MNCH among the top priorities of the Ministry of Health
Maternal, Newborn and Child Health Services in Lao PDR and the Role of the Swiss and the Lao Red Cross in Improving Access to MNCH Services
Von Bigeard Alexis, Souvannasab Bounlam, Jean-Marc Thomé / Schweizerisches Rotes Kreuz SRK
Very important progresses have been made in key Maternal, Newborn and Child Health indicators in Lao PDR. Nonetheless the most important indicators remain among the lowest of the region, sometimes at an outrageous level. The action of the SRC lies in the framework of a comprehensive National Strategy for MNCH services that dates to 2009, aiming at taking urgent and concrete action for Maternal, Neonatal and Child mortality reduction in the Lao PDR.
Lao PDR is six times bigger than Switzerland for about the same population. Its density is a challenge indeed, with the majority living in small villages of few hundreds inhabitants, scattered in remote mountainous areas. In addition, the population largely belongs to ethnic minorities. They have their own culture, their languages, and they are often foreigners in so many ways to the technicians and decision-makers sitting in Vientiane, as they may also be to the medical staff of the nearest hospital.
A country in transition with high needs in health system improvement
The country is a communist state, and it has this heritage of a hierarchical and heavy administration, easily diverted from realism or pragmatism by its own rules and procedures. But it is also a country in transition that benefits from stability and important resources such as mineral and hydro-power. A very fast growth impressively benefits the capital Vientiane (+13% GDP in 2011). It is also visible in infrastructure such as dams and roads to Vietnam or China throughout the countryside, bringing paradoxical changes into remote places. The poverty rate now stands officially below 20%, even though more than 40% of the population live with less than US$2 a day. What is surely the most worrying collateral damage is increasing inequalities that the government and its development partners aim at minimizing.
The health system is not satisfactory to the people by any standard. The buildings may be there but staff has limited capacity, they are poorly paid and often hardly committed. The quality level is quite poor and the utilization of services is extremely low. At macro level, the sector is under-funded: total health expenditure is at US$27 per person (National Health Accounts Lao PDR, MoH 2012), of which 30% comes from donors and 50% remains the burden of the population (Out of pocket – OOP). Social Health Protection is on its way, but it requires not only financial support for itself but also for the overall health system, service provision and health management included. Current public health funding needs are estimated at around US$25-30 compared to US$15 today. (National Health Sector Reform Strategy 2013-25)
It is in this context that the Swiss Red Cross (SRC) has been active for about 20 years to improve the quality of life with regards to health, hygiene and access to health services with a focus on the vulnerable population in rural areas. Today, the SRC is working in in the areas of health, disaster management and organisational development. More specifically, the interventions are in basic health care and water, hygiene and sanitation; social health protection and health financing; Maternal, New-born and Child Health (MNCH) technical support; and District Health management support. In terms of partnership with the government, the SRC happens to be altogether a technical assistant, a contractual partner, a field implementer, and a donor.
The situation of MNCH in the Lao PDR
Very important progresses have been made in key MNCH indicators in the country. Coverage of Ante-Natal Care services has more than doubled in five years, and delivery by skilled birth attendant has doubled in the same period. Noteworthy though, only ¼ of the delivery in rural areas are taking place in a facility and the latest national survey reports only 34% of children fully vaccinated by the age of 12 months. (MICS–LSIS draft report, MoH 2012)
Nonetheless the most important indicators remain among the lowest of the region, sometimes at an outrageous level. As shown in the table below, the Millennium Development Goals (MDG) 1 and 5 are very much challenging still, stunted children and Maternal Mortality Rate (MMR) especially range very high:
The national coverage rates hide increasingly high discrepancies between urban and rural, rich and poor, ethnic majority and minorities. In a map of Lao PDR, these criteria have similar patterns that also reflect the landscape of the country. Supporting the rural population in remote areas is a challenge indeed, for reasons such as lack of education, lack of means, scarcity of services and long distances to the city.
A national MNCH strategy
The action of the SRC lies in the framework of a comprehensive National Strategy for MNCH services that dates to 2009, aiming at taking urgent and concrete action for Maternal, Neonatal and Child mortality reduction in the Lao PDR (MOH Lao PDR 2009). It is composed of three objectives for a total of seven strategic actions:
- Improve leadership and governance as well as management capacity;
- Strengthen efficiency and quality of services;
- Mobilize individuals, families and communities.
