Assessment of the Integrated Management of Newborn and ... of the Integr… · assessment on Integrated Management of Newborn and Childhood Illnesses was conducted under the UN Joint

Assessment of the

Integrated Management of Newborn and Childhood

Illnesses Lao PDR

May 2017

2

Foreward

To support the implementation of the National RMNCH Strategy and Action Plan 2016-2025, this

assessment on Integrated Management of Newborn and Childhood Illnesses was conducted under the

UN Joint Programme (UNFPA/ UNICEF/WHO) funded by Grand Duchy Luxembourg.

The Ministry of Health would like to express their appreciation to the children, women, communities, as

well as the health managers and health workers in the visited sites.

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IMNCI Assessment Lao PDR 27 March – 7 April 2017

Contents

Abbreviations 3

Executive Summary 4

1. Background 7

2. Objectives 8

3. Methodology 8

4. Assumptions and Limitations 9

5. Findings 9

6. Conclusions 20

7. Proposed Actions 21

Annexes

1 …………………………………………………………… Assessment Itinerary

2 …………………………………………………………… Persons met

3 …………………………………………………………… Documents Reviewed

4 …………………………………………………………… Semi-structured questionnaires

5 …………………………………………………………… Number of HW trained in IMCI

6 …………………………………………………………… Geographical distribution of health workers

4

Abbreviations

CHW Community Health Worker

BMS Breast Milk Substitutes

DHIS 2 District Health Information System 2.

EENC Early Essential Newborn Care

EPI Expanded Programme on Immunization

HC Health Centre

HW Health Worker (doctor, nurse, midwife)

iCCM integrated community case management

IMCI Integrated Management of Childhood Illness

IMNCI Integrated Management of Newborn and Childhood Illness

LSIS Lao Social Indicator Survey

MCH Maternal and Child Health

MCHC Maternal and Child Health Centre

MDG Millennium Development Goal

OOP Out of pocket expenditure

ORS Oral Rehydration Salts

SARA Service Availability and Readiness Assessment

SDP Service Delivery Point

SO Strategic Objective

TOT Trainer of Trainees

UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

VHW Village Health Volunteer

WHO World Health Organization

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Executive Summary

Although much progress has been made in reducing under 5 mortality in Lao PDR, the under five

mortality rate, U5MR, is still high at 67/10001 Live births (LB), falling short of the MDG target of 54/1000

LB, with 44% of these deaths occurring in the first month of life, the newborn period. The majority of

these deaths are preventable with the main causes being pneumonia and diarrhoea with malnutrition

contributing to a high proportion of deaths with the stunting rate being 44%%. Inequity across

urban/rural areas is demonstrated by the difference in mortality rates, being double in rural areas

compared to urban areas (100/1000 LB in rural areas vs 45/1000 LB in urban areas), also geographical

disparity with the risk of dying in early childhood being lowest in the Central region (73/1000 LB) while

the risk of dying in the Northern and Southern regions exceeds 100/1000 LB2. Care for the specific child

conditions also varies reflecting inequities in access and utilization of services including use of ORS/zinc

for diarrhoea and pneumonia treatment as shown in the Lao Social Indicator Survey (LSIS) 2011-12.3

IMCI was adopted in Lao PDR in 1999 and implementation started in 2000, with the focus on the training

of health workers at central and provincial level using the developed IMCI national guidelines. Although

IMCI has three components, i) Health Worker Training, ii) Health System Strengthening and iii)

Community Component, most attention was paid to the training. Following initial implementation, IMNCI

stalled and has only been revitalised over the past 18 months, with the new RMNCH strategy. IMNCI is

currently a project under the MCH sub-programme of the Health Social Development Plan (2016-2020).

There is recognition that in order to achieve the Sustainable Development Goal targets of ending

preventable child and neonatal deaths, with targets of 25/1000 LB and 12/1000 LB by 2030 respectively,

more rapid acceleration in mortality reduction is required. The government’s National Strategy and

Action Plan for Integrated Services on Reproductive, Maternal, Newborn and Child Health (RMNCH) 2016-

2025, clearly outlines the commitment to strengthen implementation of IMNCI. This assessment focussed

on ways of achieving this, as well as facilitating factors and barriers in the implementation of IMNCI and

other child health strategies, and additional ways of improving access, quality, coverage and utilization of

child health services, especially important being the access to prevention and care at the community

level.

The assessment included a desk review and interviews at central level in Vientaine and two provinces,

Oudomxai in the north and Saravan in the South. The team found that although supportive policies are in

place and IMNCI is a core component of the RMNCH Strategy, it has no clear implementation plan, and

no budget line. Despite being very active the SO5 working group, but received less support than needed

by partners, resulting in minimal implementation of their 2016 activities, resulting in this SO5 having the

lowest implementation rate of all the eleven SOs. This requires urgent attention to development of a

costed implementation plan. The plan, which will include targets down to the community level and a

monitoring framework should form the basis of provincial and district planning, and be used to ensure

the necessary resources are available at all levels for implementation. Additionally development of an

investment case for newborn and child health as part of an overall investment case for RMNCH, would

serve as an advocacy tool for financing from both government budget and development partners.

1 Levels and Trends in Child Mortality, IGME - WHO 2015 2 Evaluation of RMNCH strategy and plan 2009-15. 2015 3 Ministry of Health of Lao PDR and Lao Statistics Bureau (2012) Lao Social Indicator Survey 2011-12, Final Report. Vientiane, Lao PDR: Ministry of Health and Lao Statistics Bureau.

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Regarding IMNCI implementation, most attention over the years, and in the revitalisation, has been given

to the first component of IMNCI, i.e. the training. This is generally being well-conducted, although the

team found that training materials are often scarce, especially in the pre-service training schools, also

most health workers do not have access to the chart booklet and are reluctant to use recording forms as

this leads to duplication in their work. Attention to the health system strengthening has been focussed on

availability of medicines, with little attention to supportive supervision, harmonisation of health

information data or referral, particularly important is the harmonisation of data in the health centre and

out-patient registers, and to include the IMNCI classifications in the DHIS 2. In addition building skills in

supportive supervision will lead to better support and improvement of performance of the health

workers, especially at the most peripheral levels. The community component of IMNCI was found to be

the most neglected, with no clear strategy to address integrated management of childhood illness in the

community. There is potential for rapid impact on reduction of newborn and child mortality and

improving maternal health through the deployment of CHWs trained in iCCM to the most remote villages,

and of VHWs, with additional training in CCM and in IYCF to villages with seasonal access to services.

Currently the community component of IMNCI is the least well developed, with not all villages having

VHWs and very few having CHWs. Urgent attention to this component is needed, ensuring the linkages to

and support from the health centre staff.

Appropriate implementation of all the three components of IMNCI, health worker training, health system

strengthening and community actions, paying particular attention to the remote and hard to reach areas,

can bring rapid results in reduction of deaths from newborn causes, pneumonia and diarrhoea, as well as

improve the nutrition of the children. The proposed actions have been developed based on the

assessment to overcome the bottlenecks in implementation, and move the implementation of IMNCI

forward.

The proposed actions have been divided into Immediate, Short-Term and Medium Term actions. Specific

time frame for the actions can be included after review by the MOH.

IMMEDIATE

• Sustainability

• MOH with support from UNICEF and WHO to develop a costed equity based scale up

plan for IMNCI – with clear implementation steps, and monitoring and accountability

framework aligning with the EPI and nutrition programme, as well as to WASH sector;

(With tailored plans at provincial/district level, starting with the poorest districts)

• Government to put in place a budget line for IMNCI

• Development partners to review plans and include support for IMNCI (including a link to

WB supported DLI project underway to ensure that newborn, pneumonia and

diarrhoea mortality and morbidity is addressed.

• Integration

• Under RMNCH secretariat, members from SO5 and SO7 to form temporary working

group to develop IMNCI scale up plan, budget, monitoring/accountability framework.

Especially to ensure linkage between IMCI and IYCF.

• MOH to set local coverage targets and monitoring IMCI/IYCF. Use the opportunity of the

excellent EPI microplanning as model.

