ADB. 2009. Technical Assistance Report for Building Capacity for the Health Sector Program Approach (Financed by the Japan Special Fund). Manila. (CDTA 7446-LAO).

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developed capacity for planning, financial management and the human resources needed to improve health service delivery. This addressed key constraints that were inhibiting the population’s access to health services, particularly the poor, women and ethnic groups.

B. Program Outputs

6. The program grant supported policy reforms to: (i) strengthen provincial planning and financing, including an increase in non-wage recurrent budget, standards and guidelines for hospitals, a national health information system, and expansion of health equity fund (HEF); (ii) roll out mother and child-friendly health services to increase access to MNCH based on the national strategy, and establish greater community engagement through a model healthy village (MHV) program; and (iii) improve the quality of health personnel through development of a national policy on human resources for health, and initiatives to improve quality of pre-service education and training with focus on skilled birth attendant (SBA), MNCH skills and service delivery. The government met its commitment to release program funds to the provinces for non-wage recurrent budget. Agreed policy actions were highly relevant to the health-sector reform agenda. They were developed and submitted to ADB on time as envisaged. All policy actions are still in effect and are mainstreamed into health sector programs. Details of compliance with the 12 policy actions are in Appendix 1. 7. The project grant supported capacity building and investments to implement the reforms under three outputs: (i) strengthened planning and financing; (ii) increased access to MNCH; and (iii) improved quality of human resources for health. Design and monitoring framework (DMF) targets and achievements are in Appendix 2.

1. Output 1: Strengthened Planning and Financing

8. The project achieved its performance targets for this output. Project coordination unit (PCU) provided technical support to the provinces to understand the objectives as well as MOH guidelines and standards, procedures for strategic planning, and budgeting and management to develop five-year plans and budgets for basic public health activities in the provinces. Based on their overall five-year plans, the provinces and districts received assistance to prepare and implement results-based annual operational plans, which included detailed budgets. Output 1 activities also assisted the provinces establish fund flow mechanisms that allowed them to receive program-financed block-grant disbursement directly from the Ministry of Finance (MOF). 9. The PCU, together with other MOH departments, established detailed terms of reference (TOR) and guidelines for health centers, district hospitals and district health offices. The guidelines and TOR contained detailed facility standards, organizational structure, personnel, management responsibilities, performance criteria and equipment and drugs required for the facilities. Between 2011 and 2014 the program contributed $2.4 million to the operations and maintenance (O&M) budgets of district hospitals and health centers. This boosted the number of out-patient department (OPD) and in-patient department (IPD) visits by 89% and 52%, respectively. The number of deliveries at health centers increased by 50% and the number of surgical procedures increased by 23%, while the number of caesarean sections increased by 137%. The project also achieved targets for annual allocation of O&M budget to district hospitals and health centers.

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10. Based on MOH’s experience with health equity fund (HEF) pilot programs in three provinces under the Health System Development Project,7 the project supported HEF expansion to an additional five northern provinces. The expansion was based on a firm commitment by the provinces to sustain the scheme using their own resources. HEF management committees and field support staff were trained to provide sound fund management oversight and technical support required for HEF implementation. The expansion was undertaken under the overall umbrella of the national health financing policy.

2. Output 2: Increased Access to Maternal, Newborn, and Child Health Care

11. This output was to provide the population in the eight target provinces with increased access to MNCH based on the National MNCH strategy, with priority given to districts with high maternal mortality. The MOH, with the help of development partners, had already developed minimum standards for MNCH services, and an implementation plan for district-wide advocacy and planning, with the focus on mother- and child-friendly health facilities.

12. The project achieved performance targets under this output: (i) 56 out of 59 (95%) district hospitals in target provinces provide at least five out of seven functions of basic emergency obstetric and newborn care (BemONC); (ii) 286 out of 414 (69%) health centers in target provinces had a functional delivery room and 330 (80%) had separate toilets for women. All newly constructed facilities complied with the requirements of separate male and female toilets with the female toilet having a shower near the delivery room. For out-patient facilities, 85% had functioning toilets, with 95% having at least two separate toilets; and (iii) a total of 5,254 villages were declared as MHVs in 17 provinces. This included the establishment of 2,432 MHVs in the eight northern provinces. 13. Civil works were concentrated in the eight northern provinces. The project supported construction of a new provincial hospital in Phongsaly province, renovation of a type B district hospital in Viengkham district, Luangprabang province, and renovation of a type B district hospital in Morkmai district, Xiengkhouang province. The project also supported replacement of 10 health centers and renovation of 10 others in Luangprabang, Oudomxay, and Xiengkhouang province. All civil works included installation of incinerators and waste management pits. Hospital and health center staff were provided sufficient training on hazardous waste management protocols. At completion all facilities were being used, with O&M costs covered by provincial health offices.

3. Output 3: Improved Quality of Human Resources for Health

14. As envisaged, human resources for health activities focused on training and capacity building for 3,885 health personnel over the five-year period, including obstetricians, medical officers, midwives, nurses, medical assistants, primary health care (PHC) workers, SBA and health staff with MNCH skills.8 Of the 754 medical staff who participated in training, 482 (64%) were women and 327 (43%) were from an ethnic background. In other types of training, 992 personnel were associated with education training institutions, and 1,086 were associated with the HEF. A further 982 were village health workers (VHW) or village health volunteers (VHV) who were trained by public health colleges or provincial and district health office-based health educators.

7 ADB. 2013. Project Completion Report: Health System Development Project. Manila.

8 MOH. 2015. Project Completion Report for Health Sector Development Project. Vientiane.

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15. A majority of performance targets were achieved: of the 214 health staff who completed 2-month SBA training, 135 (63%) were women and 111 (52%) were from an ethnic background. Of the 153 staff trained as community midwives, 142 (93%) were women (against a target of 50%) and 43 (28%) were from ethnic groups. Of the 225 staff trained for 2-3 years as PHC medical associates, 84 (37%) were women and 130 (58%) were from an ethnic background. Some 129 staff received obstetric and new-born emergency care training. Of these, 109 (84%) were women and 29 (22%) were from an ethnic background. In addition, 33 staff received 3 years specialist residence training, with 12 (36%) of them were women and 14 (42%) were from an ethnic background.

16. The project also assisted staff from the University of Health Sciences (UHS), MOH’s Department of Health Personnel (DOP) and Department of Training and Research (DTR) and five public health schools address weaknesses in health worker’s pre-service education and training. Engagement with the UHS, DOP, DTR and public health schools has led to substantial improvements in human resources for health. Details of the training and capacity building programs are in Appendix 3. C. Program Costs

17. At appraisal, the program allocation was $20.8 million, of which ADB provided a $10 million program grant and $10 million project grant. The government contribution was to be $0.8 million. At completion, the total program cost was $21.56 million. The program grant proceeds were fully disbursed; and $9,996,866 of project grant proceeds were disbursed. The government contribution was $1,574,240 equivalent. 18. ADB approved two reallocations of project grant proceeds in October 2013 and February 2015. Savings were identified under categories for staff development; workshops, studies, systems development; and operation and maintenance. The savings and contingencies were reallocated to finance shortfalls for civil works, equipment and vehicles, and consulting services. The grant reallocations did not result in any changes to the financing plan.

D. Disbursements

19. At completion, the program grant of $10 million was fully disbursed in two tranches following the government’s compliance with 12 policy actions. ADB approved the first set of policy actions at the time of board approval and disbursed the first tranche of $5 million on 14 January 2010. The second tranche of $5 million was disbursed on 6 March 2012. As agreed with ADB, the MOF established a suitable fund flow mechanism and subsequently made the equivalent to each tranche available in a special account and funded provincial non-wage recurrent expenditures and the HEF. All provinces were trained in planning, budgeting, financial management and monitoring. Practical financial management manuals were prepared and guided cost norms and eligibility criteria. 20. For the project grant, the project established an imprest account at the Bank of Lao PDR with an initial advance of $1 million. Disbursements were made in accordance with ADB’s Loan Disbursement Handbook (2007, as amended from time to time). Statement of expenditure (SOE) procedure was used for replenishment of the imprest account. The executing agency effectively managed SOE dispensation. By the end of 2014 the imprest account turnover ratio reached 2.9 and grant proceeds totaling $9.99 million were disbursed. The project financial statements were audited annually following procedures acceptable to ADB and the government. All six annual audited project financial statements received an unqualified auditor’s opinion.

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E. Implementation Schedule

21. Compliance with policy actions and disbursements of the program grant followed the envisaged schedule. The first set of six policy actions were approved by ADB on 10 November 2009 and the first tranche was released to MOF in January 2010. The second set of six policy actions were submitted to ADB on 28 November 2011 and approved in December 2011. The second tranche was subsequently released to MOF in March 2012. The program grant was closed as scheduled in August 2012. 22. The project component implementation schedule was initially scheduled from January 2010 to December 2013. Project implementation was delayed in the first two years due to slower than expected consultant mobilization under the piggy-back CDTA (para. 28).9 The pace of implementation accelerated by year 3; however, in October 2013 the government requested ADB’s approval to extend the grant closing date from 30 June 2014 to 30 June 2015 to allow sufficient time to complete additional training for VHWs and SBAs and install medical equipment in Phongsaly provincial hospital. 10 The planned and actual implementation schedule is in Appendix 4.

F. Implementation Arrangements

23. MOH was the executing agency and its Department of Planning and Finance (DPF) was responsible for the day-to-day management and implementation of the program. As part of reorganization, the DPF became the Department of Planning and International Cooperation (DPIC) and the Department of Finance (DOF) was created, effective on 5 April 2012. 24. Within DPIC, a PCU was established to implement the program, with the DPIC director general as PCU director, supported by three deputy directors, administrative officers and consultants. The program was also supported by a private firm, which provided accounting services.

25. Within MOH, part of the project component implementation was delegated to the DOP and DTR as implementing agencies. They were supported by the UHS and Maternal Child Health (MCH) Center. These departments and agencies were responsible for planning, implementing and reviewing project activities within their mandate. Provincial health offices served as implementing agencies, through the primary health care coordination units (PHCCU), which were responsible for (i) supporting the preparation of annual operation plans; (ii) facilitating the processing and implementation of conditional grants; (iii) implementing program activities and quality assurance, including training and minor civil works procurement; and (iv) financial management of the program funds.

26. A MOH steering committee, chaired by the Minister of Health and comprising the vice ministers and representatives of MOH departments, provided overall guidance to program implementation, particularly for the development and submission of policy actions. The MOF, Ministry of Planning and Investment (MPI) and other ministries participated in periodic steering committee meetings. 9 The consultants were mobilized in October 2010, one year after program approval.

10 ADB approved the request on 29 October 2013.

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G. Conditions and Covenants

27. Government compliance with grant covenants was satisfactory. No covenants were modified, suspended, or waived. Status of compliance with grant covenants is in Appendix 5. H. Related Technical Assistance

28. One of the major strategies for health sector improvement was t o strengthen planning and budgeting systems and financial management. At the time of program processing the government requested capacity development technical assistance from ADB to support its objectives of improving health sector performance by using a programmatic approach. The CDTA’s objectives were to (i) develop a fund flow mechanism and agreed budget norms for allocation of the program grant; (ii) build staff capacity in financial management at provincial, district and health center levels; and (iii) strengthen staff capacity in planning and budgeting for health sector operations at provincial, district and health center levels. The consultant team produced a technical manual on financial management and a manual to guide planning, monitoring and evaluation. The CDTA was strongly supported by MOF and the executing agency adopted the manuals as they were compatible with the government’s financial management system. This made it easier for both government staff and development partners to adopt the instruments as they can be applied irrespective of funding sources. All expected outputs were achieved within time and resources as planned. The CDTA was assessed as highly relevant, effective, efficient and likely sustainable and assigned an overall rating of successful.11 I. Consultant Recruitment and Procurement

29. Project consultants were engaged in accordance with ADB’s prevailing Guidelines on the Use of Consultants. The program utilized 245 person months (pm) of consulting services consisting of 53 pm for international consultants and 192 pm for national consultants. The consultants were recruited following individual consultants selection (ICS) method. The project also recruited a national architectural firm and national research firm to support civil works design and baseline and end-line surveys. A local accounting firm was recruited to assist the PCU manage the program grant. All firms were recruited following consultants’ qualification selection (CQS) method. 30. The main challenge encountered was the lack of applications from suitably qualified national consultants. Those who did submit applications did not have the relevant qualifications or experience. A suitable gender specialist, planning-financing officer and HEF officer were eventually recruited, but consultants to fill the health systems, community health development and national health medical education specialists could not be identified. The main reason was the very small pool of national consultants with expertise in these areas.

31. Vehicles and ambulances were procured through the United Nations Office for Project Services. Medical equipment for provincial and district hospitals and health centers were procured following national competitive bidding, while various other goods were procured following shopping procedures. Seven contract packages were awarded under national competitive bidding for: (i) medical equipment (four contracts) and (ii) construction and renovation of provincial and district hospitals and health centers (three contracts). They were no

11

ADB. 2011. Technical Assistance Completion Report: Building Capacity for the Health Sector Program Approach. Manila.

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major issues in the implementation of procurement activities. All procurement followed ADB’s prevailing Procurement Guidelines and government procedures acceptable to ADB.

J. Performance of Consultants, Contractors, and Suppliers

32. The performance of consultants, contractors and suppliers was satisfactory. No major problems were associated with the procurement of goods, services and civil works except for delays in construction works due to slower than expected recruitment of the domestic architectural firm. This was mainly due to difficulties in finding a domestic firm with experience designing medical facilities. The executing agency and ADB consider the performance of the international and national consultants satisfactory. 33. The PCU’s procurement unit implemented procurement activities using sound management procedures, with government staff assisted by the architectural firm for the purposes of master planning and works design, contract administration documentation, quality control, preparation of bid documents and construction supervision. All construction works were satisfactorily completed as specified in the respective civil works packages. Suppliers provided goods and vehicles in accordance with agreed specifications, prices and timelines. Overall, the performance of contractors and suppliers is rated satisfactory. K. Performance of the Borrower and the Executing Agency

34. The performance of the Borrower and executing agency were rated satisfactory. The success of the program was due to strong government ownership, particularly by the MOF, MPI and MOH. The executing agency actively coordinated with MOF, MPI and provinces to ensure timely compliance with policy actions agreed under the program grant. MOH ensured timely submission of annual work plans and budgets and release of the program funds from MOF to MOH and the various implementing agencies. Timely processing of withdrawal applications and financial reporting for the project grant enabled smooth fund flow from ADB to MOF and onwards to the provinces, which ensured there were sufficient funds available to implement project activities in accordance with annual work plans. Government counterpart contributions totaled $1.57 million, about double the $0.8 million appraisal estimate.

