Lao People’s Democratic Republic: Health Sector Governance Program (Subprograms 1 and 2)
Participatory development and full alignment of reform programs with country strategies and plans foster strong ownership and commitment from the government.
The policy actions pursued under this program were developed in an open, participatory manner. They were fully aligned with the country’s Health Sector Reform Strategy and Health Sector Development Plan. The participatory development and full alignment of the reform program with the country sector strategy and development plan ensured strong and broad ownership and commitment from the government, and with the assistance of development partners, strengthened policy dialogue and coordination.
A multiple tranche arrangement ensures satisfactory progression of reforms and strengthens government accountability for the reforms.
Effective implementation of system reforms, given their long-term horizon, requires phased support from development partners. The multiple tranche arrangement employed by this program ensured satisfactory progression as a precondition for continued ADB assistance and strengthened the government’s accountability for the reforms.
Supplementing programmatic assistance with sufficient, targeted technical assistance (TA) is effective in achieving reforms.
The combination of programmatic policy-based assistance and TA support provided under this initiative proved to be effective and should be continued. The lack of qualified and experienced local consultants had been a recurring issue, and the Ministry of Health (MOH), the executing agency, continued to face a shortage of sanctioned staff. By giving consultant support to key departments of MOH, the TA contributed to knowledge transfer and capacity building for these departments, and to stronger coordination across the MOH and other ministries.
Enhanced human development is a core strategy in the Vision 2030 of the government of Lao People’s Democratic Republic (Lao PDR) to achieve innovative, green, and sustainable growth, in line with which it has implemented the Health Sector Reform Strategy (HSRS), 2013–2025. The HSRS aims to improve access to basic health care and financial protection by 2020 and universal health coverage (UHC) by 2025 through more efficient use of public resources and expanded health financing. It is being carried out in three phases through the five-year Health Sector Development Plans (HSDP) (2013–2015; 2016–2020; and 2021–2025).
The Health Sector Governance Program (HSGP), approved by the Asian Development Bank (ADB) for a $17 million policy-based loan (PBL) in September 2015, was designed to directly support the implementation of the HSRS through the 7th HSDP, 2013–2015 and 8th HSDP, 2016–2020. Along with the PBL, ADB also approved a $6 million technical assistance (TA) loan for the HSGP and subsequently approved a $30 million grant for subprogram 2 in April 2018.
Building on earlier ADB projects, which focused on infrastructure and staff capacity development in selected provinces and helped to improve the health facility network and access to health services in these areas, the HSGP supported key system reforms in governance, health human resources, and public financial management to generate a broader impact on system performance. It targeted the key binding constraints on health system development in Lao PDR on both the supply and demand sides
HSGP’s envisaged impact of achieving UHC by 2025 was aligned with the country’s 8th National Socio-Economic Development Plan, 2016–2020. Its expected outcome was improved health service delivery, particularly for the poor, women, and children. The impact and outcome were to be delivered through the following outputs: (i) health sector reform process improved; (ii) improved delivery of free health services for maternal, neonatal, and child health (MNCH) and for the poor under the national health insurance (NHI) scheme; (iii) health human resources management capacity strengthened; and (iv) health sector financial management capacity strengthened. The planned outputs were to be achieved through 15 policy actions under subprogram 1 and 17 policy actions under subprogram 2. The World Bank provided parallel, collaborative cofinancing for subprogram 1, comprising a $13.2 million loan and a $13.2 million grant. Besides the TA loan, ADB also mobilized a $2 million capacity development TA grant from the Japan Fund for Poverty Reduction.
Minor changes were made to the program design during implementation and all output indicators or key policy actions were achieved. The health sector reform process was institutionalized under a robust set of policies and road maps. The coverage of social health protection schemes was expanded, and their management was strengthened through the integration of the NHI, the Health Equity Fund, and the free MNCU schemes. Legal and planning frameworks, including quality assurance measures, were put in place to improve health human resources management practices. Trainings and scholarships were provided to strengthen the capacities of health professionals and allied personnel. Preparation of a multi-year rolling plan framework was supported to strengthen financial management by the Ministry of Health (MOH) and so were the development of an Accounting Law and guidelines on the collection, accounting, and utilization of service charges by publicly owned health facilities; the adoption of a quarterly budget and expenditure monitoring system at central, provincial, district, and health office levels; and the regular publication of the National Health Accounts report.
Program output deliveries led to the attainment of all 4 outcome targets – 3 exceeding expectations and 1 substantially achieved. Specifically, the program helped the MOH achieve 87% NHI coverage among the general population and 100% coverage for the poor, exceeding the 80% target for both. It also helped to equip health centers, the lowest level in the health service delivery system, with essential health staff. By 2019, against a target of 80%, 85.4% of all health centers had at least one midwife, resulting in the increase in free facility-based delivery rate from a baseline of 25.5% in 2015 to 78% of all deliveries in 2019. The slight shortfall in the 80% target would have been exceeded if central hospital deliveries had been included.
Overall, the program thus contributed to the government’s goal to achieve UHC by 2025. It had the MOH as executing agency. Implementation was delegated to the relevant departments.