The SRC mainly assists the National MNCH Strategy in services improvement, in leadership and governance, and in the work with the communities. Most of all, the SRC together with the Lao Red Cross (LRC) have been developing and administering an array of financing mechanisms. Means and scope have increased since the government has developed and finally approved (2012) a National Policy for Free Maternity for all and free health Services for Children Under 5.
Social protection in health care: the SRC schemes
In 2004, the first “Health Equity Fund (HEF)” was set up in Lao PDR by the SRC, in a district of Luang Prabang province. This social assistance system provided free health care services, including food and transport, to poor and vulnerable people, capitalizing the experience of Cambodia. Not only, but inclusively, free maternity and delivery was already provided removing the main barriers (finances, transport and food) to assist the population and improve the indicators. The Ministry of Health (MOH) rapidly expanded with different patterns the HEF using development partners’ funds and limited domestic funds. SRC, in partnership with the LRC, has been closely involved in the expansion of many of the HEFs throughout the country.
“Free Maternity Policy for All Pregnant Women” as such (as an exclusive ‘package’ for everyone) has been developed since 2010, when the above-mentioned policy started to put MNCH among the top priorities of the Ministry of Health. Since it benefited from the management experiences of HEF, it was soon in place and developing. SRC, once again, could propose its role of adviser and implementer of the schemes.
“Maternity Vouchers” schemes have also been piloted at district level with several development partners, some of them using the SRC-LRC for the management. In the schemes, all pregnant women are eligible to free maternity in public facilities in a given area. In this context, the voucher is not really a proof of eligibility to services but is mainly a promotion tool.
LRC-SRC also administers several “Maternity Waiting Homes (MWH)” in remote districts. These are equipped buildings, in the premises of the hospital, where pregnant women can come and stay, so to feel precisely at home before and after giving birth, receiving focused health education and being provided with a promotion delivery kit, food and transport allowances. The MWH can be of great help in remote areas where women must travel long distance to reach the hospital, and especially for pregnancy at risk. Providing certain conditions are met, it can be a valuable additional support to financial systems of free delivery.
The LRC-SRC has also been contracted to administer “Preventive Services Purchasing Scheme (PSPS)” combined with Maternity Vouchers and free curative services for the poor (HEF). PSPS is a supply side mechanism in which a payment as incentive for performance is given to the health facility when providing services such as immunization or deworming.
Finally, the SRC-LRC are contracted to administer the newly approved policy for “Free of charge health services for all Children under five years of age (Free U5)” in several districts, in conformity with the policy of the government.
As we see from this list, the efforts to provide free services for priority targets or priority services have been important and have taken many forms. But not only does SRC intend to follow the policy; it also acts as an adviser in time of conception, as an experimenter in the field, and eventually as a monitor for capitalization. In any case, piloting and administering these schemes is first of all a matter of field operations.
Taks of SRC-LRC in the schemes
Such third-party payment mechanism development requires support to all stakeholders, and somehow the SRC carries out activities that benefit altogether the people, the providers, and the MOH in charge.
As per its primary mandate, the SRC commitment is to work close to the beneficiaries, ensuring that they are not only entitled to but truly benefit from the free services: a whole range of health services in facilities are provided, as well as free transportation and financial support to cover food expenditure while at the hospital. On a day to day basis, proximity and direct contact with the beneficiaries is a precondition when aiming at meeting their needs that are immediate and crucial for their living. Similarly, such systems dedicated to uneducated people living in remote areas demand high investment in information and communication. Eventually, the management agency is assisting the local authorities in methodological and empirical work related to identification of those in need, not so easily targeted as per a simple concept as the one of “poor”.
Another function of the third-party agency is to manage with transparency and fluidity a system that requires a whole set of procedures and tools to ensure proper accountability: the overall finances including budgeting, accounting, auditing, and administration where collaboration with the providers is essential. In addition, such systems require important deployment for physical verification and spot check control of services delivered, carried out at providers’ level and in villages.