L. Performance of the Asian Development Bank

35. The performance of ADB was satisfactory. When issues arose, ADB sought solutions through discussion and collaboration with the executing agency or concerned ministries. ADB fielded an inception mission, six grant review missions and a mid-term review (MTR) mission to monitor the program’s performance. The missions included field visits to provinces and coordinated with other development partners and the government to help steer policy reforms. ADB’s timely processing of the government’s requests for reallocation of grant proceeds and extension of the grant closing date helped ensure sufficient time and resources to complete all envisaged activities. Minor changes in project scope and implementation arrangements improved design relevance and were aligned with MOHs reorganization and health-sector priorities. Grant administration was successfully delegated from ADB headquarters to the Lao PDR Resident Mission shortly after the MTR mission in May 2012.

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III. EVALUATION OF PERFORMANCE

A. Relevance

36. The program is rated as highly relevant. Its design was well aligned with government policies on poverty reduction, rural development, and gender and ethnic inclusion. The program’s emphasis on improving service delivery in rural areas through a primary health care approach that focused on public health and prevention programs was relevant to the needs of the sector. The program was, and still is, entirely consistent with Lao PDR’s health sector strategies and priorities and in line with government aid effectiveness policies. 37. Since engaging in the health sector in 1995, ADB has financed health infrastructure and emphasized support for development of human resources for health to increase the quality and coverage of health services. MOH and provincial health administrators and providers have accumulated considerable capacity for service delivery and project management. With improved capacity the application of a sector development program modality was appropriate. The program’s financial management training together with other capacity building programs built on previous gains enabled the government to successfully introduce block-grant disbursements based on soundly formulated annual operation plans. Use of CDTA to support preparation of the sector development program was appropriate.

B. Effectiveness in Achieving Outcome

38. The program is rated as less than effective in achieving its outcome because the program fully achieved only two out of four outcome performance targets. Overall, the use of health services, particular by the poor, women, children, and ethnic groups in eight target provinces has increased. The percentage of deliveries assisted by SBA, including for the poor and ethnic groups increased from 25% in 2010 to 58% in 2014; and the number of the HEF beneficiaries increased from 100,000 in 2010 to 430,000 in 2014. Despite the use of health services by the poor, women and infants, increased by 47%, 37% and 29%, respectively from 2010 to 2014, the program did not achieve the target of an increase in the utilization by 100%. This performance target was unrealistic and set without baseline data. The results of household survey conducted in 2010 were available in 2011, after program approval. The target was not subsequently revised based on the survey results. ADB and the executing agency agreed to revise DMF indicators during the MTR mission in May 2012, but revised targets were not formalized. Another partially achieved indicator was percentage of people ill who sought assistance from VHVs. This decreased from 19% in 2010 to 6% in 2014 against a target of 38%.12 Conversely, the proportion of people ill seeking care from a government health facility has increased from 47% (2010) to 64% (2014). The likely reasons for this increase are improved road and public transport systems; increased rural incomes; greater engagement and advocacy with communities through model healthy villages committees; more children staying longer in schools, resulting in increased literacy within households; and better social protection for the poor through the HEF. 39. The program was effective in planning processes and the development of result-based plans and budgets. The program enabled the availability of funds to districts through the newly-introduced fund flow mechanism and improved planning and budgeting processes directed funds to health facilities for recurrent budget support. This included incentives for staff posted in remote rural health facilities, facilities O&M, in-service training, replenishment of drug kits,

12

Project end-line survey 2014.

9

periodic meetings, and development and support of MHVs, HEF and free MNCH. In the 2010, 2011 and 2012 plans and budgets, program fund equivalent was made available for preparation, dissemination and review of provincial results-based plans. In the 2013 plans program fund equivalent was made available for the collection of additional data at the community level to monitor MDG-related indicators and to orient planning toward reaching MDGs.

C. Efficiency in Achieving Outcome and Outputs

40. The program was efficient in increasing domestic non-wage recurrent budget and spending at the provincial level. The government budget allocation for health for the FY2010-2011 and 2012-2013 increased from 15% to 70% for that period. Financial reports from 17 provincial health offices and MOH’s DOF showed that domestic non-wage recurrent expenditures increased from 18% to 57% during the same period.13 41. The sector development program modality proved to be more cost-effective and efficient than a project-only approach. The program grant significantly decreased the cost of financial management for both the government and ADB. The flow of program proceeds from ADB to the MOF in two simple tranches after the policy actions were achieved greatly reduced transaction costs, as funds flowed directly through the government financial system to the provinces, and responsibility for financial management and auditing of these funds was integrated with all other government expenditures. The cost to process additional funds used for non-wage recurrent costs in peripheral facilities was minimal. No baseline financial or economic analysis and assumptions were made at the time of project design, or at project completion.

D. Preliminary Assessment of Sustainability

42. The program is rated as likely sustainable. The hospitals and health centers built and renovated under the project are being used, with O&M costs included in district and provincial budgets. The program policy actions and their downstream costs are likely sustainable, as current government policies and actions so far ensure that they will continue beyond the program period. For example, key documents that guide strategic and operational planning such as the MNCH strategy and health personnel development strategy are in place through 2020. E. Impact

43. The program impact was to contribute to the reduction of maternal and child mortality and malnutrition by 2015. The baseline indicators were derived from the national census (2005) for maternal and child mortality and the multi-indicator cluster survey (2006) for malnutrition. In 2011, the government carried out the Lao Social Indicator Survey, which provided intermediate estimates of impact indicators. The survey results suggested that it is unlikely that the country will reach MDG targets for maternal mortality despite significant progress. The target of reducing the maternal mortality ratio (MMR) by 75% and the national targets for child mortality have not been achieved by 2015. The government has acknowledged lessons learned and its development agenda in the post-2015 period aims to address these shortfalls and meet commitments to the United Nations Sustainable Development Goals. 44. Poverty and Social Protection. The program investments through the HEF has provided significant benefits and improved health care for women, children, disadvantaged

13

The Official Gazette, State Budget Revenue-Expenditure 2010, 2011, 2012 and 17 Provinces Financial Reports for 2013, 2014.

10

ethnic groups, and the poor, especially those living in remote areas. Increased service provision for those living in remote communities resulted in increased utilization of MNCH and basic health services. Strengthened planning and financial management capacity within the public health system saw improvements in the quality of human resources for health, particularly SBAs, and expanded health care affordability through the HEF. These elements assisted in ensuring a reduction of maternal and child mortality, and reduced key constraints to access health care services, especially in remote and rural areas. An assessment of the HEF program in the eight northern provinces over three years illustrated that HEF coverage increased significantly with the number of eligible beneficiaries increased from approximately 100,000 in the first year to more than 430,000 by the end of the third year. HEF utilization over that three years was approximately 108,884 patient-visits with 58,102 (53%) were women. Annual utilization doubled from 23,000 patient-visits in FY2011-2012 to nearly 48,000 in FY2013-2014 and economic efficiency, measured by the average total cost of an HEF patient-visit, improved from $10 in the first year to $8 per patient-visit at the end of the third year of project implementation. Administration costs to provide $1 of health care services fell from $0.35 to $0.19. Utilization of services was gender neutral, both for overall patient visits and for patient visits to each level of health-care facility. 45. Economic and Financial Benefits. The program supported the achievement of targeted MDGs through cost-effective interventions for the poor, women, children and ethnic groups. Out-of-pocket savings resulted from increased access and better quality HEF-funded services and free maternal care. Program funding improved the overall sector efficiency by reducing transaction costs and increasing recurrent operational spending so that past investments were well preserved and better used. Improved planning and financial management capacity resulted in greater efficiency of health sector financing. Program funding also improved aid effectiveness and harmonization with United Nations agencies and international nongovernment organizations working at the provincial level. Overall, program investments increased the number of people receiving quality health care and contributed directly to improving productivity.

46. Although not quantified, economic benefits are accruing from reduced health-care costs resulting from lower incidence and severity of illness. Cost savings arise from (i) improved access to prevention and health-promotion services; (ii) reduced out-of-pocket expenditures; (iii) more efficient and rational diagnoses and treatments that reduce treatment cost; and (iv) increased income through reduced sick leave or time spent caring for the sick. In addition, gains and investments in women’s health will have positive impacts on reducing the country’s population growth rate and improving the health and welfare of children and families.

47. Gender Impact. The program is categorized as Gender Equity as a theme (GEN). A gender action plan (GAP) was prepared to ensure that activities were responsive to the needs of women and ethnic groups. GAP implementation and monitoring was included in grant covenants. Sex-disaggregated data collection was integrated into the project’s monitoring and evaluation system. At completion, all 37 GAP actions were implemented. The program achieved 29 out of 32 qualitative gender actions and four out of five gender actions with quantitative targets were achieved. Implementation of the GAP is assessed as successful. Key achievements include: (i) 70 (66%) out of 106 participants in health manager training and 150 (53%) out of 280 technical training participants were women (target 20%); and (ii) 754 staff members received in-service training, of whom 482 (64%) were women (target 50%). This contributed to increased utilization of health services by women and the poor in target provinces. The number of births attended by SBA increased from 25% in 2009 to 58% in 2014,

11

with an average increase of 6% per year (target 5% per year). Details of gender equity results and achievements are in Appendix 6.

48. Institutional impact: The program’s contribution to institutional development was significant. A sound policy framework was established based on the policy actions and program for inclusive development, with high participation of women and disadvantaged groups. A significant reduction in fiduciary risks at the central and provincial levels is being engendered by better public financial management. Public managers and staff have increased their skills and capacity to undertake strategic and operational results-based planning and budgeting. Notably, policy reforms and capacity building have enabled the DPIC, provincial and district health offices to confidently formulate and implement multi-component projects with support from the government and multiple development partners.

49. Environmental impact. The program was classified as environmental category B. No major negative environmental impacts were encountered as a result of project activities. Initial environmental examinations and environmental management plans were prepared and implemented for health facilities supported by the program. The main environmental concerns related to solid and medical waste management and disposal. The project provided funding and technical support for national staff training to implement the national integrated health-care waste-management plan, which was developed based on World Health Organization guidelines.

IV. OVERALL ASSESSMENT AND RECOMMENDATIONS

A. Overall Assessment

50. Overall, the program is rated successful. This rating is based on the assessment of relevance, effectiveness, efficiency, and sustainability.14 Of note is the maturity of the sector and deep engagement between the government and development partners, who have collectively brought to fruition the health sector working group that helps support policy reforms in the sector. The government has accorded high priority to the health sector and there is serious collaborative engagement by development partners to supports the government’s reform agenda. The program’s institutional development impacts are assessed as significant. Calculation of the overall program rating is in Appendix 8. B. Lessons

51. The program tested a new fund flow mechanism for the health sector. Based on the successful trial the government has increased funding for health at the provincial level, resulting in expanded health services coverage, particularly for MNCH services and the provision of free health care for the poor. The framework engendered the provinces to allocate additional funds for non-wage recurrent costs to support the additional services, and demonstrates that block-grant transfers based on sound fiscal planning can be an effective mechanism to reduce transaction costs and expand social services. 52. The coverage for the HEF scheme supported by the program increased from three pilot provinces to cover all eight target provinces. This resulted in a higher number of eligible beneficiaries and health service utilization by the poor. Despite this, a large percentage of the eligible beneficiaries were not accessing the free HEF-funded services. There are many reasons: (i) potential beneficiaries didn’t know about the services, suggesting a need for better

14

ADB. 2013. Guidelines for Preparing Performance Evaluation Reports for Public Sector Operations. Manila.

12

social marketing; (ii) services at health facilities are still substandard; (iii) most ethnic and poor villages are geographically remote, with no health facilities; and (iv) cultural beliefs that favor the use of traditional medicine or birthing at home. District health services need to be more proactive and reach out to communities in remote areas. Assisted birthing in the home would help, while growth monitoring, nutrition and food security, and proper immunization of infants, children and adults could make substantial impacts on the population’s health and nutritional status.

53. Funding is necessary, but is not sufficient for building capacity in the provinces and districts as they move to decentralized governance. Strengthening regulatory arrangements and institutional capacity is dependent on good management and financial procedures. A number of the provinces have increased management and technical competency and can play a valuable role through mentoring and/or twinning programs to help expand successful initiatives to others provinces.

54. Output and outcome performance monitoring was generally limited to the baseline, midterm and end of program survey. Key core performance data should be collected, analyzed and reported on a quarterly basis, in alignment with standard government indicators. This provides provinces and the national level with an up-to-date status of program performance and comparative data across provinces. These data should inform the annual planning process and identify where additional support is needed.

C. Recommendations

1. Program Related

55. The MOH and ADB should ensure continuity of the 12 policy actions implemented under the program, with endorsement by the government to ensure that activities continue beyond the life of the program. ADB should continue to monitor the government’s compliance with these policy actions when programming future support for the health sector. 56. The CDTA supported development of two technical manuals. One on financial management and another on planning, monitoring and evaluation. These can be used irrespective of funding source and are compatible with the government’s financial management system. The MOH and MOF should promulgate the manuals to enable one national systemic approach for planning, budgeting and implementation of health sector operations. 57. The program has contributed to major reforms and achievement of some MDGs and established a foundation for risk-pooling and making health care more affordable for the poor. These achievements should be benchmarked and carried forward in future programs.