• Community

• Continue work on development of an strategy/ framework for community service

delivery to clarify options for PHC at village level with options for deployment of CHWs.

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Ensure a consultative process to ensure that all stakeholders are included with the MoH

responsible. WHO and UNICEF support.

• MOH to advocate with MOHA to rapidly deploy those CHWs already trained to hard to

reach districts and villages.

SHORT TERM

• IMNCI Algorithm

• Include beriberi for those provinces most affected – NB Need to develop policy and

protocol for B1 supplementation. IMNCI working group, clinicians and paediatric

association.

• Develop short module on ‘How to practice IMNCI’ to add to the training. IMNCI working

group with UNCIEF and WHO support

• Ensure harmonised nutrition messages between IMNCI and IYCF. SO5 and SO7 teams,

with UNICEF support.

• Training

• Pre-service:

• Increase pool of tutors with IMCI TOT in Provincial Public Health Schools. MOH

TOTs. DP support.

• Provide adequate teaching materials, including chart booklet for each student.

DP support

• Consider using computerised IMCI for introduction to Medical Students and

tutors. WHO to provide Computerised IMCI USB/CD

• In-service

• Provide chart-booklet for each HW trained – consider desk-top job-aid (1 page

newborn, 1 page child). MOH centre, DP support

• Include training of supervisors in the overall training plan.

• Include follow-up after training – especially to HC staff. MOH build into

implementation plan.

• Supervision

• Build in case management to supportive supervision – particularly for HC staff and

Community Health Workers. DH

• Prioritise hard to reach areas. Province and District Health teams

• Community

• MoH to develop a consensus on improved community and family practices, and

promotion of care seeking behaviour. eg. revision of the Village Health Volunteer

module, and utilizing existing community health contacts including nutrition/ EPI

activities to raise awareness on CCM of pneumonia and diarrhoea and strengthen

practices.

• Include kits containing ORS/Zinc and antibiotics for treatment of pneumonia by CHWs

iCCM

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IMNCI Assessment Lao PDR 27 March – 7 April 2017

1. Background

The Lao People’s Democratic Republic (PDR) is a landlocked, mountainous country with a young and

ethnically diverse population of 6.5 million, of which 59 per cent are children and young people below

the age of 25. With 49 official ethnic groups comprised of 167 subgroups with different dialects,

languages, cultures and traditions

The country has achieved Millennium Development Goal, MDG, targets on poverty reduction, universal

access and gender parity in primary education, maternal mortality reduction, and access to water and

sanitation. The country’s under-five mortality rate fell from 162 deaths per 1,000 live births in 1990 to 67

in 2015, thus falling short of the target of the 2/3 reduction target of MDG 4. The majority of child deaths

are due to preventable causes, such as neonatal conditions, pneumonia and diarrhoea. Neonatal deaths

are 44% of under five deaths. There are significant variations by region, also inequities with significant

disparities between urban and rural, upland and lowland, wealth quintiles, mother’s education and

ethnicity.

Early childhood mortality rates for rural areas are double those for urban areas (100 deaths per 1000 live

births in rural and 45 in urban areas) and the risk of dying in early childhood is lowest in the Central

region (73 deaths per 1000 live births) while the risk of dying in the Northern and Southern regions

exceeds 100 deaths per 1000 live births4. Care for the specific child conditions also varies reflecting

inequities in access and utilization of services including use of ORS/zinc for diarrhoea and pneumonia

treatment as shown in the Lao Social Indicator Survey (LSIS) 2011-12.5

Causes of child mortality Children receiving main interventions

IMCI was adopted in Lao PDR in 1999 and implementation started in 2000, with the focus on the training

of health workers at central and provincial level using the developed IMCI national guidelines. Leadership

was committed and an IMCI committee established and led by the Hygiene and Health Promotion

directorate and then later by the main Children’s Hospital. Whilst some aspects of all the three

components of the IMNCI strategy (Health worker training, Health Systems strengthening and

4 Evaluation of RMNCH strategy and plan 2009-15. 2015 5 Ministry of Health of Lao PDR and Lao Statistics Bureau (2012) Lao Social Indicator Survey 2011-12, Final Report. Vientiane, Lao PDR: Ministry of Health and Lao Statistics Bureau.

01020304050607080

Pneumoniareceiving

antibiotics

Diarrheagiven ORS

Fullvaccination

Vitamin Alast 6

months

Urban Rural without roads

9

Community Component), at the central, provincial and community level have been implemented, this

may not always be aligned and coherent.

IMNCI is currently a priority project under the MCH sub-programme of the Hygiene and Health

Promotion Programme in the 8th Five –year Health Sector Development Plan (HSDP) 2016-2020. There is

recognition that in order to achieve the Sustainable Development Goal targets of ending preventable

child and neonatal deaths, 25/1000 LB and 12/1000 LB respectively, more rapid acceleration in mortality

reduction is required. At referral level the Pocket Book for paediatric care is being introduced to improve

quality of care, also an Early Essential Newborn Care, EENC, programme has been developed and since

2014 is in the process of being rolled out in the country. There is also need to refocus attention to the

other main killers of children under 5 years. In line with the ‘A Promise Renewed’ strategy, Lao PDR has

committed to scaling up efforts to bring health services closer to underserved communities to address

high under-5 mortality rates through iCCM.

The government’s National Strategy and Action Plan for Integrated Services on Reproductive, Maternal,

Newborn and Child Health (RMNCH) 2016-2025, clearly outlines the commitment to strengthen

implementation of IMNCI. This assessment focussed on ways of achieving this, as well as facilitating

factors and barriers in the implementation of IMNCI and other child health strategies, and additional

ways of improving access, quality, coverage and utilization of child health services.

2. Objectives

The IMNCI strategy is particularly focussed at the out-patient MCH centres, first level health facilities and

community level, the strategy is complemented by the Pocket Book6 for paediatric care at referral level

and the EENC programme, also being introduced at hospital level. The assessment focussed on IMNCI,

with use of the pocket book and EENC being included for context.

The objectives of the assessment of the Integrated Management of Newborn and Childhood Illness

(IMNCI) were to review the implementation of IMNCI for the improvement of the health, identify the

facilitating factors and bottlenecks, as well as the opportunities and responses required to improve

access, quality, coverage and utilization of integrated child services within the IMNCI strategy.

Specifically the IMNCI assessment:

• included reviewing the three main components of IMNCI strategy, and examined the IMNCI

programme within the current initiatives in the health systems strengthening, and the building

blocks, e.g. the human resources, financing, etc.

• looked at the policy environment.

• developed draft recommendations for inclusion in an action plan for the scale up of the IMNCI in

Lao PDR, as well as identifying the key stakeholders and resources required.

• made recommendations on creating a learning system for continuous improvements to the

IMNCI.

3. Methodology

The assessment included the following:

i) Desk Review of data, reports, scientific articles and other information about child health and

IMNCI in country.

6 WHO Pocket Book for Paediatric care in hospitals. Laos edition 2016.

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ii) Key informant interviews using a semi-structured questionnaire with policy makers,

programme managers, paediatricians and development partners at National level, including

issues related to IMNCI Organisation and Management e.g.

i. Policy in place

ii. Leadership and governance/ ownership at all levels.

iii. Integration with other programmes

iv. Financing: is it sufficient and sustainable? Are subnational administrations

mobilizing resources for IMNCI

v. Equity focused areas

vi. Health systems strengthening

vii. Health sector review/ reform process

iii) Visit to 2 provinces and districts in the provinces. The provinces and districts were selected

by the MoH based on the presence of revitalization of IMNCI training. Semi structured

interviews conducted at Provincial, District and Village levels (see annex), and focus group

discussion with village heath committees and the community related to IMNCI

implementation

i. Service delivery integration, with high impact evidence based interventions

ii. Community/ Family Health Practices

iii. Health workforce:

Capacity building Training (preservice, in-service, refresher) manuals, update

interventions in newborn and nutrition.

iv. Information and Supervision and Monitoring,

v. Availability of Commodities

4. Assumptions and limitations of the assessment.

The methodology was not a comprehensive evaluation of IMNCI implementation with visits to only two

provinces, districts and health centres, however as the visits were to provinces and districts where IMNCI

has been revitalized, the assumption is they would give the best-case scenario. It is also assumed that the

recommendations derived from the assessment will be applicable nationwide, including the hard to reach

areas, although these were not visited. Through the review of documents and discussions with national

level officers the assessment has tried to minimize these limitations.