Last but not least, another function of the SRC consists in supporting the government, based on evidences and experience. As a matter of fact, the tasks of the management agency include monitoring, reporting, analysis, capacity building, as well as support in designing systems or guidelines and even assistance in defining policies and strategies.
The SRC and LRC have formed a Management Agency Consortium in order to jointly propose their services to the Ministry of Health in the field of social assistance schemes’ management. Supporting the government policy and providing administration in highly technical issues implemented in remote areas is not an easy role for an organization. The combination of the international expertise and the local organization in the Red Cross spirit happens to meet the needs, and the Consortium has regularly been granted the confidence of the Ministry of Health, despite the understandable resistance of a contracted-out model. In practice, the MOH contracts the management agency following an official bidding process with clear terms of references.
As per today, the SRC-LRC is the only third-party management agency administering projects and funds from several donors that include the World Bank, Luxemburg Development Cooperation, NGOs and even government funds. As one can imagine, the third-party system is not always easily accepted as it may go against interests. Specifically, the funds’ management targeting public health objectives is definitely considered the administration’s responsibilities in such a country where the State is strong and ownership demanded.
Surely what has given the Consortium some legitimacy and time to pilot is not only its technical skills and its close relationship with the authorities: firstly the LRC is a semi-governmental agency, and secondly the relationships of the SRC with the MOH have lasted long and have brought results. Besides, the set-up is not a fully contracted-out system. The SRC-LRC contracts clearly state that the third-party must streamline and progressively handover to the National Health Insurance Agency (NHIA) that should soon be created following the approval of a Prime Minister decree. It is thus anticipated that the third-party progressively disappears or is absorbed by the NHIA; the role of the SRC is progressively moving from management to monitoring and control, and will eventually turn into a more classic role of technical assistance.
In the meantime the SRC-LRC provides the important accountability towards MOH and donors, and it ensures a split between purchaser and provider as well as independent monitoring which are essential factors in a context of growing corruption. The flexibility is another key added value of the management agency in terms of funding and responsiveness. Finally, the policy advises, advocacy and technical assistance together with the work in the field is a key advantage.
One must look at the results keeping in mind that the implementation of free maternity is still recent, as it started only few years ago. Nevertheless, it can be observed that the provision of free services have contributed to the increase of delivery rate in facility from 10% to 30%.
However, the increase is much less automatic than it is when it comes to fee exemptions of curative services. As illustrated in the graph the utilization in this case directly increases sharply.
This suggests that, for delivery, money is not the main barrier. Supply factors appear to be more important such as the presence of a trusted midwife, the consideration of ethnic issues, etc. In a difficult supply context, the management agency has to focus on MNCH promotion and proximity contact with women before seeing utilization increase. A major difficulty related to Free Maternity for all is related to the unequal results between the rich and the poor: after five years of implementation in the first piloted district, the non-poor deliver four times more in facilities than the poor (41% versus 11%).
One clear lesson is that there is no quick fix. Financial measures cannot immediately purchase quality services, especially when it comes to maternity. This is evident from the experience and common sense, and still it is forgotten in many situations of the international cooperation.
The inter-relations between several needs are also obvious while working in such complex set ups. Solid health systems foundations are needed, that is a strong primary health care system with the building blocks including a set of interventions in supply (staffing, training, equipment), in demand (access, Information, communication), as well as in leadership and governance.
Eventually a lot seems to depend on a good process: sequencing and continuity of interventions are key, as are evidence-based decisions that cannot be achieved without a strong proximity monitoring of financial measures.
*Bigeard Alexis: Consultant for SRC Laos, Souvannasab Bounlam : SRC Project Manager in in Lao PDR. Thomé Jean-Marc: Swiss Red Cross Country Delegate in Lao PDR; Advisor to the Swiss Red Cross/Lao Red Cross Health Equity Fund & Free MNCH Management Agency.
- MOH Lao PDR (2012) National Health Accounts Lao PDR
- MOH Lao PDR (2012) National Health Sector Reform Strategy 2013-25 (Draft)
- MOH Lao PDR (2012) MICS–LSIS draft report
- MOH Lao PDR (2009) Strategy and Planning Framework for the Integrated Package of Maternal Neonatal and Child Health services 2009-2015