58. ADB, as part of its commitment to supporting health sector reform in Lao PDR, could assist the government undertake a cost benefit analysis of using the HEF to support the country moving towards universal health coverage. This would support strategic planning as part of the reform agenda and help the government and development partners with budget forecasting.

59. Programs should be viewed as part of an ongoing and continuous journey of long-term ADB and development partner support to the health sector, rather than separate stand-alone project interventions. Results, achievements and partial achievements should be viewed in context of a continuum of linked reform activities and improved overall health sector performance.

13

60. The appropriate timing for preparation of a project performance evaluation report would be December 2017.

2. General

61. DMF indicators should be realistic and based on relevant up-to-date baseline data. Opportunities to adjust the DMF during implementation should be taken when appropriate. The government and ADB are encouraged to ensure that future programs/projects are well-resourced to attain project readiness and enable timely start-up.

Appendix 1 14

COMPLIANCE WITH POLICY ACTIONS

Tranche Policy Actions Status of Compliance and Implementation

Output 1: Strengthened Planning and Financing

Tranche 1 Policy Action 1. The MOF has approved the program funding mechanism for supplementary support for the provincial health sector.

Fully Complied

The Ministry of Finance (MOF) approved the program funding mechanism. A Memorandum of Understanding was signed between the MOF and the Ministry of Health (MOH) in October 2009 that outlines the flow of funds for program support to the provinces. Based upon this MOU, the MOH developed detailed regulations, procedures, budget norms, and structures to manage the funds flow. The Minister of Health issued a decision approving these regulations and they were endorsed by the MOF. Based upon these regulations and procedures, detailed implementation guidelines and financial management manuals were developed. The MOF released funds requested by provincial health offices as per approved individual provincial annual operational plans and budgets. The provincial health offices released funds to the district for implementation of activities. All funds requested by provincial health offices were managed as per the agreed program funding mechanism. The program funding mechanism has been effective in channeling funds from the MOF to the provinces since 2010.

Tranche 1 Policy Action 2. MOH has approved the National Health Information System Strategic Plan (2009–2015).

Fully Complied

The MOH approved the National Health Information System Strategic Plan. Development of the strategic plan was undertaken under the Health System Development Project

1 and was approved for

implementation by Minister of Health in 2009. Since 2009, the statistics units of provincial health offices have been providing quarterly reports to the statistics division of the Department of Planning and International Cooperation, MOH

2. These reports are checked for completeness and accuracy and

are aggregated at the national level as part of the annual National Health Statistics Report. The National Health Statistic Reports for FY2009-2010, 2010-2011, 2013-2014 and 2014-2015 have been released.

1 ADB. 2013. Project Completion Report Health System Development Project. Manila. (Grant 0079).

2 Formally the Department of Planning and Finance.

Appendix 1 15


Tranche 1

Policy Action 3. The government has committed to increase the aggregate domestic non-wage recurrent budget for health by at least 10% annually from 2009/2010 to 2013/2014

Fully Complied

The government increased the aggregate domestic non-wage recurrent budget for health by at least 10% annually from 2010 to 2014. The government through the policy letter dated 9 October 2009 signed by the Minister of Finance confirmed the government’s commitment to increase the aggregate domestic non-wage recurrent budget for the health sector by at least 10% annually from FY2009-2010 to 2013-2014. The MOF issued the letter No. 2733 dated 28 November 2011 confirming that budget allocation to the health sector for the FY2010-2011 was 15% higher than the budget allocation for the health sector in FY2009/2010. From FY2009-2010 to FY2010-2011, the total budget allocation to the health sector increased by 17% and the budget for non-wage recurrent expenditures increased by 15%. From FY2010-2011 to FY2011-2012, the total budget allocation for the health sector increased by 24% and the budget for non-wage recurrent expenditures increased by 70%.

Tranche 2 Policy Action 1. Provincial authorities have approved results-based annual operational plans and budgets that meet minimum MOH standards.

Fully Complied

The provincial health offices approved results-based annual operational plans and budgets that met minimum MOH standards. Seventeen provincial health offices developed and submitted to the MOH results-based annual plans and budgets for the FY2010-2011, 2011-2012, 2012-2013, 2013-2014, and 2014-2015. These plans met planning and budgeting standards issued by the Ministry of Planning and Investment (MPI) and the specific standards required by the MOH. The plans and budgets were included into provincial master plans and submitted by the MPI to the National Assembly for approval.

Tranche 2 Policy Action 2. MOH has issued a decision approving standards, guidelines and terms of reference for district hospitals.

Fully Complied

The MOH approved standards, guidelines, and terms of reference for district hospitals. The MOH issued a decision No. 2312 dated 30 December 2009 on organization and implementation for district hospitals. The standards and terms of reference for district hospitals were revised within the framework of the Health Sector Reform Strategy (2013-2020). Detailed job descriptions for key staff positions for these facilities were also developed. The standards and terms of reference were disseminated countrywide through regional workshops. The MOH’s Department of Health Personnel is responsible for enforcing and monitoring implementation and compliance with the district hospital standards, guidelines and quality of staff.

Appendix 1 16


Tranche 2 Policy Action 3. Provincial authorities, on aggregate, have increased non-wage recurrent spending by 10% compared to 2009/2010 level, as reported to the MOF.

Fully Complied

The provincial authorities have increased domestic non-wage recurrent spending by 10% compared to FY2009-2010 level. According to financial reports prepared by finance division of provincial health offices, on aggregate, non-wage recurrent expenditures in 17 provinces increased by 18% from FY2010-2011 to FY2009-2010, and by 57% from FY2010-2011 to FY2011-2012. The MOF confirmed the increase in recurrent spending to ADB by letter No. 2733 dated 28 November 2011.

Output 2 : Increased Access to Maternal, Newborn and Child Care

Tranche 1 Policy Action 4. MOH has approved the National Strategy for MNCH.

Fully Complied

The MOH approved the Strategy and Planning Framework for Integrated Package of Maternal, Newborn, and Child Health (MNCH) Services (2009-2015) in 2009. The strategy was incorporated into the MOH‘s seventh Health Sector Development Plan (2011-2015) which gave priority for interventions achieving health related Millennium Development Goals (MDG) targets. The strategy is the guiding document for development of MNCH services at all levels, including health facilities, equipment, development of human resources, and provision of funds for operations. The Health Sector Reform Strategy prepared by the MOH and adopted by the National Assembly in December 2012 confirmed that MNCH program targets are one of the priorities to reach the MDGs. The second National Strategy and Action Plan for Integrated Services on Reproductive, Maternal, Newborn and Child Health 2016-2025 was developed in December 2015.

Tranche 2 Policy Action 4. MOH has issued an implementation plan for district-level roll-out of maternal, newborn, and child-friendly health facilities, providing a minimum package of MNCH services.

Fully Complied

The MOH issued an implementation plan for the district-wise roll-out of maternal, new born and child-friendly health facilities providing a minimum package of MNCH services. The MNCH center developed a national strategic implementation plan for the integrated package of maternal, neonatal, and child health services (2009-2015). The plan was approved by MOH (decision No. 1794/MOH), on 4 November 2011. The high priority given to provision of MNCH services was confirmed by the Health Sector Reform Strategy developed by the MOH and adopted by the National Assembly in December 2012.

Tranche 1 Policy Action 5. MOH has issued Decision 381, establishing the directives for piloting at least two model health villages per district in all provinces, totaling about 300 villages, and also issues guidelines for implementation.

Fully Complied

The MOH issued decision No. 381 establishing the directives for piloting at least two model healthy villages (MHV) per district in all provinces, totaling about 300 villages and issued guidelines for implementation. The MOH, with support from the Developing Model Healthy Villages in Northern Lao PDR project,

3 developed and tested approaches and guidelines for MHV. Funding

was allocated under the program grant (G0172) to develop MHV. The MHV implementation guidelines were finalized and approved. In 2011, the MOH approved an MHV expansion plan in 64 priority development zones (2012-2015).

3 ADB. 2014. Implementation Completion Memorandum Developing Model Healthy Villages in Northern Lao People’s Democratic Republic (Financed by the Japan Fund for

Poverty Reduction). Manila.

Appendix 1 17


Tranche 2 Policy Action 5. MOH has issued a decision to scale up model healthy villages, including at least 300 remote villages by end 2015.

Fully Complied

The MOH issued a plan to scale up model healthy villages, including at least 300 remote villages by 2015. The MOH developed a plan for expansion of model healthy villages in 64 priority groups of villages for the health sector (2012-2015) and the plan was approved by MOH (decision No 1856/MOH, on 15 November 2011). The MHV plans were implemented in 64 priority groups of villages with provincial health offices preparing annual results-based plans and budgets to develop the MHV program expansion. MHV regular activities are being implemented, including collection of basic data, preparation of plans with villagers, dissemination of MHV information, particularly information on sanitation, organization of peer education activities, training or retraining of village health volunteers with drug kits, and others activities required for MHV declaration. The number of MHV countrywide increased from 1,917 in 2012 to 4,553 in 2015.

Output 3: Improved Quality of Human Resources for Health

Tranche 1 Policy Action 6. The government has approved a detailed national implementation plan for skilled birth attendants.

Fully Complied

The MOH approved the National Skilled Birth Attendance Development Plan for 2008-2012. The Department of Training and Research of the MOH developed an implementation plans for increasing in the number of SBA, and for monitoring the implementation of the SBA program. The government and development partners supported the implementation of the SBA program. As of December 2015, a total of 1,784 midwives (including registered midwives and community midwives) graduated since 2009, including 90 supported by the project in the eight target provinces.

Tranche2 Policy Action 6. Prime Minister has approved the National Policy on Human Resources for Health.

Fully Complied The Prime Minister approved the National Policy on Human Resources for Health. The MOH developed the Health Personnel Development Strategy by 2020, which was approved by the Prime Minister through decree No. 495/PM dated 11

November 2010.

The strategy was the guiding document for the development of human resources for health. It provided a conceptual framework and strategic directions to guide investment and coordinate efforts in HRH development. The strategy was disseminated at central and regional levels to support of the provincial authorities implement the Plan. The MOH five-year plan for human resources for health was developed and costed based on the strategy.

FY=fiscal year, MHV=model healthy village, MNCH=maternal, newborn, and child health care, MOF=Ministry of Finance, MOH=Ministry of Health, MOU=memorandum of understanding, SBA=skilled birth attendants. Source: MOH, 2013. Health Sector Development Program: Project Grant 0172 Completion Report. Vientiane.

Appendix 2 18

DESIGN AND MONITORING FRAMEWORK TARGETS AND ACHIEVEMENTS

Design Summary Performance Targets and Indicators Achievements

Impact Reduced maternal and infant mortality, and child malnutrition.

(i) Infant mortality rate reduced from 55 to 45 per 1,000 live births between 2009 and 2015, and from 90 to 60 per 1,000 live births among poor ethnic groups.

(ii) Maternal mortality ratio reduced from 300 to 260 per 100,000 live births between 2009 and 2015.

(iii) Child malnutrition reduced from 30% to 25% between 2009 and 2015.

The infant mortality rate (IMR) was 68 per 1,000 live births and under-five mortality was 79 per 1,000 live births in 2012.

The maternal mortality ration (MMR) was 357 per 100,000 live births (the 95% confidence interval is between 269 and 446) in 2012. Over the life of the project 21,000 women had been assisted by trained personnel in delivering in a health facility or at home, of which 28% of all the expected births in these eight provinces. This was an increase of 33% in the number of women undertaking assisted deliveries in 2010.

The prevalence of underweight children under the age of five was 27% and the prevalence of stunting in children under the age of five was 44%.

Outcome Improved use of Primary Health Care, in particular by the poor, women, children, and small ethnic

groups.

(i) Use of health services by the poor, women, infants, and ethnic groups increased to twice the baseline of 2009 by 2014.

(ii) Percent of deliveries by skilled birth attendants increased by 5% each year, including for the poor and ethnic groups.

(iii) Consultations of VHVs increased to twice the baseline of 2009 by 2014.

(iv) The number of poor and women accessing health equity funds increased by 10% each year.

Partly Achieved. The use of health services by the poor, women and infants, increased by 47%, 37%, and 29%, respectively from 2009 to 2014.

The target increase in utilization of health services to double the baseline of 2009 was unrealistic in that it expected utilization to reach 100% with the project resources and timeframe.

Achieved. In the eight target provinces, the number of births attended by a SBA increased from 25% in 2009 to 58% in 2014. During the duration of the project 256 staff were trained as SBA against a project target of 236.

Not Achieved. The percentage of people ill in the past four weeks and who sought assistance from VHV decreased from 19% in 2009 to 6% in 2014 against a target of 38%. Conversely the percentage of people ill in the past 4 weeks seeking care from a government health facility increased from 47% (2010) to 64% (2014).

Achieved. The HEF scheme was extended from three pilot provinces to five additional provinces meaning that all eight provinces were covered by the HEF, increasing beneficiaries from 100,000 to 430,000, with the total number of patient visits over three years at 109,000 with female visit at 58,000.

Appendix 2 19


Outputs 1. Strengthened planning and financing capacity

(i) Provincial annual operational plans and budgets are results-based, realistic, and largely implemented as planned by December 2013.

(ii) Measurable annual improvement of operations and maintenance of district hospitals and health centers between 2010 and 2014.

Achieved. All 17 provincial health offices developed and submitted to the MOH results-based annual plans and budgets for the FY2010-2011, 2011-2012, 2012-2013, 2013-2014, and 2014-2015. These plans met planning and budgeting standards issued by the Ministry of Planning and Investment (MPI) and the specific standards required by the MOH. In FY2010-2011 the implementation of operational performance-based plans approved was 82%. For FY2011-2012 and FY2012-2013 the number operational performance-based plans approved had increased to 96%.

Achieved. Between 2011 and 2014, the project contributed $2.4 million for operations and maintenance (O&M) of district hospitals and health centers. This helped achieve increased numbers of OPD and IPD visits by 89% and 52%, respectively. The number of deliveries at health centers increased by 50%, and the number of surgery procedures by 23%, with Cesarean-sections increasing by 137%. The project also achieved its target of 10% annual O&M allocation for district hospitals and health centers.