5. Findings:

5.1. Policy and Strategy environment:

Countries that have been successful in rapidly reducing maternal and under five mortality, have included

key targets in their National Development Plans, as well as focused strategies that include financial

protection and provision of services from community through to referral levels7. The Lao People’s

Democratic Republic has developed its Eighth National Socioeconomic Development Plan, 2016-2020,

that aims to reduce poverty significantly and graduate from its least developed country status by 2020.

Strong economic growth, driven primarily by natural resources and energy sectors, enabled the country

7 Bangladesh, CHW, Ethiopia, HEW, Sri Lanka, MCH PHN examples.

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to move from a low income to a lower middle-income country in 2011. The eighth plan localizes the

Sustainable Development Goals into national targets and places a strong emphasis on the achievement of

off-track Millennium Development Goals, which include under five mortality and undernutrition/stunting.

The plans and strategies are in place for health sector reform with the Health Sector Development Plans

2016-20, a clear Health Sector Reform Plan 2013-25, that is now into its second phase, a RMNCH strategy

2016-25, and many other supporting strategies e.g. e-health, HIS integration roadmap, HRH Strategy,

2014 Newborn Action Plan, to name a few, (annex 3) with emphasis on the Priority Programmes, to

implement quality health services with focus on reaching the poorest, vulnerable population living in

remote areas, ultimately in achieving the universal health coverage. The MOH indicated that they will use

domestic financing to target and deploy Community Health Workers, CHWs, to two districts in each

province, although this is still to be achieved. It will be important that the districts selected are those with

the poorest and hard to reach communities in order to maximize effectiveness. A recent report on

Strengthening Health Care through Community Health Workers8, analyses the costs and benefits of

adding a community cadre and notes an economic return in investment of upto 10:1, which is in addition

to the returns of mortality reduction and a healthier population. The current policies and strategies in Lao

PDR, create a good environment for achieving further reduction in child mortality.

Government expenditure on health has historically been very low in Lao PDR, a 2016 World Bank report

on government expenditure on health in Lao PDR9 noted the increasing levels of government expenditure

on health with high levels of out of pocket, OOP, expenditure, and unsustainable dependence on external

financing. However there is a planned increase in the overall budget to health, with the target of 9% of

the government budget being allocated to health by 2015 (expenditure reached 5.4% by 2011/12).

Although health expenditure for MCH services is not separately available, the WB analysis of health

expenditure also noted variations in health expenditure by province, per capita government spending on

health is higher in sparsely populated and poorer provinces such as Sekong and Attapeu, where health

needs are likely to be greater, as opposed to in wealthier provinces such as Champassak, Savannakhet,

and Vientiane Capital. This is appropriate in order to address inequities. The Free MCH services initiated

by the Prime Minister in 2013 (decree number 178/PM) are being rolled out, also the National Health

Insurance Scheme is being implemented since late 2016. The assessment team found evidence of both in

action at the village level, with mothers describing usage of the free MCH services, also instances of use

of the NHI scheme, although the team found that some facilities still charged fees for child services and

medicines had to be purchased, in addition referral by ambulance is co-financed, or transport is provided

by the patients.

Provinces have developed 5 year costed plans (2016-2020), although funds allocated are not sufficient to

cover all the activities in the plans, leading to a prioritization exercise by the provincial head and his team.

It was not clear exactly how activities are prioritised, although both the provincial health directors

commented that MCH is a high priority.

For effective implementation, strategies need to be complemented with implementation plans. There is a

costed implementation plan for the roll-out of the EENC strategy with clearly defined targets, however

there is currently no costed implementation plan for IMNCI (which should include national, provincial and

district targets for implementation of the three components with a clear time frame, monitoring

framework, allocated responsibilities and resource needed/available). Thus although it is included as one

of the pillars of the RMNCH strategy in SO 5, and is also included in provincial and district plans. IMNCI

risks being left behind as the costed activities are prioritized.

8 Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations. Ethiopia and Liberia with the One Million CHW Campaign. July 2015 9 Government Expenditure on Health in Lao PDR: Overall trends and findings from a health center survey. World Bank May 2016

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5.2. IMNCI Organization and Management

5.2.1. History to present

IMCI was introduced in Lao PDR in the late 1990’s, and following adaptation of the modules and

translation into the Lao language, implementation was started by 2000. Between 2000 and 2007 there

was rapid scale up of the clinical component, 11 day training of IMCI throughout all provinces and

districts, though coverage of training did not extend to all health centres. Training at health centre level

was more concentrated in the northern provinces than the southern provinces. By 2007, 533 Health

Workers had been trained in IMCI, with 137 being TOTs, and 56 had been trained in follow-

up/supervision, Vientiane and Oudomxay had the greatest number of clinical and TOT at district level10.

Follow-up was conducted by the central level to three Provinces, Oudomxay Vientiane and Sekong.

However there was little specific follow-up after training to other provinces or other levels.

In 2008, the duration of the training was shortened from 11 days to 5 days. Shortened courses on IMCI were introduced by the IMCI national trainers at a World Bank-supported project in Attapeu and Savannakhet. In 2009, other shortened courses which combined IMCI and neonatal care were introduced and conducted in Khammuane Province, Savannakhet, Vilabouly District and Louang Prabang Province (3 days for IMCI and 2 days for neonatal care).

The IMNCI strategy was developed with three components, Health Worker training, Health System strengthening and the Community Component, and intended for use at first level facilities, complemented by the community component. A Multi-country evaluation of IMCI 1997-2007 and Global Review of IMNCI conducted in 201611 showed the greatest effect where all three components were implemented alongside each other, i.e. in the same districts and facilities. However in practice many countries focussed on the health worker training, with some attention to the medicines supply component of health system strengthening, with the community component being implemented much later and often in different districts to the health facility component.

The assessment found most attention to training, but that training had initially been dependent on external financing and had stopped when external financing had no-longer been available, only restarting in the past year with the new RMNCH strategy and availability of government funds (complemented by DP funds). Attention to the health system strengthening has been focussed on availability of medicines, with little attention to supportive supervision, harmonisation of health information data or referral, with the community component being most neglected, with no clear strategy to address integrated management of childhood illness in the community.

In May 2011, the IMCI manual for five-day course was reviewed by a WHO consultant and IMCI national focal person in the Maternal and Child Hospital. In this regard, the English and Lao version of IMCI chart booklet, IMCI training manuals, IMCI recording forms for the Sick Child and Sick Young Infant and mother’s card were reviewed12. This was further reviewed and revised in 2016, to fully update the IMNCI materials in line with the latest WHO recommendations and to ensure consistency with the recommendations in the WHO pocket book for in-patient paediatric care – which has also been translated into Lao. As indicated above IMNCI is intended for use by health workers in first level facilities and out patients of district hospitals, the assessment and treatment algorithms for the newborn and child are included in a chart booklet, which each health worker should have readily available for use as they conduct their consultations. There are also a complementary set of wall charts for use in training, which have in some countries been made available for use in health centres. The Pocket Book of paediatrics for

10 September 2007 data summarised by MOH and JICA Kids Smile project, introduction of IMCI by province 11 Towards a grand convergence for child survival and health: a strategic review of options for the future building on lessons learnt from IMNCI. WHO 2016 12 IMCI in Laos – WHO consultant 2011

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hospital care is a much more detailed book, with details of diagnosis and management of the sick newborn and child upto 5 years, the target is the doctor at the district, provincial and central hospital. The pocket book is intended to complement IMNCI as children are referred from the first level to more specialised care. It was not entirely clear if there is a good understanding of the complementarity between these two sets of materials, as they are implemented by different teams and there seemed to be no cross reference between the two.

5.2.2. Coordination and Financing

Each of the 11 Strategic Objectives of the RMNCH Strategy has a chair and committee who developed the

SOs. The overall responsibility for coordination and coherence across the SOs being with the Department

of Hygiene and Health Promotion. IMNCI is a project under the MCH sub-programme of the Health Social

Development Plan (2016-2020). Department of Health Care is responsible for the IMNCI at facility level.