2. Increased access to Maternal, Newborn, and Child Health care.

(i) District hospitals meeting 75% of MNCH standards (BemONC services) increased by 5% each year.

(ii) Health facilities with sufficient amenities for privacy needs of women increased by 5% each year.

(iii) Number of certified model healthy villages increased by 50 each year as targeted by ethnic group.

Achieved. There was no baseline for this indicator. However, a health facility survey conducted in the northern region in August 2014 assessed the availability of basic emergency obstetric and newborn care (BemONC) equipment and functions and comprehensive emergency obstetrics and newborn care (CemONC) functions in type A district hospitals. The results show that 56 out of 59 (95%) district hospitals provided at least five out of seven functions.

Achieved. There was no baseline data for this indicator. At completion, of the 414 health centers across the eight provinces, 286 (69%) have a delivery room, and 330 (80%) had functioning separate toilets for women. All newly constructed facilities complied with the requirements of separate male and female toilets, with the female toilet having a shower near the delivery room. In the OPD 50 of 59 (85%) had functioning toilets, with 37 of 39 (95%) having at least 2 separate toilets.

Achieved. A total of 5,254 villages were declared model health village, which included the establishment of 2,432 MHV in the 8 northern provinces since 2010, with an average of an increase of 486 villages per year.

Appendix 2 20


3. Improved quality of human resources for health.

(i) At least one staff member trained as a skilled birth attendant per district per year.

(ii) At least 50% of trained staff members are female.

(iii) At least 75% of trained staff members achieved basic skills.

(iv) University and college master plans are approved by 2013, with affirmative actions for females and ethnic groups.

Achieved. The project supported training and capacity building of 3,885 health personnel over the 5-year period.

A total of 153 staff trained as community midwives, 142 (93%) were women, 43 (28%) were from an ethnic background. Some 214 health center staff completed two months SBA training, of whom 135 (63%) were women, 111 (52%) were from an ethnic background. Of the 754 specialist and mid-level health staff trained, 482 (64%) were women, and 327 (43%) were from an ethnic groups.

992 staff from the health training institutions received education training and the 1,086 provincial and district staff received HEF training, for a total of 2,078, of which 1,205 (58%) were women. Of the 225 staff who were trained for 2-3 years as PHC medical associates, 84 (37%) were women, 130 (58%) were from an ethnic background.

Of the129 staff who received training in obstetrics and newborn emergency care, 109 (84%) were women, 29 (22%) were from an ethnic background.

33 staff received three years specialist residence training. Of these 12 (36%) were women, 14 (42%) were from an ethnic background.

Data not available to measure this indicator.

Achieved. University of Health Science developed an ethnic and gender inclusive 5-year strategic development plan that was endorsed by the MOH. The plan provided the guidelines on training methodologies, level and skills required for lecturers, quality assurance criteria and processes, as well indicative criteria for class sizes for different types of trainings.

BemONC=basic emergency obstetric and newborn care, CemONC=comprehensive emergency obstetrics and newborn care, HEF=health equity fund, IMR=infant mortality rate, IPD=in-patient department, MMR=maternal mortality ratio, SBA=skilled birth attendance, MOH=Ministry of Health, MPI=Ministry of Planning and Investment, O&M=maintenance and operations, OPD=out-patient department. Source: MOH. 2015. Health Sector Development Program: Project Grant 0173 Completion Report. Vientiane and the program completion review mission. MPI. 2012. Lao Social Indicator Survey 2011-2012. Vientiane

Appendix 3 21

TRAINING PROGRAMS PROVIDED

Training and Capacity Building Program

Tra

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Gender and Ethnicity Provinces

Ce

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Le

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20

10

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11

20

11

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12

20

12

-20

13

20

13

-20

14

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1. Long Term Training

Specialist Resident Training 3 Yr. 24 24 17 7 10 2 1 7 2 2 2 3 5 Specialist Resident Training 3 Yrs. 9 9 4 5 4 1 2 2 1 1 2

Sub-Total 33 33 21 12 14 3 3 9 3 2 2 4 7

Percentage (%) 64 36 42

PHC Medical Assistant (Mid-level) 1 Yr. 94 94 58 36 59 6 25 12 7 15 10 2 17

PHC Medical Associate (Post basic) 2 Yrs. 30 30 23 7 13 3 3 3 4 6 4 4 3

PHC Medical Associate (Post basic) 2 Yrs. 30 30 22 8 12 5 2 4 3 3 4 5 4

PHC Medical Associate (New entry) 3 Yrs. 27 27 12 15 15 4 6 2 5 2 3 5

PHC Medical Associate (New entry) 3 Yrs. 12 12 6 6 1 3 8 1

PHC Medical Associate (New entry) 3 Yrs. 32 32 20 12 30 3 3 3 6 4 10 3

Sub-Total 154 71 225 141 84 130 17 34 28 19 38 24 32 33


Community Midwives (Post Basic) 1 Yr. 60 60 7 53 8 10 8 10 10 12 10

Community Midwives (Post Basic) 1 Yr. 30 30 4 26 7 4 26

Community Midwives (Direct entry) 2 Yrs. 63 63 0 63 28 3 8 9 17 13 5 8

Sub-Total 60 93 153 11 142 43 3 18 9 12 53 23 17 18


Total Long Term Training 60 187 164 411 173 238 187 23 55 46 34 93 49 53 58


2.Special Skills Training SBA Short Training 2 m 58 58 25 33 33 10 6 8 6 7 10 11 SBA Short Training 2 m 80 80 28 52 38 6 16 11 18 10 10 9 SBA Short Training 2 m 7

6 76 26 50 40 13 10 4 13 12 7 17

Total SBA Training 58 80 76

214 79 135 111 29 32 23 37 29 27 11 26


EmONC 3 w 17 40 57 1 56 11 5 10 6 8 8 7 8 5 Obstetric and newborn emergency care for district hospital staff

12 w 42

42 3 39 18 5 3 5 3 7 7 7 5

MCH Team Training 20 20 11 9 0 5 5 5 5 MCH Team Training 10 10 5 5 0 4 6

Appendix 3 22

Training and Capacity Building Program

Tra

inin

g D

ura

tio

n 2010 to 2014

Gender and Ethnicity Provinces

Ce

ntr

al

Le

ve

l

20

10

-20

11

20

11

-20

12

20

12

-20

13

20

13

-20

14

To

tal

Ma

le

Fe

ma

le

Eth

nic

Ph

on

gs

aly

L

ua

ng

na

mth

a

Ou

do

mx

ay

Bo

ke

o

Lu

an

gp

rab

an

g

Hu

ap

ha

nh

Xa

ya

bu

ry

Xie

ng

kh

ua

ng

Total MNCH Training 17 60 10 42

129 20 109 29 15 17 16 16 15 14 26 10


Total Participants 754 272 482 327 67 104 85 87 137 90 90 94

Percentage % 36 64 43

VHW Training 112 112 73 39 88 15 11 13 13 15 15 15 15 VHV Training on Drug Kits 295 295 43 26 35 35 48 62 17 29 VHV Re-training on Drug Kits 575 575 85 45 69 70 96

125 18 67

Total VHW and VHV Training 870 112 982 73 39 88 143 82 117 118 159 202 50 111

Technical Skills Training

Training on GIS for Mapping 17 2 2 3 2 2 2 2 2 Planning Training for Technical staff at Central and 17 provinces.

54

3 3 3 3 3 3 3 3 30

Total Technical Training 71 5 5 6 5 5 5 5 5 30

3.Education Skills Training: A series of workshops of 2 days to 2 weeks on education methodology, refresher on continuing education and skills training of lecturers.

852

852

Educational Development skills training in all the provincial PHS 129 129

Medical Education Short Term training in Khon Kaen University, Thailand 11 11

Total Education Skills Training 992 992

4. Basic Skills in HEF for Management, staff and HEF committees Training HEF DHO Team in 3 provinces 104 28 44 32

Training HEF Management Team (8 provinces) 144 28 20 20 40 36 Training of 8 Provincial HEF Management committees 112 14 14 14 14 14 14 14 14

HEF Training District management in 8 provinces 96 12 12 12 12 12 12 12 12 HEF training of provincial hospital staff. 56 7 7 7 7 7 7 7 7

HEF training of District hospital staff. 310 35

25 35 25 50 45 55 40

HEF training of health center staff. 124 14 10 14 10 20 18 22 16 HEF Retraining in selected provinces 89 49 40

HEF Training in Phonsaly and Luangprabang 51 21 30

Total Basic Skill training in HEF 1,086 180 88 110 88 213 132

154 121

TOTAL 3,885 395 279 318 298 514 429 299 331 1,022

DHO=department of health office, EmoNC= emergency obstetric and newborn care, GIS=geographic information system, HEF=health equity fund, MCH=maternal and child health, m=month, PHC=primary health care, PHS=public health school, SBA=skilled birth attendant, VHV=village health volunteer, VHW=village health worker, w=week, Yr.=year. Source: MOH, 2015. Health Sector Development Program: Project Grant 0173 Completion Report. Vientiane and program completion review mission

Appendix 4 23

IMPLEMENTATION SCHEDULE

Activity/Task 2009-2010

2010–2011

2011–2012

2012–2013

2013–2014

2014–2015

Fiscal Year Quarters 01-03 04-06 07-09 10-12 01-03 04-06 07-09 10-12 01-03 04-06 07-09 10-12 01-03 04-06 07-09 10-12 01-03 04-06 07-09 10-12

Component 1: Strengthened planning and financing

1.1 Enhanced planning and financing capacity National meeting on the program

Strengthen planning division of Ministry of Health

Create internal financial control unit

Train provinces on program approach

Train districts on program approach

Health equity fund provincial capacity building

Consulting services

1.2 Efficient program administration and coordination

Program coordination and monitoring

Appendix 4 24


2010–2011

2011–2012

2012–2013

2013–2014

2014–2015

Fiscal Year Quarters 01-03

04-06

07-09

10-12

01-03

04-06

07-09

10-12

01-03

04-06

07-09

10-12

01-03

04-06

07-09

10-12

01-03

04-06

07-09

10-12

Component 2: Increased access to Maternal, Newborn, and Child Health care (MNCH)

2.1 Upgraded hospitals and health centers National strategy for MNCH

Guidelines for provincial and district hospitals

Consulting services

District wise roll out of mother and child MNCH package

Improving district hospitals

Improving health centers

Assess equipment needs

Replace MNCH equipment

Ambulances for type district hospitals

Motorcycles for health centers

Appendix 4 25


2010–2011

2011–2012

2012–2013

2013–2014

2014–2015

Fiscal Year Quarters 01-03

04-06

07-09

10-12

01-03

04-06

07-09

10-12

01-03

04-06

07-09

10-12

01-03

04-06

07-09

10-12

01-03

04-06

07-09

10-12

2.2 Expanded model healthy villages Guidelines and strategic plan

Provincial and district capacity building

Village capacity building and monitoring

Component 3: Improved quality of human resources for health

2.1 Trained Skilled Birth Attendants Upgrading staff to skilled birth attendants

Upgrading primary health care workers to mid-level

Training high level primary health care doctors

2.2 Improved quality of pre-service education Institutional development plans

Upgrade faculty

Consulting services

Teaching and curriculum improvement

Human resource management information system update

Department of health personnel capacity building

Planned

Actual

Appendix 5 26

COMPLIANCE WITH GRANT COVENANTS

Reference in Grant Agreement Covenants Status of Compliance

Program Grant Agreement, Article IV, Section 4.02 (a)

The Recipient shall maintain, or cause to be maintained, records and documents adequate to identify the Eligible Items financed out of the proceeds of the Grant and to record the progress of the Program.

Complied

Program Grant Agreement, Article IV, Section 4.02 (b)

The Recipient shall enable ADB's representatives to inspect any relevant records and documents referred to in Article IV, Section 4.02 (a).

Complied

Program Grant Agreement, Article IV, Section 4.03 (a) Program Grant Agreement, Article IV, Section 4.03 (b)

As part of the reports and information referred to in Section 6.04 of the Grant Regulations, the Recipient shall furnish, or cause to be furnished, to ADB all such reports and information as ADB shall reasonably request concerning (i) the Counterpart Funds and the use thereof; and (ii) the implementation of the Program, including the accomplishment of the targets and carrying out of the actions set out in the Policy Letter. Without limiting the generality of the foregoing or Section 6.04 of the Grant Regulations, the Recipient shall furnish, or cause to be furnished, to ADB quarterly reports on the carrying out of the Program and on the accomplishment of the targets and carrying out of the actions set out in the Policy Letter.

Complied The project quarterly progress reports and annual reports submitted to ADB include information on progress and achievement of program and project implementation as well as status of implementation of policy actions

Program Grant Agreement, Schedule 4, para.1

MOH, acting though DPF shall be the Program Executing Agency responsible for coordinating all policy, legal and regulatory actions. MOH shall ensure that (i) the policy reforms set out in the Policy Letter are duly carried out in a timely manner; and (ii) provisions for reporting, monitoring and auditing and other administrative requirements are strictly complied with.

Complied


The MOH Steering Committee chaired by the Minister of Health and comprising the vice ministers of MOH and representatives of various departments of MOH shall provide overall guidance in Program implementation. MOF, the Ministry of Planning and Investment, and other ministries shall join the Committee as required. MOH's sector coordination working group and technical working groups for human resource development, MNCH and health shall meet regularly to develop the health sector plans and coordinate the program management.

Complied


Within DPF, the already established project PCU headed by the Deputy Director General of DPF as Program Director shall serve as Program PCU. The PCU shall comprise three (3) deputy directors, two (2) administration officers, and one (1) private firm for accounting services and shall be responsible for (i) Program coordination; and (ii) timely submission of policy measures.

Complied


Within MOH, NIAs shall be established under the Departments of Organization and Personnel, Curative, Food and Drugs, and MNCH hospital. NIAs shall be responsible for planning, implementing and reviewing delegated Program activities within their responsibilities.

Complied

Appendix 5 27



The Recipient shall: (i) ensure that the objectives achieved, policies adopted, and actions taken prior to the date of this Grant Agreement, as set forth in the Policy Letter, shall continue to be in full force and effect for the duration of the Program period and subsequently; (ii) carry out the policies and actions in accordance with the schedule of policy reforms contained in the Policy Matrix and ensure sustainability of the reforms beyond the Program period; and (iii) carry out all of its obligations as stipulated under this Schedule and the Grant Agreement, in a timely manner.

Complied


The Recipient shall ensure that all action plans developed as a result of the Policy Matrix shall be fully implemented by the end of the Program period.

Complied


The Recipient shall keep ADB informed of, and the Recipient and ADB shall from time to time exchange views on, sector issues, policy reforms and additional reforms during the Program period that may be considered necessary or desirable, including the progress made in carrying out the Program.

Complied


The Recipient shall engage in policy dialogue with ADB, in a timely manner, on problems and constraints encountered during Program implementation and on desirable changes to overcome or mitigate such problems and constraints.

Complied


The Recipient shall keep ADB informed of policy discussions with other multilateral or bilateral agencies that have implications for the implementation of the Program, and shall provide ADB with an opportunity to comment on any resulting policy proposals. The Recipient shall take ADB’s views into consideration before finalizing and implementing any such proposals.

Complied


The Recipient shall ensure that (i) counterpart funds in an amount equivalent to the Program funds are made available to the Participating Provinces for non-salary recurrent budget support in the health sector, and shall not be used to pay for any costs accruing prior to the Effective Date or for payment of electricity bills; and (ii) the counterpart funds equivalent to the Program funds are completely additional to the non-salary recurrent expenditures accrued in financial year 2008-2009, in real terms.

Complied Budgets for the FY2010-2011, 2011-2012, 2012-2013, 2013-2014 and 2014-2015 were submitted to the MPI, and incorporated into the government annual budget plan and approved by the National Assembly. These funds have been made available for the health sector in provinces. The MOF released all funds requested by provincial health offices as per their annual plans and budgets


The Recipient shall, and shall cause MOH to ensure, that quarterly and annual reports are submitted to ADB on the progress of the Program and related policy issues, including the progress milestones vis-à-vis the achievement of indicators, identification of issues and proposed adjustments, as needed. The Program reviews shall be carried out in conjunction with the Project reviews, as detailed in the Project Grant Agreement.

Complied

Appendix 5 28



MOF, through DPF shall (i) monitor the implementation of policy actions set out in the Policy Matrix and its impact on inclusive development, good governance and improved service delivery, in line with the Program impact and outcome indicators agreed upon between ADB and the Recipient; and (ii) submit to ADB quarterly reports, until the completion of the Program, on the status of the formation and implementation of the Recipient's policy actions.

Complied

Project Grant Agreement, Article IV, Section 4.02 (a)

The Recipient shall (i) maintain, or cause to be maintained, separate accounts for the Project; (ii) have such accounts and related financial statements audited annually, in accordance with appropriate auditing standards consistently applied, by independent auditors whose qualifications, experience and terms of reference are acceptable to ADB; (iii) furnish to ADB, as soon as available but in any event not later than nine (9) months after the end of each related fiscal year, certified copies of such audited accounts and financial statements and the report of the auditors relating thereto (including the auditors' opinion on the use of the Grant proceeds and compliance with the financial covenants of this Grant Agreement as well as on the use of the procedures for imprest account/statement of expenditures), all in the English language; and (iv) furnish to ADB such other information concerning such accounts and financial statements and the audit thereof as ADB shall from time to time reasonably request.

Complied

Project Grant Agreement, Article IV, Section 4.02 (b)

The Recipient shall enable ADB, upon ADB's request, to discuss the Recipient’s financial statements for the Project and its financial affairs related to the Project from time to time with the auditors appointed by the Recipient pursuant to Section 4.02(a) here above, and shall authorize and require any representative of such auditors to participate in any such discussions requested by ADB, provided that any such discussion shall be conducted only in the presence of an authorized officer of the Recipient unless the Recipient shall otherwise agree.

Project Grant Agreement, Article IV, Section 4.03

The Recipient shall enable ADB's representatives to inspect the Project, the goods financed out of the proceeds of the Grant, and any relevant records and documents.

Complied

Project Grant Agreement, Schedule 4, para.1

MOH, acting through DPF shall be the EA for the Project responsible for the overall implementation and coordination of the Project.

Complied


The MOH Steering Committee chaired by the Minister of Health and comprising the vice ministers of MOH and representatives of various departments of MOH shall act as the PSC to provide overall guidance in Project implementation. MOF, the Ministry of Planning and Investment, and other ministries shall join the PSC as required

Complied


Within DPF, the already established PCU headed by the Deputy Director General of the DPF as Health System Development Project Director shall serve as Project PCU. The PCU shall comprise three (3) deputy directors, two (2) administration officers, and one (1) private firm for accounting services and shall be responsible for (i) Project coordination; (ii) preparing and managing the Project annual plan and budget; (iii) providing guidance to NIAs and PIAs; (iv) monitoring social and environmental safeguards; (v) ensuring that ADB requirements are being complied with; (vi) monitoring and evaluating the Project; (vii) submitting quarterly progress and financial reports to ADB; (viii) conducting reviews and surveys; (ix) major Works and procurement of goods and services; (x) hiring consulting services, and (xi) administrative and financial management.

Partly Complied Social and environmental safeguards were monitored and reported in the project quarterly progress report. However, no separate annual environmental safeguard monitoring report prepared and submitted to ADB.

Appendix 5 29



Within MOH, NIAs shall be established under the Departments of Organization and Personnel, Curative, Food and Drugs, and MNCH hospital. NIAs shall be responsible for planning, implementing and reviewing delegated Project activities within their responsibilities.

Complied


PHOs in the Participating Provinces, through their Primary Health Care Coordination Units shall act as Project PIAs and shall be responsible for (i) supporting the preparation of annual operational plans; (ii) facilitating the processing and implementation of conditional grants; (iii) implementing provincial Project activities and ensuring the quality of these activities, including training and minor Works procurement; and (iv) financial management of the Project.

Complied


The Recipient shall ensure that the counterpart financing necessary for the Project is provided in time, and that MOH, through DPF, make available all funds and resources necessary for construction, operations and maintenance of the Project on a timely basis. MOH shall further ensure that additional counterpart funding is available to cover any funding shortfalls that may incur during Project implementation.

Complied


MOH, through DPF, shall ensure that PIAs in each Participating Province prepare annual reports, plans and budgets for every fiscal year for the approval of the PSC and shall further ensure that PSC approves these annual reports, plans and budgets in a timely manner.

Complied


The Recipient shall ensure that the Internal Financial Control Unit, Department of Planning and Finance of MOH has been empowered to conduct periodic inspection of Health Sector Development Project accounts in the participating Provinces.

Complied The internal financial control process was established and regular inspections of program accounts in provinces and districts were carried out. Annual audits of project expenditures were carried out by the State Audit Organization. A total of six audited project financial statement reports with unqualified auditor’s opinion were submitted to ADB


MOH shall ensure that in the event that any resettlement impacts are detected for an activity (i) the RP for such activity in accordance with the LARF and ADB’s Involuntary Resettlement Policy (1995) is prepared; (ii) RPs are prepared on the basis of the detailed technical design, disclosed to Project affected people, and submitted to ADB for review and approval; and (iii) all compensation and rehabilitation assistance is paid before disposition of assets.

Complied Site surveys were carried out in Xiengkhuang, Oudomxay, Luangprabang, Xayabury, Phongsaly provinces. No resettlement impact has been detected

Appendix 5 30



MOH shall ensure that the GEGAP is fully implemented and that all Project activities are designed and implemented in accordance with ADB’s Policy on Gender and Development (1998) and Policy on Indigenous People (1998) including, but not limited to: (i) 40% female participation in Health System Development Project supported training programs; (ii) inclusion of equitable provisions relating to the MNCH, gender, and ethnic groups in annual operation plans and budgets; (iii) inclusion of provisions for gender and ethnic groups for all targets relating to workforce and consumers in all guidelines, terms of reference, policies, master plans, strategies, and action plans developed under the Health System Development Project; and (iv) all monitoring and evaluation data disaggregating by sex and ethnicity.

Complied Data on gender and ethnicity were systematically collected, particularly with regard to training activities. The gender action monitoring table was updated quarterly and report through project quarterly progress reports.


MOH shall ensure that the construction and/or upgrading of all health facilities comply with all applicable laws and regulations of the Recipient, the IEE, and the ADB’s Environment Policy (2002). MOH shall further ensure that (a) ADB is informed if the construction and/or upgrading of any health facility requires the removal of hazardous materials; (b) Decree 1706 on health facility waste management and National Integrated Health Care Waste Management Plan is disseminated; and (c) the Health Care Waste Management Guidelines developed by World Health Organization are translated in Lao language and are adopted by the Recipient.

Complied The domestic architect firm, in collaboration with the Project Coordination Unit civil works unit, ensured that construction of health facilities complied with all applicable laws and regulations of Lao PDR, initial environmental examination, and ADB’s Environment Policy. The initial environmental examination (IEE) and environmental management plan (EMP) were incorporated in bid documents for civil works. By the end of 2012, the domestic architect firm had carried out an inspection based on EMP and provided a report to confirm that the environmental safeguards were complied with.

Appendix 5 31



MOH shall ensure that (i) relevant provisions of ADB’s Anticorruption Policy (1998, as amended to date) are included in all bidding documents for the Project; (ii) MOH staff not familiar with ADB’s Anticorruption Policy receive orientation; (iii) the system of notice board display of information at the PHOs is established to display, among other things, information on contracts, list of participating bidders, name of the winning bidder, basic details on bidding procedures, contract award, and list of Goods and services procured; and (iv) the steering committee of MOH comprising representatives from MOF, Ministry of Planning and Investment, Ministry of Justice, and ADB acts as the grievance redress body to (a) receive and resolve complaints/grievances or act upon reports from stakeholders on misuse of funds and other irregularities; (b) review and address grievances of stakeholders of the Project, in relation to either the Project, any of the service providers, or any person responsible for carrying out any aspect of the Project; and (c) proactively and constructively respond to them.

Complied


Without limitation to the overall application of Section 4.02 of this Grant Agreement, MOH shall, and shall cause the PIAs to ensure, that (i) separate records and accounts are maintained for the Project to identify Goods and services financed under the Project; (ii) Project accounts, including financial statements, are audited annually by the Recipient's State Audit Organization or any other certified auditor acceptable to ADB, using international accounting and auditing standards; (iii) the auditor's report and copies of the certified accounts and related financial statements, including auditor's opinion on the use of Grant proceeds, and compliance with Grant covenants, is submitted to ADB no later than nine (9) months after the close of each fiscal year in English language; and (iv) a separate audit opinion is issued on the use of the imprest account and statement of expenditure procedures.

Complied


MOH shall ensure that (i) quarterly progress reports on Project implementation are submitted to ADB within 30 days of the end of each quarter; (ii) the progress reports are in English and in a format acceptable to ADB and include, among other things, progress made against established targets, problems encountered during the previous quarter, steps taken to resolve problems, compliance with Grant covenants, and the proposed program of activities for the succeeding quarter; and (iii) a Project completion report is submitted to ADB, within three (3) months after physical completion of the Project, providing details of Project implementation and accomplishments, outstanding issues, and proposed remedial actions.

Complied Project quarterly progress reports submitted on time.


The Recipient and ADB shall conduct joint Health System Development Project reviews, including Project midterm and completion reviews. The reviews shall (i) focus on Project outcome, activities, inputs, administration, policy reforms provided in the Policy Letter, and institutional and sustainability aspects including aid coordination; and (ii) examine compliance with social, environmental, financial, and other covenants in this Grant agreement.

Complied

ADB= Asian Development Bank, DPF= Department of Planning and Finance, EA=Executing Agency, EMP=Environmental Management Plan, GEGAP=Gender and Ethnic Group’s Action Plan, IEE= Initial Environmental Examination, LARF=Land Acquisition and Resettlement Framework, MOF=Ministry of Finance, MOH=Ministry of Health, MNCH=Maternal, Newborn, and Child Health, MPI= Ministry of Planning and Investment, NIA=National Implementing Agency, PCU=Project Coordination Unit, PIA=Provincial Implementing Agency, PSC=Project Steering Committee. Source: MOH, 2013. Health Sector Development Program: Program Grant 0172 Completion Report. Vientiane, MOH, 2015. Health Sector Development Program: Project Grant 0173 Completion Report. Vientiane, ADB. 2014. Implementation Completion Memorandum of Developing Model Healthy Villages in Northern Lao People’s Democratic Republic (Financed by the Japan Fund for Poverty Reduction). Manila and program completion review mission.

Appendix 6 32

SUMMARY OF GENDER EQUALITY RESULTS AND ACHIEVEMENTS

I. PROJECT DESCRIPTION

1. The Asian Development Bank (ADB) approved the Health Sector Development Program on 10 November 2009 and it became effective on 17 December 2009. The program component (G0172) supported major policy reforms to improve the quality of health services, while counterpart funds supported an increase in non-wage recurrent budget. The project component (G0173) supported capacity building for implementation of the reforms, and selective investment to improve access to health services. The completion date of the program component was 31 August 2012 and the project component was completed on 30 June 2015. The program was categorized Gender Equity as a Theme (GEN).

2. The program impact was to reduce maternal and infant mortality and malnutrition by 2015. The outcome would be improved use of primary health care (PHC), in particular by the poor, women, children and ethnic groups. The program outputs were (i) strengthened planning and financing; (ii) increased access to maternal, newborn, and child health care (MNCH); and (iii) improved quality of human resources for health.