Department of Hygiene and Health Promotion/ Maternal Child Health Centre responsible for the

community iCCM.

Whilst all the three main components for IMNCI strategy, and at the central, provincial and community level are being implemented, they are not always aligned and coherent. The SO5 committee is headed by the head of the paediatric hospital. There is an IMCI working group that cuts across SO 4 and 5 to align the newborn and child components of IMNCI, although not an official group, they meet every 3 months to follow-up. There is a dichotomy between the clinical responsibility of the paediatric hospital for ensuring availability of trainers and quality training, and that of the MCHC – which has managerial responsibility. Service delivery and health systems are responsibility of Department of Hygiene and Health Promotion, and Department of Health Care, both departments are under the Vice Minister of Health, whilst there is no single MOH department or Centre designated to take lead on policy development, implementation or coordination of CHW‐based issues13. Programmatic supervision is undertaken at each level of the health service as integrated supervision – which leaves follow-up after training as a potentially isolated, and mainly neglected activity. The evaluation of the previous strategy 2009-15 ‘A planning framework for integrated maternal, neonatal and child health services’14 noted that the degree of implementation of each component was dependent on projects supported by development partners. It also noted that Training in Integrated Management of Childhood Illnesses (IMCI) was revitalized in 2009 and 583 staff members were trained by May 2014. However, implementation was limited to certain provinces and follow up of the practices of the trainees was never conducted. Throughout the report IMCI/IMNCI was mentioned only once, reflecting the minimal attention to implementation in the previous strategy. With the current RMNCH strategy, although IMNCI is included as a key component of SO 5, there is no

specific budget for IMNCI or Child Health as a whole, rather different components have different funding

channels (e.g. Pocket Book, EENC, Nutrition, EPI). As IMNCI is included in the RMNCH strategy there

should now be an IMNCI budget, however at central level a budget is requested from government for

specific training activities – or series of activities - rather than for a consolidated roll-out plan, and the

paediatricians are invited to teach. In the province and district, IMNCI needs to be included in their plans,

but have to compete with other activities for funding prioritization. Current budgeting is project based

rather than results or outcome based – although there is a move in this direction. Results based financing

would need to have specific IMNCI-related indicators included. Development partners may support

activities at central, provincial, district or community levels. The previous 2009-16 strategy did not

13 WHO Technical Paper 1: Analysis of the Scope and investments in ongoing community‐based health worker initiatives 14 Evaluation of the Lao PDRs strategy and planning framework for integrated maternal, neonatal and child health services 2009-15. April 2015

14

include specific targets on IMNCI, nor even on pneumonia and diarrhoea. It will be important to include

indicators on IMNCI, for example in the World Bank supported DLI.

The SO5 working group is very active, but received less support than needed by partners, resulting in minimal implementation of their 2016 activities. In discussion with the different partners15, their support is focussed on health systems strengthening, national insurance, Maternal Health services (EMONC, Maternal/Newborn, RH), Early Essential Newborn care, Pocket Book, Nutrition, Community Action, but little focus on common childhood illnesses at community and health centre levels. In addition the coordination between different development partners is not optimal and needs to be more coordinated, in support of all the Strategic Objectives of the National RMNCH Strategy. Immunization is described as the best investment for future generations16 . IMNCI has also been described as worth the investment, as it costs up to six times less per child correctly managed than current care17. Development of an investment case for newborn and child health as part of an overall investment case for RMNCH, would serve as an advocacy tool for financing from both government budget and development partners.

5.3. Implementation of IMNCI and other child health strategies

Each of the different programmes relating to child health (e.g. EPI, Nutrition, EENC, etc) have their own

programmatic approach and funding stream, EPI is well-funded with clear plans down to microplanning

at health centre and community levels, supplies-chain management, supervision and monitoring systems.

Nutrition is managed by the Nutrition Centre, with a five day training on Infant and Young Child Feeding,

IYCF, targeted at the same health workers as IMNCI, being conducted by the department of hygiene and

health promotion, with the central level trainers being drawn from the same pool of paediatricians. There

is currently no management of severe acute malnutrition at health centre and community levels, and

very little at District and Provincial levels. Early Essential Newborn Care, EENC, is managed by the MCHC

centre, though through a different SO to child health, and has a separate group of trainers. The Pocket

book for paediatric in-patient management has been introduced well at central and provincial levels, and

currently introduction to district hospital level has started. At community level, some of the village health

volunteers have been trained on community case management of pneumonia and diarrhoea, CCM, and

the newly trained Community Health Workers have been trained on integrated CCM. In the end of year

review 2016 of implementation of the SO activities SO5 (Child Health) lagged far behind the other SOs,

only implementing 2.2% of the planned 44 activities due to financial constraints18. There is no evidence

of linkages between the different trainings, nor of an overall coordinated implementation plan.

5.3.1. Health workforce

IMNCI implementation is focussed on the first level health facility and the community, the main health workers implementing IMNCI are the nurse and midwife at health centre level, and the community health worker, or village health worker at community level. However for training and supportive supervision the paediatricians, doctors and provincial and district level, as well as the nurse tutors and trainers need to be trained and well-versed in IMNCI. In addition those planning and managing programmes at central, provincial and district levels, although may not need to be trained in IMNCI, would need to be well-

15 Partner Agencies including: UNICEF, UNFPA, LuxGov, USAID, AusAID, SDC, UNDP, WHO, JICA, UNAIDS, WFP

16 GAVI Alliance 17 WHO Multi-country Evaluation of IMCI. http://www.who.int/maternal_child_adolescent/topics/child/imci/en/ 18 Progress on RMNCH Strategy; RMNCH review meeting December 2016. MOH Dr Kaisone Chounramany DHHP

15

oriented, in order to appreciate the three components and its linkage with other programmes such as nutrition. The Human Resources development strategy by 2020 aims to effectively and efficiently develop sufficient number of qualified Health Workers in three categories and three generations in different health positions and categories. From a baseline number of 3385 (doctors, nurses and midwives) in 2009 equivalent to 0.5 HW/1000 population19. This has increased to 1.1/1000 by 2015, due to the rapid training and recruitment of more than 1000 midwives, however quality of training and subsequent practice is recognised as a major issue20. Although there was interest in continued professional development by a number of health workers, especially those with training roles, this is limited to sporadic training courses, or on-line searches in Thai language. More use could be made of mobile technology for updating and continued education, as the network covers most of the country. In the facilities visited, the central level had specialist paediatricians, obstetricians, general medical practitioners, nurses, midwives and students under training. The two provincial hospitals had both specialists and generalist doctors and nurses and midwives. The districts visited did not have specialists, rather generalist doctors and nurses and midwives. One of the districts, Beng, does not conduct caesarean sections as it has no operating theatre. The two health centres visited, one HC has 4 staff, the other HC has 7 staff and 7 students. The outpatient load was similar in both health centres, which were both within easy reach of the main road. Given the overall numbers of health workers in the country, the issue of how and where HW are deployed and the mix of new and more experienced staff is important as well as the quality of training of the different categories of health workers All these issues are addressed in the Human Resources for Health Strategy, as is the urban rural balance. It will however take time to redress the urban rural balance, not only in terms of numbers of health workers, but also in their types and quality. The financial incentive21 of an additional 30%-50% of basic salary for civil servants working in rural areas will help with rural recruitment, although virtually all the medical specialists are in the urban areas – central or provincial levels, with the majority of primary care and lower level nurses being in the rural areas. The HRH Development strategy promotes safety and supportive working environment, but there is need for clear guidelines as to how this will be implemented, also a need for more training on supportive supervision for continuous professional development.

5.3.2. Capacity building, IMNCI Training

i) Preservice

The Medical Faculty has 46 staff including 6 paediatricians and 4 Obstetricians/Gynaecologists, plus

lecturers from the hospital and visiting lecturers from Thailand, and occasionally Australia and South

Korea. Paediatric training is conducted through integrated care – ie. A systems approach, which

depending on the cases available teaching is done on either adult or child. Students also have two

months practice on the paediatric ward. Two of the staff were trained in IMCI in 2005, though have not

included IMCI in the teaching, but in the practical sessions in the outpatients. The Pocket Book for

paediatric care is used in the training and is seen as particularly helpful for medicine doses, duration of

treatment etc. EENC is included in the curriculum and two trainers have been trained and apply to their

work, but other staff not trained. There are no specific community practices included in the teaching.