II. GENDER ANALYSIS AND PROJECT DESIGN FEATURES

A. Gender Issues and Gender Action Plan Features

3. Women in the Lao People’s Democratic Republic (Lao PDR) are more vulnerable and deprived than men because of their unequal access to land, food, education, and health care, and their long working hours. While gender roles vary within rural communities, women from ethnic groups tend to be the most disadvantaged. Compared with men, women on average have far lower literacy levels, school enrollment and completion rates. This education gender gap widens at higher levels of schooling. Women are key beneficiaries from investments in health care as they are primarily responsible for taking care of daily household needs and family health. The choice of health practices, such as the location of births and use of birth attendants continues to be shaped by culture and tradition, decisions that frequently do not appear to be controlled by women but more likely the decisions of parents and their husband. Early marriages and early child-bearing ages of women also build on such traditions, which have severe implications for the health and well-being of girls whose bodies are not sufficiently developed to withstand pregnancy and childbirth.

4. The GAP was developed to support gender sensitive planning, budgeting, and reporting at all levels and to integrate equity concerns in all program activities and to ensure that women and ethnic groups have equal opportunities to participate in, and benefit from, the program. The key gender targets include:

(i) At least 20% of participants in health manager training and 40% of participants in technical training are women;

(ii) At least one of two village health volunteers in each village is a woman; (iii) Provincial, district, and village health committees include at least 30% female

members and a proportional mix of ethnic groups; (iv) Ministry of Health (MOH) has secured at least 50% of funding for implementation

of the national skilled birth attendance development plan;

Appendix 6 33

(v) At least 30% of participants for upgrading teaching staff are women, and ethnic groups are proportionally represented, and at least 50% of trained staff members are women.

B. Overall Assessment of Gender-Related Results and Achievements

5. The GAP consisted of 37 gender actions. At program completion, all 37 actions were implemented. The program achieved 29 out of 32 of qualitative gender actions and four out of five quantitative targets (80%). The implementation of the GAP is assessed as successful. The key achievement included: 70 (66%) out of 106 participants in health manager training and 150 (53%) out of 280 participants technical training were women (target 20%). The government has allocated funding for implementation of the National Skilled Birth Attendance Development Plan (2009-2012) with KN5,101,863,000 ($633,064) which is 59.6% of total required budget of KN8,548,231,048 ($1,060,706) (target 50%). The project grant supported six training courses for upgrading teaching staff in university and three provincial health science colleges, 373 (52%) out of 712 trainees were women (target 30%) and 411 (61%) out of 672 staff members trained (in-service training) were women (target 50%).

6. The project coordination unit (PCU) in MOH’s Department of Planning and International Coordination, together with the provincial health departments, were responsible for implementation, monitoring, and reporting on the GAP. An international gender consultant (2 person-months) and national gender consultant (17 person-months) were recruited on an intermittent basis to support implementation of the GAP over four years of program implementation. Sex-disaggregated data collection was integrated into overall project’s monitoring and evaluation (M&E) system. The GAP monitoring table was regularly updated and attached to project quarterly progress reports. GAP implementation progress was included in grant covenants and incorporated into project activities to ensure that the activities were responsive to the needs of women and ethnic groups.

C. Gender Equality Results

1. Participation, Access to Project Resources, and Practical Benefits

7. The program interventions benefited women through MOH’s development of standards, guidelines, and terms of reference for district hospitals, which included gender and ethnic group targets for staffing and requirements to ensure adequate facilities for women. For instance, the Health Personnel Development Strategy 2020 sets targets for female staffing for skilled birth attendants (SBA). Standards for district hospital and health center design gave attention to the privacy needs of women such as separate toilets for women, and delivery and post-delivery rooms.

8. The project grant supported training on (i) gender awareness raising for health officers in eight target provinces and staff from the MOH, 26 (58%) out of 45 were women; (ii) SBA for district and health center staff, 135 (63%) out of 214 participants were women and 111 (52%) were ethnic people. As part of these training courses, constraints to women’s access to health care services, such as cultural and traditional beliefs and poverty, and the possible responses to these constraints, were discussed. For example, geographical barriers that prevent women from accessing safe delivery services in health facilities can be addressed by developing the network of SBA and strengthening their skills in home delivery. Also, cultural barriers were addressed by giving priority to women in training for; (iii) community midwifery for health center staff, 142 (93%) of 153 participants were women and 43 (28%) were from ethnic groups; (iv) comprehensive emergency obstetric and newborn care (EmONC) for health center staff, all 56

Appendix 6 34

participants were women and 11 (19%) were from ethnic groups; (v) basic emergency obstetric and newborn care (BemONC) for health center staff, 39 (92%) out of 42 participants were women and 18 (43%) were from ethnic groups; (vi) training on PHC for village health workers, 39 (35%) out of 112 participants were women and 88 (78.5%) were from ethnic groups and (vii) upgrading low-level PHC workers to mid-level skills for improving access to health services in remote areas, 35 (37%) out of 94 participants were women and 48 (51%) were from ethnic groups. Women and ethnic groups were consulted in the planning, implementation and monitoring of provincial health offices’ annual operational plans. Project support for capacity building for health staff was a key achievement of the project, as shown in the case studies below.

The Value of Capacity Building of Key Staff

Dr. Phengsavanh Soulichai, a 39-year-old woman from Phongsaly Provincial Hospital, was among those who received support from the project to take a three-year postgraduate specialist course in gynoecia-obstetric care at the University of Health Science, in Vientiane. Before taking this course, she worked as a general practitioner, assisting normal delivery. After her graduation in October 2012, she returned to work at the Phongsaly Provincial Hospital and was appointed as a head of the gynoecia-obstetric unit. After the training, she gained more confidence to perform her tasks, especially in dealing with complicated cases. At project completion, she had diagnosed and treated four cancer cases (two breast cancers and two uterus cancers) and 94 cases of gynoecia patients, provided counseling to women in high-risk pregnancies; assisted in normal and complicated deliveries consisting of transverse delivery and breech position. vacuum-assisted delivery); provided services for dilatation and curettage (32 cases), female sterilization (107 cases), hysterectomy (12 cases), ovary cyst (14 cases), uterus trauma (2 cases). In addition, she worked with another surgery team on 35 appendicitis cases and five stomach perforation cases. As a result, she became the main teacher and lecturer on the field of gyneco-obstretic for health staff in the provincial and district hospitals. She also carried out onsite training for colleagues in the gynoecia-obstetric unit. The project effectively supported human resource development for health and has had a positive impact on ethnic women and children’s access to high quality gyneco-obstretic care and treatment. This support should be scaled up to other fields for care and treatment as it also contributes to the achievement of Millennium Development Goals 3, 4 and 5.

9. Health facilities: The project supported construction of a new provincial hospital in Phongsaly province, renovation of Viengkham district hospital in Luangprabang province and renovation of Morkmai type B district hospital in Xiengkhuang province. The project also supported the replacement of 10 health centers and renovated 10 other health centers in Luangprabang, Oudomxay, and Xiengkhuang provinces. Construction and renovation of these facilities gave special attention to expanding services for women, including provisions for privacy. The district hospitals have a delivery room that provides quietness and visual privacy and easy access to dedicated toilets and showers for women. The health centers include two separate toilets, one for men and one for women, with the women’s toilet having easy access from the delivery room.

10. Services: The project focused on improving service delivery for women. As a result, in eight target provinces, the deliveries assisted by SBA increased from 28.2% in fiscal year (FY) 2009-2010 to 35% in FY2011-2012 and 48.5% in FY2013-2014. To support the poor, especially women and ethnic people, the project supported awareness-raising activities for the Health Equity Fund (HEF), with radio programs in three ethnic languages (Lao, Khmou and Hmong) and dissemination of brochures at all health centers and through every village health committee (VHC). Peer educators delivered information to the poor, especially to women and ethnic groups

Appendix 6 35

who cannot read and write. From January to December 2014 the number of female patients who used the HEF were 21,375 (52%) out of 41,380, while 17,200 (42%) were ethnic people.

Effectiveness of Lao Women Union Involvement at Community Level

Ms. Vanly Sipaseurth, the president of the Lao Women’s Union (LWU) for Namor district, Oudomxay province. She said that it was a good idea that the project set up a quota for training for women in management and technical training programs, which helped to upgrade female health staff’s knowledge. This led to more female staff working at district hospitals and health centers. She also appreciated having the LWU involved in the promotion of the benefits of the Health Equity Fund (HEF) to assist poor families in Namor district. The LWU had (i) one deputy head engaged in the district health committee, and (ii) an established network throughout all villages in the district. This enabled them to inform all communities about the benefit packages of the HEF scheme, free maternal delivery, family planning, nutrition as well as general health and nutrition services that are available at health centers, and district and provincial hospitals. She confirmed that over the life of the project, there was a marked increase in the number of individuals and families from the poorer social-economic communities who used general health services when they were sick, as well as seeking deliveries at a health facility at no cost. She said that the District LWU was happy that the poor are protected by the HEF scheme because it reduced the risk for pregnant women as they had access to free delivery. As the LWU slogan states, "mothers survive and children are safe".

2. Strategic Changes in Gender Relations

11. Institutional changes included the improved capacity of health staff in gender-sensitive planning and budgeting. This was demonstrated in the MOH’s five-year Health Sector Development Plan (2011-2015), which was developed based on the second five-year National Strategy for the Advancement of Women (2011-2015). Gender mainstreaming was integrated into planning and budgeting at provincial and district levels. The MOH’s Human Resource Development Strategy by 2020 sets clear targets and a timeline for the recruitment of female staff at each level of the health system. For example, representation of women and ethnic groups among health leaders and managers was targeted to increase by 35% for women and 20% for ethnic groups by 2015, and by 50% and 35%, respectively, by 2020. The data on health service coverage indicators were disaggregated by sex and ethnicity.

Positive Changes in Traditional Norms

Ms. Earlor is from a poor family in Namkuang village, Xiengkhuang province. Earlor, a Hmong woman, is 29 years old and, together with her husband Songya, they have had 5 children, aged 2, 4, 7, 9 and 11. All five children were born at home. One of their five children was affected by polio. In July 2015, she was seven months pregnant with her sixth child. Earlor said that she had never thought about giving birth in hospital because her family had no money and her parents’ generation had always delivered their babies at home. Ms. Earlor’s opinion changed after local health staff conducted community awareness sessions in her village on the risks of delivering at home, and the availability and supporting benefits of the health equity fund for poor families. The couple decided to have their child delivered in the district hospital. The child was born healthy. With program support, the district and health centers conduct outreach activities on integrated maternal and child health services in villages four times a year. During these visits separate discussion session were held with potential health equity fund beneficiaries to inform them about the HEF benefit packages.

Appendix 6 36

12. At the community level, the project set targets for the involvement of women and ethnic groups in project activities, which is at least one female village health volunteers (VHV) in each village and one female staff member in each health facility. The basis of the plan was that the female VHVs and health center staff have greater empathy with the female community members and could contribute to better understanding of women’s health concerns, which in turn would lead to behaviour change thereby resulting in increased health service utilization among women and ethnic groups.

3. Contribution of Gender Equality Results to Overall Program Outcomes and Effectiveness

13. The GAP contributed to attaining the overall goal of improving health status in the eight targeted provinces, particularly among the poor, women, children and ethnic groups. The project's gender equality results were due to the GAP's sound design, implementation and monitoring. The GAP was well incorporated into program activities, which addressed access barriers to health services for women and ethnic groups as well as other key issues identified during project appraisal. Greater health service utilization and changed behaviour in service utilization among women and ethnic groups were achieved as a result of the expanded health service networks, increased number of skilled female health staff and culturally appropriate health promotion activities delivered to community members.

I. LESSONS LEARNED AND RECOMMENDATIONS

14. The following factors were considered significant in achieving GAP targets:

(i) The ADB project officer and social development officer (Gender) provided clear

guidance and technical support on GAP implementation; and

(ii) The project management team was receptive to gender concerns and strongly

supported GAP implementation and monitoring.

15. GAP implementation was generally successful. However, two performance targets were not achieved, and two other targets were only partly achieved. Unachieved performance targets include:

(i) Not achieved target: at least one out of two VHVs in each village should be female. The proportion of villages that have at least one female VHV was 30% against a target of 50%. The key constraints for increasing women’s representation in VHVs are (a) women in remote areas, especially those from ethnic groups, did not meet some selection criteria for VHVs, such as the ability to read and write in Lao language; (b) women follow traditional practices and beliefs that they should strictly follow the decision of elders, parents, and husbands, in which cases women are not allowed to participate in any social events in the community without permission from these people and (c) most women are confined to undertaking housework as their domestic and social tasks;

(ii) Not achieved target: the action was to include contraceptive pills in village drug kits. However, in May 2012, the MOH amended the list of essential drugs, and contraceptive supplies were not included in the list of drugs for village drug kits. The contraceptives are not authorized for distribution below the health center level due to

Appendix 6 37

the MOH requirement that contraceptives should be provided under guidance of medical staff;

(iii) Partly achieved targets: the provincial, district and VHCs include at least 30% female members and a proportional mix of ethnic groups. The actual proportion of women in the provincial health committees was 24%, and 18% in the district health committees, and 32% in the VHCs. This was due to the fact that the provincial and district health committee members are directors or deputy directors of the provincial and district departments, have low female representation. It should be noted that these positions are appointed by provincial and district authorities, placing the process beyond the scope of the program. In the future, if this performance indicator is to be included in the GAP, the program has to include affirmative actions to increase the number of women in these positions at provincial and district levels;

(iv) Partly achieved target: one female staff in each health facility. In the eight target provinces, 83% of 414 health centers had at least one female staff and 32.6% of 1,345 health center staff were from ethnic groups. This because (a) it was difficult to find women in remote areas who completed secondary school in order to continue to study in health science and work at the health center on graduation; and (b) health centers in remote areas are not attractive to health staff from urban areas due to difficult transportation and poor living conditions. To address these challenges, the MOH offers scholarship to women who completed secondary education and are committed to work in health centers in remote area, to study in medical college and the University of Health Science.

16. The following recommendations will enhance long-lasting impacts on women in future projects:

(i) GAP requirements and gender targets should be clearly communicated at all levels

of project implementation, and as early during implementation as possible;

(ii) Project M&E system should integrate sex-disaggregated data right at the beginning

of project implementation to ensure accuracy of reporting;

(iii) Gender indicators related to program component should be integrated into the policy

matrix;

(iv) Project managers should coordinate more closely with the MOH’s Division of the

Advancement of Women (DAW) when formulating and implementing the GAP to

strengthen coordination mechanism between DAW and the project, and gradually

build the division's capacity to co-lead GAP implementation and monitoring, as well

as to sustain the gender gains achieved beyond the life of the project.