There has been no use of computerised IMNCI, which would be of potential benefit in early medical

training.

19 Human Resource Development by 2020 Strategy. MOH 2010 20 Health Centre Workers in Lao PDR. World Bank 2015 21 Decree 468/PMO.

16

The nursing and midwifery students are taught at the school of health sciences or at one of the public

health schools. The public health school in Oudomxay conducts 3 courses; Nursing – 3 year course post-

secondary school. 65 students enrolled 2016, Midwifery – 3 year post-secondary school. 22 students

2016 (started 2015 with 25 students) and Community Health workers, CHW – 6 month course, post 7

years of schooling. 25 students enrolled, this is the 3rd course. Out of the 24 teaching staff only one has

been trained in IMNCI, thus runs the IMNCI teaching, although the practical in the hospital are conducted

by the hospital staff. The trainer is also a TOT for district level training, (DH + HC staff). With KOIKA

support they are able to give the chart booklet and checklist to the students. Although in Saravane the

trainers were using the chart booklet from the hospital, so provision of materials is not constant. For

EENC, the teachers have not been trained, but it is included in the ward practice. None of the teachers

have been trained in the Pocket Book. The separation of the theory and clinical teaching, means

assessment of the trainees as to their knowledge and practice is quite difficult.

The CHW training includes 5 modules, one of which is the management of common symptoms and MCH,

both of which are taught by the doctors from the provincial hospital. The tutors noted a problem of

commitment of CHW as only the first group was deployed after training, the current third group do not

know if they will be deployed after completing their training. There are also some language problems

when the students come from remote areas and don’t speak Lao.

A consistent approach to pre-service training would be beneficial, with capacity development of the

tutors as well as the availability of materials to support the teaching.

ii) in-service

Most of the IMNCI training is conducted as in-service training courses, which requires availability of

resources for the trainers, as well as the health workers to leave their stations to come for training. After

a lull in the training, it has been revitalised since 2016 following the development of the new RMNCH

strategy and the updating of the training materials. The 5 day in-service course includes 3 days child and

2 days newborn, with the modules having been shortened through reduction in the number of exercises

and reading. The Trainers of Trainers, TOT, courses is a 3 days course. However quality is an issue

especially those trainings conducted by the provinces without central level trainers. Although we heard

there is a selection of trainers out of a pool of those trained, it was not clear what the criteria for their

selection is. Some of the doctors from central and provincial level are called upon for the clinical aspects

of training, or for running the courses, but are not involved in the planning. There is no training currently

in follow-up and supportive supervision, although occasionally follow-up is conducted from central level

to provincial level. In the provincial and district hospitals many of the health workers interviewed had

been trained 10 years previously, with IMNCI training restarting last year. At both of the health centres

visited there were one or more HW trained in IMNCI, at one HC the HW had been trained in IMNCI during

their pre-service course, and at the other HC the HW had been trained on IMCI in-service in 2010. One

MCH centre and one Health centre had wall charts and chart booklet respectively, however overall there

was a lack of materials/job aids. In the district hospitals and the Health Centres there was a reluctance to

practice IMNCI due to the lack of recording forms, or the perception that recording forms are too labour

intensive, as the HW then has to record the data in a separate record book. The use of the record book

rather than recording forms would facilitate use of IMNCI. In addition linking the IMNCI data to DHIS 2

will be important so that the HW can use the same terminology for both forms.

Training in EENC had been conducted with evidence of change in practice in both Provincial hospitals and

one district hospital, also both provincial hospitals and one of the district hospitals staff had received

training in use of the pocket book. Where training had been conducted the pocket book was available,

however the use of the pocket book does not seem to extend to care of the small and sick newborn. The

17

pocket Book is mainly used for looking up drug doses and duration of treatment. In one of the district

hospitals there had been training on newborn resuscitation by partners, the Helping Babies Breathe, HBB

manual, with material/ flipchart were present.

5.3.3. Case management

To review case management of children under 5 years, including newborns, the assessment team

discussed with the health workers (doctors, nurses and midwives) and reviewed hospital in-patient

records, outpatient record books.

i) Newborn care

a) Immediate: Facilities that had received training in EENC were practicing according to the new

guidelines, those which had not yet received training still practice separation of the mother and

baby after delivery, though have reduced the separation time post caesarean section to 4 hours.

The IYCF guidelines also include early initiation of breastfeeding within 60min of delivery, though

were not readily available in the facilities visited. Resuscitation equipment was available in all

hospitals, however storage in an appropriate place and regular monitoring of cleanliness needs

to be improved. In addition infection control practices, including sterilisation practices of

equipment used for deliveries is very weak and needs improving. There is need to prioritise

provincial and busy district hospitals for the training, also to include the private facilities

conducting deliveries.

b) Care of the small newborn: This is currently a neglected area at provincial and district hospitals.

In the provincial hospitals visited, there are no protocols for feeding or oxygen therapy for

preterm or Low birthweight babies (although feeding of LBW infants is included in the IYCF

guidelines). Nor any systematic Kangaroo Mother Care. In one facility the pre-term nursery is

directly off the adult intensive care ward, with no handwashing facilities, the mothers of 2

preterm babies had not accompanied the babies to the hospital on transfer from the district,

thus there was no breastmilk available for the babies. Others were being given oxygen with no

monitoring as the pulse oximeter was broken. As most of these babies are cared for at provincial

hospital level, priority should to be given to training in the feeding and care of small and sick

newborns. The paediatricians from central level hospitals could facilitate this.

c) Postnatal care of the newborn: The traditional practice of fire-bed is good in that mother and

baby are kept together for the first 1-2 weeks, however if often accompanied by food taboos for

the mother and the fire can cause a smoky environment. We understand that the food-taboo

practices are being addressed – and also attention is being paid to the problem of indoor air

pollution from the charcoal fires. However there is currently no specific cadre to conduct home

visits to the mother and newborn. In one village we found that the Village Health Volunteer was

undertaking this role. There is potential for training the CHWs and the VHWs to conduct the

home visits for support to the mother and baby, this is essential for the promotion of EBF and to

support mothers to exclusively breastfeed and manage breast problems, also for mothers

nutrition and health.

d) Care of the sick newborn: Care of the sick newborn is included in IMNCI for first level health

facilities, at the district hospital there is no separation (or place for separation) of sick newborns

from older children, thus cross-infection is a possibility. Review of space available and allocation

18

of a designated area for newborns upto 2 months, plus adequate handwashing facilities would

improve infection control.

ii) Care of the child up to 5 years

a) Provincial and District Hospitals: The main problems for children admitted were diarrhoea and

pneumonia, though in Saravan province there are many cases and deaths from Beri-Beri. In-

patients are managed using the pocket book. However there tends to be overuse of IV fluids,

which without the appropriate safeguard of fluid regulation can be dangerous. Oxygen was only

available in one facility. There was widespread use of formula and feeding bottles, none of the

facilities were baby friendly (though had previously been designated some 10 years previously,

they had not been continuously monitored). In addition IYCF guidelines are not being followed in

the facilities.

b) MCH Clinics in hospitals: The staff of the MCH clinics had been trained in IMNCI, however use of

the IMNCI for managing children varied considerably. Not all facilities had a separate MCH Clinic,

though all had a separate EPI room. One of the MCH centres had IMCI wall charts. Staff citied

lack of recording forms as a problem to practice of IMNCI. Recording of management in the

record books varied according to practitioner, where the HW had been trained, review of the

record books showed more compliance to the IMNCI treatment guidelines, than where the HW

had not received IMNCI training. This was particularly relevant for treatment of diarrhoea,

antibiotics vs non-antibiotic use, and pneumonia – where those without IMNCI training often use

multiple medicines.