Appendix 6 38

ACHIEVEMENTS OF GENDER ACTION PLAN IMPLEMENTATION

Gender Action Plan

(GAP Activities, Indicators and Targets, Timeframe and Responsibility)

Achievements

A. Strengthening Planning and Financing (1) The national health information

system strategic plan requires

disaggregated use of service data by

gender and ethnic group.

Achieved

The National Health Information System Strategic Plan includes collection of service-use data according to sex and ethnicity of patients. For example, the inpatient registration form no. 1 includes details on gender and ethnicity disaggregated data. Other data variables include residence, age, and occupation. Ethnicity is currently recorded in the inpatient and outpatient registers.

(2). Provincial annual operation plans and budgets give priority to MNCH services, and especially address needs of the poor, women, and ethnic groups.

Achieved The annual operational plans of FY2010-2011,2011-2012, 2012-2013, 2013-2014,and 2014-2015 gave priority to maternal, newborn and child health (MNCH) services, and addressed needs of the poor, women, and ethnic groups to achieve health-related Millennium Development Goals (MDGs). Eight northern provinces allocated sufficient budget for implementation of Health Equity Fund (HEF). Budget allocation for HEF is based on the number of the poor and the rate of poverty.

(3). MOH standards, guidelines, and terms of reference for district hospitals include gender and ethnic group targets for staffing and requirements to ensure adequate facilities for women.

Achieved

The Health Personnel Development Strategy by 2020 has stipulated that gender and ethnicity considerations must be an integral part of staffing levels. Female staff must represent at least 50% health sector workforce at all levels. Skilled Birth Attendants must be 100% female. The Skilled Birth Attendance Development Plan and the Strategy and Planning Framework for the Integrated Package of MNCH Services (2009-2015) focused more on women's needs and MCH staffing, ensuring increasing numbers of female staff and staff with ethnic backgrounds.

Standards for district hospital and health center design approved by MOH in January 2012 and the revised standards approved in March 2014 requires to include the privacy needs of women and a separate toilet is provided for women next to the delivery and post-delivery rooms.

(4). Guidelines for 5-year plans and annual operation plans and budgets adequately address poverty, gender and ethnic group concerns.

Achieved

The MOH’s five-year sector development plan (2011-2015) and its annual operational plans (AOP) have specific references to equality, gender and ethnicity. The quality standards of the University of Health Science include provision for gender equality and affirmative action for specific ethnic groups. For example, the plan and AOPs gave priority to maternal and child health services, and emphasizes geographical focus on remote areas where the poor and ethnic people live.

(5). Training of provincial and district health officers adequately addresses poverty, gender and ethnic group concerns.

Achieved Training guidelines prepared under the project provide orientation to gender concepts, gender gaps, ethnicity and other factors determining health inequity. Training for provincial health staff on project’s gender requirements and gender and ethnic group development plan, and mainstreaming gender and ethnicity concerns into AOPs of provincial health offices were conducted by the MOH’s Division for Advancement of Women. Constraints of women’s access to health centers and hospitals, such as poverty, cultural and traditional norms, and solutions to these issues were discussed during the following training courses supported by the project.

Appendix 6 39

Gender Action Plan


Achievements

(i) A training on gender awareness for health officers in eight target provinces, 26 (58%) of 45 were women;

(ii) Eight 2-month training on SBA for district and health center staff, 135 (63%) out of 214 participants were female and 111 (51%) were from an ethnic background;

(iii) Seven trainings on community midwife for health center staff, 142 (93%) out of 153 participants were female and 43 (28%) were from an ethnic background;

(iv) Four trainings on comprehensive emergency obstetric and newborn care for health center staff, 56 (98%) out of 57 participants were female and 11(19%) were from an ethnic background;

(v) A training on basic emergency obstetric and newborn care for health center staff, 39 (98%) out of 56 participants were female and 18 (32%) were from ethnic backgrounds;

(vi) Seven trainings on primary health care for village health workers, 39 (35%) out of 112 participants were female and 88 (79%) were from an ethnic background; and

(vii) Three trainings to upgrade low-level primary health care workers to mid-level skills for improving access health service in remote areas, 35 (37%) of out of 94 participants were female and 48 (51%) were from an ethnic background.

(6). Women and ethnic groups are consulted in the planning, implementation, and monitoring of provincial health plan (e.g., the Lao Women’s Union and the Lao Front for National Construction).

Achieved

The MOH was using a participatory planning manual which stated that women and men of all ethnic groups should be involved in the planning process.

Provincial health offices confirmed that representatives of the Lao Women’s Union (LWU) and the Lao Front for National Construction, as well as women and ethnic groups, were consulted during the planning, implementation, and monitoring of the provincial health plan. In the process of development of AOPs, a number of consultations took place at heath center, district and provincial levels. The plans were then submitted to the Department of Planning and International Cooperation, MOH to consolidate into MOH’s annual plan.

The key women’s issues raised during the consultation included the barriers that prevent women from accessing health services. Firstly, from a cultural perspective, women and men still hold traditional beliefs regarding pregnancy that home deliveries is traditional and not life threatening; therefore it is not necessary to visit health facilities. Secondly, the majority of ethnic women cannot speak the Lao language, and therefore rely on their husbands or relatives to accompany them to the health facilities. To address these issues, the project encouraged women from local communities to be village health volunteers by setting up a quota for female village volunteers.

(7). Provincial 5-year plans, annual operation plans and budgets, and district plans and budgets include poverty, gender, and ethnic-group targets and staffing and service coverage.

Achieved All provinces developed provincial five-year operational plans based on the MOH’s seventh five-year Health Sector Development Plan (2011-2015), which gave priority to MNCH services, especially addressed the needs of the poor, women, and ethnic groups within the general framework, and towards reaching health-related MDGs by 2015. Annual operation plans for FY2012-2013, 2013-2014, and 2014-2015 prioritized MNCH services and included HEF, which gives priority to the poor.

(8). Provincial and district facilities have gender and ethnic targets for personnel, management, facilities, and coverage.

Achieved

The five-year Strategic Human Resources Development Plan was developed based on the Health Personnel

Appendix 6 40

Gender Action Plan


Achievements

Development Strategy by 2020 includes a gender perspective. The MOH’s staff recruitment plan included the following targets.

(i) Capacity building of leaders and health managers:

Target by 2015: 35% of female staff, and 20% of ethnic groups Target by 2020: 50% of female staff, and 35% of ethnic groups

(ii) Capacity building for technical staff:

Target by 2015: 60% of female staff, and 18% of ethnic groups Target by 2020: 60% of female staff, and 18% of ethnic groups

For health facilities supported by the project, attention has been given to services for women and to their privacy. District hospitals have delivery blocs that provide auditory and visual privacy and easy access to dedicated toilets for women. In health centers, the design includes a delivery room with visual privacy and some auditory privacy. The health center design includes two separate toilets for men and women with easy access from the delivery room.

In terms of coverage, the project focuses on service delivery for women. The MOH’s data show a significant increase in utilization of services for women. For instance, in the eight target provinces, the deliveries assisted by SBA increased from 28.2% in FY2009-2010 to 35% in FY2011-2012 and 48.5% in FY2013-2014. Similarly, the proportion of caesarean section operations performed increased from 1.07% in FY2009-2010 to 2.01% in FY2011-2012 and 2.4% in FY2013-2014.

(9). Health equity fund design and guidelines provide for reaching women and ethnic groups in terms of targeting, awareness, and sensitization activities in a form and language understood by the key target groups, particularly ethnic groups.

Achieved

The HEF design and guidelines provide targeting mechanisms for reaching the poor whatever their sex and ethnic group. The HEF follow-up survey conducted in 2010 showed that the scheme reached women and the poor and there was no significant difference in service utilization between men and women. Also, the survey showed a significant increase in utilization of the HEF among ethnic groups. The HEF guidelines approved in 2011 did not include sex-disaggregated and ethnic groups data. With inputs from a gender consultant, the guidelines were reviewed and revised to include sex and ethnic disaggregated data in October 2014.

In 2013, significant efforts for reaching women and ethnic groups were made to increase awareness of the HEF among the eligible poor, including ethnic groups by conducting focus group discussions with village women. The issues identified from the focus group discussions included (i) lack of health staff who can speak ethnic language; (ii) some women were not aware of the HEF and their entitlements under the scheme; (iii) health promotion activities conducted in villages were mostly attended by men (as a head of household). To address these issues, the project tailored its information dissemination approach by using radio messages in Lao, Khmu and Hmong ethnic languages, village speakers, and village peer education networks.

From January to December 2014, 41,380 patients used HEF. Of these, 21,375 (52%) were women and 17,200 (42%) were ethnic people.

Appendix 6 41

Gender Action Plan


Achievements

(10). Provincial health equity funds provide for reaching women and ethnic groups in their targeting system and for appropriate awareness and sensitization activities in a form and language understood by the key target groups, particularly ethnic groups.

Achieved

To support the poor, especially women and ethnic people, the project supported awareness-raising activities through the Health Equity Fund (HEF), with radio programs in three ethnic languages (Lao, Khmou and Hmong), with brochures delivered to all health centers and every village health committee (VHC) to inform villagers about health services and the HEF. Peer educators delivered information to the poor, especially to women and ethnic groups who cannot read and write.

Focus groups discussions with female and ethnic beneficiaries were carried out in provinces with low utilization of HEF (Oudomxay, Phongsaly, Huaphanh and Luangprabang) to better understand the barriers to accessing health services under the HEF scheme. The findings were used to improved HEF operations. The findings of the focus group discussions were discussed under item (9) above.

(11). Health equity fund surveys disaggregate data by gender and ethnicity; health equity fund facility records document data on gender and ethnicity.

Achieved

The design of household survey of HEF conducted in 2008 and 2010 disaggregated the information on gender and ethnic groups at individual level. Health equity fund facility keep records on data on gender and ethnicity of their patients.

(12). Facility records track MNCH and use of health equity funds (e.g., routine deliveries, c-sections and blood transfusions).

Achieved

The MOH’s Health Information Management System keeps detailed MNCH utilization, while HEF has its specific recording and reporting system. Provincial and district hospitals type A were reporting monthly on utilization of HEF and its related expenditures. The district hospitals type B and health centers were reporting this information on a quarterly basis.

B. Increased Access to Services, Particularly for Women, Children, and Ethnic Groups

(13). The national MNCH strategy is based on a participatory planning approach involving beneficiaries, provides adequate analysis of bidding constraints of MNCH with special attention to social and poverty dimensions of women and ethnic groups, and proposes realistic solutions and budgets to address these.

Achieved

The project supported the development of the National Strategy and Planning Framework for Integrated Package of MNCH Services (2009-2015) and the SBA Development Plan (2008-2012) and these were incorporated into provincial health offices’ AOPs.

The strategy includes mechanisms and resources to increase the minimum package of MNCH services to meet the MDGs. It included training on a large scale of MNCH teams, upgrades and new equipment for facilities with a priority to provide MNCH services, and the provision of funds for operations. Priorities were given to increased access to services for women, ethnic groups and population who live in remote areas.

Appendix 6 42

Gender Action Plan


Achievements

(14). MOH approves an implementation plan for the roll-out of mother-and-child-friendly health facilities to all districts.

Achieved

The MOH has approved the National Strategy and Planning Framework for Integrated Package of MNCH Services (2009-2015). The implementation plan for the strategy was approved by MOH through its decision No. 1794/MOH dated 4 November 2011.

Classifications of mother-and-child-friendly health facilities applied only for provincial and district hospitals, not in health centers.

The eight provincial hospitals and nine district hospitals with mother-and-child-friendly health facilities include:

Provincial hospitals: provincial hospitals of Huaphanh, Luangprabang, Xayabury, Xiengkhuang, Phongsaly, Bokeo, Oudomxay, Luangnatha province.

District hospitals: Viengxay, Huameang, and Vienthong district hospitals in Huaphanh province; Xiengngeun, Nan, and Luangprabang district hospitals in Luangprabang province; Phieng and Botene district hospitals in Xayabury province; and Kham district hospital in Xiengkhuang province.

(15). Guidelines for model healthy villages include specific actions to ensure participation of women and ethnic groups in village committees and other decision-making forums for model healthy villages, and to ensure substantial benefits to women and ethnic groups.

Achieved

The MOH, with support from the Developing Model Healthy Villages in Northern Lao PDR project,1 developed and

tested approaches and guidelines for model healthy villages (MHV). The guidelines included requirements for involvement of women and ethic people in the process of consultation and implementation of MHV activities. A representative of Village LWU is part of the VHCs. Representation of LWU in VHCs plays important role in raising women’s voice during the decision-making process.

(16). All eight provinces implement mother-and-child-friendly health facilities in at least one district.

Achieved

Each province had mother-and child-friendly health facilities in at least one district hospital.

Criteria for the hospitals to be declared as a mother-and-child-friendly hospital include: (i) promotion of exclusive breastfeeding is provided in the hospital, especially during health education sessions during antenatal and post-natal checkups; (ii) no promotion of breast-milk substitutes: formula milk, cereal and button milk; and (iii) no advertisement (e.g., office equipment, calendars, hand bags, logosQetc.) or cash incentives from breast-milk substitute companies are available in the hospital.

1 ADB. 2014. Implementation Completion Memorandum of Developing Model Healthy Villages in Northern Lao People’s democratic Republic project (Financed by the Japan

Fund for Poverty Reduction). Manila.

Appendix 6 43

Gender Action Plan


Achievements

(17). All renovated and upgraded hospitals and health centers have sufficient facilities and equipment for maternal health care, and sufficient privacy for women, including separate toilet facilities.

Achieved

As of 30 June 2015, construction of 10 health centers, renovation of two district hospitals, and renovation of 10 health centers in eight target provinces were completed. All these health facilities include separate or enclosed delivery rooms, separate toilets and shower rooms for men and women.

The procurement of equipment gave priority to provision of the package of MNCH services as defined in the strategy and planning framework for integrated package of MNCH Services 2009-2015.

(18). Training of midwives and skilled attendants includes awareness on barriers for facility-based deliveries by mothers from ethnic groups and possible solutions (e.g. use of village funds).

Achieved

Training of midwives and skilled birth attendants included discussions on barriers for facility-based deliveries by mothers from ethnic groups and possible solutions to address these barriers. For example, (i) addressing geographical barriers through development of the health network, home delivery by SBA, and improve referral system; (ii) overcoming cultural barriers by giving priority to and encouraging women and people from ethnic backgrounds from local communities to study in medical college or to be trained as midwives or SBA; (iii) addressing financial barriers through setting up and improving operations of the HEF.

(19). At least 20% of participants in health manager training and 40% of participants in technical training are female.

Achieved

70 (66%) out of 106 participants in health manager training were women, and 150 (53%) out of 280 participants in the technical training, were women.

(20). VHV and peer educator schemes are reviewed, strengthened, and sustained from a gender and ethnic group perspective.

Achieved

The ethnic group perspective was fully part of the VHV and peer education concepts and strategy as these were developed to provide services to villages with difficult access to health facilities, and these services were provided by people from the community to the community.

The VHV scheme was sustained from a gender perspective through the active involvement of representatives of the LWU, engagement in supporting the VHVs and VHCs.

A gender perspective was included in the VHV scheme through the content of the training and retraining modules that prioritize MNCH health care topics.

(21). VHV and peer educators are trained to better understand MNCH services, know danger signs, and to promote timely referrals.

Achieved

The topics of the training for VHVs and peer educators prioritized the training for VHVs, and focused on diagnosis and treatment of common illnesses, and MNCH (MCH, nutrition, birth spacing, EPI, referral systemQetc.) services. Total VHV participants who were trained was 5,704 of whom 1,233 (22%) were women and 3,018 (53%) from ethnic groups.

(22). At least one of two VHVs in each village is female.

Not achieved

The number of VHVs in eight northern provinces was 5,704, 1,233 were female (22%) (against a target of 50%).

Issues and Challenges: The key constraints for increasing women’s representation in VHVs include (i) women in

Appendix 6 44

Gender Action Plan


Achievements

remote areas, especially those from ethnic groups, did not meet some of the VHV selection criteria;2 (ii) women

follow traditional practices and beliefs that they should strictly follow the decision of elders, parents, and husbands, in which cases women are not allowed to participate in any social events in the community without permission from these people; and (iii) most women are confined to undertaking housework as their domestic and social task.

For similar projects in the future, gender need assessments should be conducted at community level to identify constraints for women participating in VHVs. Project interventions should be designed to facilitate women’s participation, for instance through the provision of affirmative training at a community level.

(23). Provincial, district, and VHVs include at least 30% female members and proportional mix of ethnic groups

Partially achieved

The proportion of women in the provincial health committees was 24% and in the district health committees was 18%, while the proportion in the VHCs was 32% against a target of 30%.

Issues and Challenges: Underachievement of the proportion of women in the provincial and district health committees was due to the fact that the committee members are directors or deputy directors of the provincial and district departments, which have low women representation. These positions are appointed by provincial and district authorities, placing the process beyond the scope of the program.

In the future, if this performance indicator is to be included in the GAP, the program or project should include affirmative actions and resources to increase the number of women in these positions at provincial and district levels.

(24). Provincial and district annual operation plans and budgets include provisions for women and minority ethnic groups to ensure their inclusion and participation.

Achieved

AOPs of provincial health offices for FY2010-2011,2011-2012, 2012-2013, 2013-2014,and 2014-2015 gave priority to MNCH services, and addressed needs of the poor, women, and ethnic groups to achieve health related MDGs. Eight target provinces allocated sufficient amounts for implementation of HEF. Budget allocation for HEF is based on the number of the poor and the rate of poverty. Women and ethnic groups were consulted in the planning, implementation, and monitoring of the AOPs of the provincial health offices.

(25). Culturally appropriate information about health services and their expansion is disseminated using communication strategies that build upon ethnic group’s respective language and literacy levels.

Achieved

VHCs, VHVs and peer educators were literate, can speak Lao, and can disseminate information. And information dissemination also delivered in three different ethnic languages.

To support the poor, especially women and ethnic people, the project supported awareness-raising activities for the Health Equity Fund (HEF), with radio programs in three ethnic languages (Lao, Khmou and Hmong) and brochures delivered to all health centers, every village health committee (VHC) including village Lao Women’s Union to inform villagers about health services and the HEF. Peer educators delivered information to the poor, especially to women and ethnic groups who cannot read and write. From January to December 2014 the number of female patients who used HEF were 21,375 (52%) out of 41,380, while 17,200 (42%) were ethnic people.

2 The criteria includes willingness to work voluntarily, be trusted by the communities, respect local culture and traditions, in good health, at least 18 years old, has good

communication skills, can read and write (completing primary education is an advantage).

Appendix 6 45

Gender Action Plan


Achievements

(26). Village drug kits include contraceptive supplies.

Not Achieved

Contraceptive are provided at health center level in 8 provinces. As per Lao PDR’s policy, contraceptives have to available at health center level (not village drug kit).

Issues and Challenges: In May 2012, the MOH amended the list of essential drugs, and contraceptive supplies were not included in the list of drugs for village drug kits (managed by trained VHVs). The contraceptives are not authorized for distribution below the health center level due to the MOH requirement that contraceptives should be provided under guidance of trained health staff.

C. Better Quality of Human Resources for Health

(27). The national human resources for health policy adequately address gender and ethnic group aspects of the workforce and consumers.

Achieved

The Health Personnel Development Strategy by 2020 has addressed gender and ethnic group aspects of the health sector by setting specific targets for recruitment of female health staff and staff who are from ethnic groups.

(28). MOH has secured at least 50% of funding for implementation of the national skilled birth attendants development plan.

Achieved

Through the Minister of Health’s decree No 2167/MOH dated 06 September 2013, the government allocated KN5,101,863,000 or 59.6% of KN8,548,231,048 required for the implementation of the national skilled birth attendance development plan.

(29). Female staff members and staff members from ethnic groups are at least proportionally represented in skills upgrading for medical assistants, midwives, nurses and PHC workers.

Achieved

52 (39.6%) out of 131 participants participated in skills upgrading for medical assistants were women and 46 (35%) were from ethnic groups. 143 (93.4%) out of 153 participants participated in training for community midwives were women and 44 (28.7%) were from ethnic groups. 35 (37.2%) out of 94 participants participated in primary health workers were women and 48 (51%) were from ethnic groups.

(30). The implementation plan for the national human resources for health policy is developed using a participatory process approved by the human resources development working group and addresses shortages of female and ethnic staff members and students, staff retention in remote areas, and staff incentives.

Achieved

The development of the implementation plan was developed through a participatory approach and under the guidance of the human resources development working group. The Health Personnel Development Strategy by 2020 addressed gender and ethnic aspects in health personnel by setting targets for recruitment of female staff and staff with ethnic backgrounds. The targets had been incorporated in AOPs of the sector.

Staff deployment gave priority to increase positions at health center and district level. In FY 2013-2014, the health sector received 4,000 staff quota allocation from the government, of which 80% were deployed at the district and health center level.

Appendix 6 46

Gender Action Plan


Achievements

(31). The university and college master plans are developed using a participatory process approved by the human resources development working group, and include gender and equity analysis and specific actions to improve educational attainment for female and ethnic group students.

Achieved

The development of the Master Plans were undertaken in with a participatory engagement approach under the guidance of the human resources development working group.

The five-year plan development plan (2011-2015) of the University of Health Sciences includes: (i) improving ethics and attitudes of health professionals and social responsibility; (ii) emphasis on clinical research to address local health needs and constraints for accessing to health services; (iii) responsiveness to the socio-economic and cultural context of the country; and (iv) sensitivity of issues related to equity, particularly from the perspective of gender and ethnicity and remote areas.

(32). At least 30% of participants for upgrading teaching staff members are female, and ethnic groups are proportionally represented.

Achieved

The project supported six trainings for upgrading teaching staff in the University of Health Science and three provincial health science colleges. A total of 373 (52%) out of 712 trainees were women and 35 (5%) were from ethnic groups.

(33). The human resources management information system includes gender- and ethnic-specific information.

Achieved

The health personnel information management system managed by the MOH’s Department of Heath Personnel includes sex and ethnic disaggregated data. In 2014, the total number of health staff (including central, provincial, district and health center levels) is 19,704, of which 12,370 (63%) were women and 1,854 (9%) were from ethnic groups.

(34). MOH sets gender and ethnic human resources development targets for each health facility to ensure adequate presentation of the population in catchment areas, including at least one female staff member in each facility

Partly Achieved.

The MOH sets gender and ethnic human resources development targets (details refer to action 8 above).

In eight target provinces, 345 (83%) out of 414 health centers had at least one female staff; 443 (32.6%) out of 1,345 health center staff were from ethnic groups.

Issues and Challenges: The key constraints were (i) it was difficult to find women in remote areas who completed secondary education to continue to study in health science and work at the health center on graduation; (ii) health centers in remote areas are not attractive to health staff from urban areas due to difficult transportation and poor living conditions. Responding to these challenges, the MOH offers quotas for females who completed secondary education and are committed to work in health centers in remote area, to study in medical college and the University of Health Science.

(35). Plans of public health schools include provisions for gender development and equity.

Achieved

Plans of public health schools were developed within the framework of the Health Personnel Development Strategy by 2020 that addressed shortages of female and ethnic staff and students. Gender concerns are included in some subjects such as gynecology and obstetrics care, MCH services, and community health.

Appendix 6 47

Gender Action Plan


Achievements

(36). Gender and ethnic issues are mainstreamed in the national human resources for health policy.

Achieved

Gender and ethnic concerns were integrated in the national human resource development strategy. For example, the objective 3 of the National Human Resources Development Strategy by 2020 specified promotion of gender equality and equal opportunity among health personnel regardless of gender and ethnicity.

(37). At least 50% of trained staff members are female.

Achieved

482 (64%) out of 754 staff trained (in-service training) under the project were women and 327 (43%) were from ethnic groups.

In addition, 109 (66%) out of 164 persons attended pre-service training were women and 72 (44%) were from ethnic groups.

AOP=annual operational plan, EPI=expanded programme on immunization, HEF=health equity fund, LWU=Lao Women’s Union, MCH=maternal and child health, MDGs=Millennium Development Goals, MHV=model healthy village, MNCH=maternal, newborn, and child health, MOH=Ministry of health, SBA=skilled birth attendants, VHC=village health committee, VHV=village health volunteer. Source: MOH, 2015. Health Sector Development Program: Project Grant 0173 Completion Report. Vientiane, ADB. 2014; Implementation Completion Memorandum of Developing Model Healthy Villages in Northern Lao People’s Democratic Republic (Financed by the Japan Fund for Poverty Reduction). Manila and the program completion review mission.

Appendix 7 48

ANNUAL ALLOCATION OF PROGRAM FUNDS BY PROVINCE FROM 2010 TO 2015

Province Provincial

Expenditure 2010-2011

Provincial Expenditure 2014-

2015

Provincial Expenditure 2014-

2015

Provincial Expenditure 2014-2015

Provincial Expenditure 2014-2015

Total Provincial Expenditure 2010-2015

Phongsaly 80,946 189,148 173,669 186,836 165,798 796,397

Luangnamtha 79,111 219,178 245,280 251,826 182,445 977,840

Oudomxay 127,630 285,268 301,803 330,522 287,155 1,332,378

Bokeo 63,147 208,775 231,692 231,536 158,762 893,912

Luangprabang 157,912 304,143 311,576 334,584 238,896 1,347,111

Huaphanh 118,764 297,017 325,683 340,899 281,398 1,363,761

Xayabury 113,609 222,681 240,467 256,422 206,044 1,039,223

Xiengkhuang 126,751 228,110 243,061 249,341 175,521 1,022,784

Total 867,870 1,954,320 2,073,231 2,181,966 1,696,019 8,773,406

South South South South South

Vientiane Cap. 6,606 12,589 12,056 13,392 44,643

Vientiane 10,725 14,294 14,316 15,516 54,851

Borikhamxay 7,818 10,680 10,675 11,364 40,537

Khammouane 35,120 45,910 15,547 15,700 112,277

Savannakhet 11,919 15,302 16,658 16,682 60,561

Saravan 29,413 46,959 14,263 14,998 105,633

Sekong 6,013 8,863 9,672 10,273 34,821

Champassak 42,911 47,837 15,484 16,401 122,633

Attapeu 6,297 9,857 8,983 10,673 35,810

Total 156,822 212,291 117,654 124,999 0 611,766

Project Coordination Unit (MOH) 19,967 99,043 101,039 95,049 128,130 443,228

TOTAL 1,044,659 2,265,654 2,291,924 2,402,014 1,824,149 9,828,400 Note: Program funds refer to Grant 0172. Source: MOH, 2015. Health Sector Development Program: Project Grant 0173 Completion Report. Vientiane and program completion review mission.

Appendix 8 49

CALCULATION OF OVERALL PROGRAM RATING

Criteria Weight Rating Score20 Relevance 25% Highly Relevant 3.0 Effectiveness 25% Less than Effective 1.0 Efficiency 25% Efficient 2.0 Sustainability 25% Likely Sustainable 2.0 Weighted Average Successful 2.0 Source: Asian Development Bank estimates.

20

ADB. 2013. Guidelines for Preparing Performance Evaluation Reports for Public Sector Operations. Manila.

Appendix 9 50

CONTRIBUTION TO THE ADB RESULTS FRAMEWORK

No. Level 2 Results Framework Indicators (Key Outputs and Beneficiaries)

Targets Achievements

1. None None The program contributed to improving health service delivery, particularly for the poor, women and ethnic groups.

Source: program completion review mission.

Approved PCR G0172 G0173 30 June 2016 · PDF fileAOP – annual operational plan BemONC...

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