c) Health Centres: Both the health centres visited has staff who had received some IMNCI training,

either pre-service or recent in-service training. However they noted that they had limited

number of cases for practice during their training and no follow-up after training. One of the

nurses had a chart booklet which she had purchased herself at the training. However the issue of

recording forms and translation to the record books was raised again. In addition the IMNCI

classifications do not fit with DHIS2 for the district information system. Linking of the IMNCI

information to the register and then to DHIS2 forms would facilitate use of IMNCI in managing

children. In both the HCs visited the utilisation was very low with less than 10 sick children per

day (often <5 patients), although other services are also provided at the HC, including

immunization, ANC, adult patients, the case load in generally very low.

d) Community: The main problems cited by the mothers were diarrhoea, fever, malaria. All had

heard about the importance of breastfeeding and had received information on complementary

feeding, from the Lao Women’s Union. They said the children are much healthier than

previously, as they have better information and practices given by the Village Health Volunteer,

VHW. The VHW in one village had been trained in community case management of pneumonia

and diarrhoea, and had the forms and records readily to show. She is very active and

demonstrates the potential of the VHW to conduct health education, conduct post-natal visits

and case management of simple childhood illness, which would be important in the most remote

and difficult to reach villages. The rapport between the VHW and the village chief was excellent

in the 2 villages visited. In the one village the VHW had been active for 10 years and developed

her rapport over this long period. In the other having been selected by the village, worked closely

with the village chief and was supported by the health centre staff.

5.3.4. Availability of Medicines and other Commodities

19

A survey of 401 facilities conducted in 2014 by MOH and UNFPA noted that facilities at all levels had the

eight child survival medicines available with the exception of zinc. While 96 percent of all facilities survey

report managing zinc, only 16 percent of those actually had the medicine available on the day of visit.

When excluding zinc, “no stock out” of the remaining seven medicines is still relatively low with only 58

percent of facilities reporting availability of the products in the previous six months. Overall, 90 percent

of service delivery points, SDPs, reported having their own cold chain to store medicines. Almost all the

facilities reported cold chain capacity and an electric refrigerator (97 percent)22 . The Service Readiness

Availability, SARA, survey conducted in 2015 showed that no facility had all the essential medicines at any

one time23, with 53% availability of 12 essential medicines at Health Centre level, although essential

medicines were mostly available at district hospital levels. In addition the surveys found on average, 5 of

the 6 basic equipment required by the facilities to perform their core function was available on site at

health centres, with a stethoscope, blood pressure apparatus and an adult weighting scale available in

over 90 % per cent of HC, over a third of health centres did not have an examination light, and only about

45 % had all the 6 basic equipment required to perform basic health services to the population.

All the facilities visited had all essential medicines, apart from zinc, which has a national procurement

problem. Equipment was mainly available, although not all had appropriate infant/child weighing scale,

and the quality of equipment and storage was very variable.

5.3.5. Referral system

The district hospital use their ambulance for referral of patients to the Provincial Hospital, with some of

the cost of ambulance covered by health insurance, with a co-payment. From the HC to the district

hospital patients either use their own transport or call for ambulance from DH. (again with co-payment).

From village level to health centre, patients usually walk or use their own transport, for the free MCH

service the village chief gives a paper which the family takes to the health centre. Thus in principle the

system for referral has greatly improved with the free MCH service and the new Health Insurance

scheme. It was noted however that there is often bi-passing of one level by families, depending on the

condition. This is understandable, especially if the referral facility is in the opposite direction to a higher

level facility, or road access to a higher level facility is easier. In addition the transport costs, although

reduced by the Health Insurance, still have a co-payment element, and often own transport is the

method used. Most of the patients, both in-paediatric patient and out-patient at provincial and district

hospitals come from the nearby areas, and referral being mainly used for maternity or pre-term babies.

Transport costs in the very remote areas will still present a considerable barrier to referral for the poorest

communities.

5.3.6. Supervision and Monitoring

There is a clear supervision and monitoring system in place, with monthly meeting of district staff at the

provincial level to review all activities and share information. The District Health Team conduct integrated

supervision (all programmes), and programme supervision. Also monthly monitoring meeting in the

district with the HC staff. There are also supervision and monitoring visits by the district level to the HC

level on hygiene and health promotion, MCH, immunization, although curative care is supervised by the

District Hospital. The HC staff informed that they receive a supervisory visit from the district level, mainly

for health education issues, monitoring of record keeping, finance, medicines, EPI and health

22 Facility assessment for Reproductive Health Commodities and Services in Lao PDR. MOH/UNFPA 2014 23 Service Availability and Readiness Assessment Survey Report. Lao, PDR. WHO 2015

20

management issues. However clinical mentoring/ supervision is rarely included, and there has been no

follow-up or supervision following IMNCI training. None of those interviewed had undergone supervisory

skills training, thus capacity building of supervisors is needed. In addition reporting of data etc. has a one-

way channel from the village, to HC to district to province to central level. Effective supervision includes

the use of data to improve district planning/ programming.

5.3.7. Outreach

Outreach is conducted from the district to the Health Centres quarterly, to support HC staff in their

outreach – although resources are not always available. The HC staff conduct outreach to villages and

outreach posts, usually on a quarterly bases to each site. The comprehensive outreach visits include

Health Education, ANC, Immunization, FP, Nutrition/Vit A, deworming, Iron+folate for pregnant women

and Growth Monitoring. Some of the outreach visits are conducted jointly with the District team,

however access can be a problem to the remote villages, especially in the rainy season. The VHWs is

involved in the outreach sessions, both in informing the villagers of the outreach schedule and

encouraging attendance, as well as working with the HC staff. HC staff feel these services are very

important – as access is often poor, and use their own money if no fuel is available for the motorbike.

There is however a limitation to the outreach services with regards to clinical care, as no IMNCI services

are provided, which although would be limited in terms of frequency of service availability, would be an

opportunity for supportive supervision of the CHWs and VHWs, and could be an encouragement for the

community to use the HC on other occasions.

5.3.8. Health Information System (record books, DHIS 2, Village records)

The health information system is well developed with information flowing from the village to the health

centre, to the district, to the province, although duplication in the number of registers and forms to be

completed was seen. This is currently being addressed. A common complaint was the lack of IMCI

recording forms, or where available, difficulty in transcribing into the register. This can be alleviated if the

register includes the IMNCI classifications. Also noted was the lack of alignment between the registers

and IMNCI classifications – a review of the DHIS 2 forms to include or align with IMNCI classifications

would help in the reporting. It was also noted that not all ANC visits are recorded, due to a discrepancy

between the insurance system and reporting. Both these need to be addressed. One of the districts

visited gave a presentation of their district data, which was clearly being used for planning, although

feedback to health centre level is limited. The immunization data was well used in most of the facilities

visited, both for estimating the number of children to be vaccinated, as well as vaccine coverage by

month. Plans have been made for similar charts to be used for ANC, SBA and pneumonia and diarrhoea,

although currently these charts are empty. The team was also informed that the number of ANC visits are

only recorded as per the health insurance book and do not reflect the actual number of visits made. This

needs to be addressed in the supervisory visits.

5.3.9. Community: Village volunteers, Community Health Workers, Family Health Practices

The village chief and deputy chief in the two villages visited were very engaged and proud to inform the

team how the health of their villages has improved with the village volunteers. Citing an increase in the

number of latrines and a reduction in malnutrition. Although some cases of diarrhoea and pneumonia

still occur, now with free MCH, if a child is sick the mother comes to the village chief for a ticket and goes

to the health centre. The deputy chief conducts a monthly meeting with the village volunteers to discuss

21

health issues. In both of the villages the VHW conducts health education, either themselves or with the

HC staff when they visit for outreach. In one village the VHW does antenatal and postnatal visits (2 x AN,

3 x PN), for birth preparedness and care of mother and newborn, she has also been trained in community

case management (CCM) and has a small drug kit which she replenishes using her own money. The

villagers also mentioned receiving information on breastfeeding and infant feeding from members of Lao

Women’s Union, and all were well versed in the importance of exclusive breastfeeding, although good

complementary feeding practices were less evident. The practice of ‘fire-bedding’ after delivery was

described in both villages, with some of the food taboos and safety issues having been addressed through

health education. At village level, we saw very well kept and detailed records of CCM and home visits to

the mother and newborn. In addition the Village Chief has details of each family and household on the

village. This functions well when the VHW is literate, the record system could be simplified, which would

be an advantage in villages where the VHW is less literate.

The VHW who is trained in CCM receives a stipend from the district. This has encouraged her to stay in

this position for the last 10 years. Usually a VHW will only stay in the position of 2-3 years. This was a very

good example of a model village. Both villages demonstrated the potential of good promotion of key

family practices and the second village also demonstrated the potential of community case management,

with no deaths in the village of mothers, newborns or children for a long time.

Currently the community component of IMNCI is the least well developed, with not all villages having

VHWs and very few having CHWs. There is potential for rapid impact on reduction of newborn and child

mortality and improving maternal health through the deployment of CHWs trained in CCM to the most

remote villages, and of VHWs, with additional training in CCM to villages with seasonal access to services.

As shown in the figure24 above, the model of good collaboration between the HC staff, the village chief

and the VHW/CHW needs to be promoted.

6. Conclusions

With the key causes of under 5 mortality in Lao PDR still being newborn, diarrhoea, pneumonia and

malnutrition, IMNCI remains a central strategy for reduction of under 5 mortality in the country. However

since its introduction the main focus has been on health worker training and mostly dependent on

24 WHO/UNICEF Joint Statement on integrated Community Case Management. WHO 2012

22

external financing. Much of the focus on training has been on in-service rather than pre-service training,

and it has not yet become the ‘sine qua non’ for case management practice in the country. Apart from

the availability of essential medicines, the other health system components, have not been systematically

reviewed to ensure inclusion of and compatibility with IMNCI, resulting in IMNCI being seen as additional

to rather than a fundamental component of HSS.

Furthermore the community component has been the most neglected component, with key family

practices included in the short VHW training, and some projects including additional training for VHW on

community case management of pneumonia and diarrhoea. The Community Health Worker training has

great potential, though deployment of the CHWs is currently stalled. Given the low utilisation of health

facilities, attention to the community component, deployment of the CHWs already trained and

supportive supervision, could give quick wins in reduction of U5 mortality25 in the remote areas. With the

current training of CHWs in Laos, they are well positioned to do both IEC on family and community

practices as well as iCCM. However the VHWs with their 10 day training, would need significant additional

training (as in the case of the village visited), to do iCCM, and it would be better to continue the effort on

IEC of Family and Community Practices, complemented with IYCF. In both cases the support of the HW in

the HC is needed, so they also need appropriate training.

In order that IMNCI is fully implemented in a sustainable manner, a clear costed implementation plan,

which addresses the three components of IMNCI is urgently needed. The plan, which will include targets

down to the community level and a monitoring framework should form the basis of provincial and district

planning, and be used to ensure the necessary resources are available at all levels for implementation.

Additionally there is the opportunity to include new technology for training, supervision and monitoring.

Appropriate implementation of the three components of IMNCI, paying particular attention to the

remote and hard to reach areas, can bring rapid results in reduction of deaths from newborn causes,

pneumonia and diarrhoea, as well as improve the nutrition of the children. The proposed actions have

been developed based on the assessment to overcome the bottlenecks in implementation, and move the

implementation of IMNCI forward.

7. Proposed actions:

Proposed actions to overcome the problems in IMNCI implementation are divided into Immediate, Short

Term and Medium Term. Following review by the MOH – specific responsibility and time frame can be

added.

IMMEDIATE

• Sustainability

• MOH with support from UNICEF and WHO to develop a costed equity based scale up

plan for IMNCI – with clear implementation steps, and monitoring and accountability

framework aligning with the EPI and nutrition programme, as well as to WASH sector;

(With tailored plans at provincial/district level, starting with the poorest districts)

• Government to put in place a budget line for IMNCI

25 Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations. Ethiopia and Liberia with the One Million CHW Campaign. July 2015

23

• Development partners to review plans and include support for IMNCI (including a link to

WB supported DLI project underway to ensure that newborn, pneumonia and

diarrhoea mortality and morbidity is addressed.

• Integration

• Under RMNCH secretariat, members from SO5 and SO7 to form temporary working

group to develop IMNCI scale up plan, budget, monitoring/accountability framework.

Especially to ensure linkage between IMCI and IYCF.

• MCHC to set local coverage targets and monitoring IMCI/IYCF. Use the opportunity of

the excellent EPI microplanning as model.

• Community

• Continue work on development of a strategy/ framework for community service delivery

to clarify options for PHC at village level with options for deployment of CHWs. Ensure a

consultative process to ensure that all stakeholders are included with the MoH

responsible. WHO and UNICEF support.

• MOH to advocate with MOHA to rapidly deploy those CHWs already trained to hard to

reach districts and villages.

SHORT TERM

• IMNCI Algorithm

• Include beriberi for those provinces most affected – NB Need to develop policy and

protocol for B1 supplementation. IMNCI working group, clinicians and paediatric

association.

• Develop short module on ‘How to practice IMNCI’ to add to the training. IMNCI working

group with UNCIEF and WHO support

• Ensure harmonised nutrition messages between IMNCI and IYCF. SO5 and SO7 teams,

with UNICEF support.

• Training

• Pre-service:

• Increase pool of tutors with IMCI TOT in Provincial Public Health Schools. MOH

TOTs. DP support.

• Provide adequate teaching materials, including chart booklet for each student.

DP support

• Consider using computerised IMCI for introduction to Medical Students and

tutors. WHO to provide Computerised IMCI USB/CD

• In-service

• Provide chart-booklet for each HW trained – consider desk-top job-aid (1 page

newborn, 1 page child). MOH, DP support

• Include training of supervisors in the overall training plan.

• Include follow-up after training – especially to HC staff. MOH build into

implementation plan.

24

• Supervision

• Build in case management to supportive supervision – particularly for HC staff and

Community Health Workers. DH

• Prioritise hard to reach areas. Province and District Health teams

• Community

• PHC and MCHC to develop a consensus on improved community and family practices,

and promotion of care seeking behaviour. eg. revision of the Village Health Volunteer

module, and utilizing existing community health contacts including nutrition/ EPI

activities to raise awareness on CCM of pneumonia and diarrhoea and strengthen

practices.

• Include kits containing ORS/Zinc and antibiotics for treatment of pneumonia by CHWs

iCCM

MEDIUM TERM

• Medicines

• Re-order Zinc for management of diarrhoea. Include how to use zinc in supportive

supervision and on-job training

• Include distribution of nutrition supplies e.g. Vitamin A, deworming, sprinkles, RUTF with

essential medicines to ensure consistent supply.

• Equipment/supplies

• Ensure neonatal ambu bags and sterilisation equipment in all Hospitals and HF

conducting deliveries are both available and maintained.

• Training

• Consider innovations – Computerised IMCI, use of mobile technology/app for mobile

phones etc. MOH to link with e-health strategy.

• Review IMCI and IYCF training for HC level; methodology, content, duration, etc. IMCI

WG.

• Include treatment of SAM in IMCI. Nutrition and IMCI WG.

• Review PHC manual regards IMCI and IYCF. PHC with support of UNICEF

• Integrated Supportive Supervision

• Build skills in supportive supervision.

• Encourage peer to peer learning between those trained and other staff in all levels of

the health system.

• Cluster village volunteers for updating and support. PHC through Prov and Distr Health

teams.

• Outreach strategy

• Review and reprioritise most hard to reach areas.

• Health Information System

25

• Review the number of registers and forms to be completed at HC and village level and

rationalise.

• Include IMNCI categories in the OPD registers for use at MCHCs and HCs, and include

categories in DHIS2.

• Community

• Utilise the enhanced collaboration between SO5 and SO7 to coordinate and enhance

BCC on IYCF in the community, through VHWs, CHWs and other community cadres.

OTHER ISSUES

• Care of the Small and Sick newborn

• Institute a protocol for feeding pre-term and low-birthweight babies. Available in the

Pocket Book – include a specific module in the training. Melbourne University.

• Start kangaroo mother care for stable PT and LBW babies.

• Protocol for oxygen therapy for preterm babies and monitoring with pulse oximeter

• This is included in the Pocket Book – but will require additional training for

implementation: prioritise provincial hospitals – then district hospitals with many

deliveries. Can use the opportunity of Phase II District level Pocket book training.

• Baby Friendly Hospitals, BFHI

• Consideration should be given as to whether Hospitals that were previously designated

baby friendly should be supported to re-attain this BFHI status, with the appropriate

monitoring mechanism in place. Or if training in EENC and adherence to IYCF guidelines

can achieve adherence to provisions of the Code26 of Marketing of BMS. .

• Use EENC as entry point to improve breastfeeding practices.

• Code of Marketing of Breastmilk substitutes

• Strengthen provisions and monitoring of the Code.

• Infection Control – Quality Improvement

• These need to go hand in hand.

• Formative research on feeding practices

• Research into feeding practices has been done

• Need to investigate what caregivers are willing to do (small doable actions) to improve

IYCF practices

26 International Code of Marketing of Breastmilk substitutes and subsequent resolutions. WHO resolutions.

26

Principal investigator: Dr Elizabeth Mason, UNICEF Consultant

Assessment Team

MOH

Dr Kaisone Chounramany, Deputy Director General, Department of Hygiene and Health Promotion

Dr. Sommanikhone Phangmanixay, Director, Children Hospital.

Dr. Kopkeo Souphanthong, Deputy Director, Maternal and Child Health Center.

Dr. Sayavone Khounnolath, Head of Child Health Division, Maternal and Child Health Center

Dr. Phengchoi Panyalath, technical staff, Maternal and Child Health Center

Dr. Foukty Phengphakeo, technical staff, Maternal and Child Health Center Dr. Koulap, Children Hospital.

Dr. Douangmala, Children Hospital.

UN

Dr. Hendrikus Raaijmakers, Chief Health and Nutrition, UNICEF Lao PDR.

Dr. Salwa AlEryani, MCH Specialist, UNICEF Lao PDR.

Dr. Onevanh Phiahouaphanh, Health Specialist, UNICEF Lao PDR.

Dr. Shogo Kubota, Technical Officer, WHO, Lao PDR.

27

Annex 1

IMNCI assessment In-country itinerary 28th March-7thApril 2017

Tuesday, 28th March

8:00-8:30 UNICEF Health and Nutrition section

08:30-09:30 WHO technical meeting

9:30-10:30 Meeting with UNICEF Myo-Zin Nyunt, dep rep

10:30-12:00 Visit Children’s Hospital

12:00-13:00 Lunch

14:00-15:00 Briefing meeting with MOH (DHHP and DHC): Dr. Kaisone, Deputy Director General, Department of Hygiene and Health Promotion, and Assoc. Prof. Dr. Bounnak Saysanasongkham, Deputy Director General, Department of Health Care (venue: DHHP).

15:00-14:00 Meeting Dr. Sysavanh Vongpachanh and Dr. Tiengthong Khomthilath, professors at University of Health Sciences

Wednesday, 29th March

9:30-11am Visit Maternal and Newborn Hospital

10:00-12:00 Meeting Director of School of Health Technology in Vientiane Capital

12-13:00 Lunch

13:00-14:00 Care International

14:30-15:30 Lux Development Project

Thursday, 30th March

8:30-10:00

10:00-10:30 Go to airport

11:40 – 12:30 Travel to Oudomxay (Flight QV 501, flight time at 11:40am)

13:00 – 14:30 Check-in the hotel and Lunch

14:45 – 15:15 Briefing meeting with Director of Provincial Health Office

15:30 – 16:30 Visit public health medical school and meet with Director of the school

Friday, 31st March

7:00 – 8:30 Travel to Beng district by rental car (mini van).

8:30 – 9:00 Briefing meeting with Head of DHO Beng district

9:30 – 11:00 Visit Beng district hospital

11:00 – 12:00 Visit Napa health centre in Beng district

12:30 – 13:30 Lunch

14:00 – 15:00 Visit Ban Phiahouanam village in the area of Napa health centre: interview VHV/village chief, focus group discussion with child caretakers

15:30 – 17:00 Travel back to city of Oudomxay

Saturday,1st April

8:00 – 9:45 Visit provincial hospital in Oudomxay

10:00– 10:30 De-briefing meeting with Director of Provincial Health Office to share main findings from the field visit.

10:30 – 11:30 Lunch & go to airport

13:00 – 13:50 Travel to Vientiane (Flight QV 502, flight time at 13:00pm)

Monday, 3rd April

7:30 – 8:45 Flight Vientiane to Pakse (QV223, flight time at 7:30am, arrive in Pakse at 8:45am)

9:00 – 11:00 Travel by car from Pakse to Saravan by rental car (mini van)

11:00-12:00 Briefing meeting Director of Provincial Health Office of Saravan. Dr Boualay Senkeomyco

28

12:00 – 13:30 Lunch

13:30 – 16:00 Visit provincial hospital in Saravan

Tuesday, 4th April

8:30-9:00 Meeting Head of District Health Office of Kongsedone

9:15-10:30 Visit Khongsedon district hospital

10:30-12:00 Work with district MCH staff

12:00-13:00 Lunch

13:00-14:30 Visit Thaluang health center

14:30-16:00 Visit Meunguankao village

16:00-17:00 Travel to Pakse (stay overnight in Pakse)

Wednesday, 5th April

12:30-13:20 Return to Vientiane (QV306, flight time at 12:30pm, arrive VTE at 13:20pm)

15:00-16:30 Technical meeting with Dr. Sommanikhone, Dr. Kopkeo, Dr. Sayavone, Visith from CIEH and Dr. Sommana from DHC, UNICEF, WHO and UNFPA at MCHC.

Thursday, 6th April

13.00-14.00 Meeting with nutrition UNICEF

14.00-15.00 Meeting with Development Partners

15:00-16:00 Meeting with Dr. Chandavone Phoxay, Deputy Director General, Department of Hygiene and Health Promotion.

Friday, 7th April

10.00-12.00 De-briefing meeting with MOH, UN, DPs, at MOH

13.30-14.30 Meeting with Dr. Viengvilay Chanthavong, Head of PHC Division, DHHP.

16.00-17.00 Meeting with Dr. Anonh Xeuatvongsa, Deputy Director MCHC, Manager NIP

29

Annex 2: List of Persons Met

Vientiane

Dr Kaisone Chounramany, Deputy Director General, Department of Hygiene and Health Promotion,

Assoc. Prof. Dr Bounnak Saysanasongkham, Deputy Director General of Department of Health Care.

Dr Chandavone Phoxay, Deputy Director General, Department of Hygiene and Health Promotion

Dr Sommanikhone Phangmanixay, Director of Children’s Hospital, Head of RMNCH SO5-Subcommittee.

Dr Pondawan, Deputy Director, Children’s Hospital.

Dr Kopkeo Souphanthong, Deputy Director of Maternal and Child Health Center

Dr Anonh Xeuatvongsa, Deputy Director of Maternal and Child Health Center.

Dr Sysavanh Vongpachanh and Dr. Tiengthong Khomthilath, professors at University of Health Sciences.

Dr Sivanesay Chanthavongsak, Deputy Director, National Mother and Newborn Hospital.

Dr Saiyadeth Chanthavong, Head of Administration Office, PMCT Focal Point, Mother and Newborn

Hospital.

Dr Sysavanh, School of Health Technology in Vientiane Capital.

Head of Paediatrics, Medical School.

Dr Sayavone Khounnolath, Head of Child Health Division, PMCT Focal Point, Maternal and Child Health

Center.

Dr Sommana Rattana, Deputy Head of Local Hospital Division, Department of Health Care.

Dr Viengvilay Chanthavong, Head of PHC Division, Department of Hygiene and Health Promotion.

Oudomxay Province

Dr Bounliene Vongphasith, Director of Provincial Health Office

Dr. Souvanthong, Deputy Director of Provincial Hospital

Dr Somchay, paediatrician, Chief of pediatric ward

Ms. Bouavinh, Provincial MCH staff

Doctor in charge, Maternity

Six teaching staff, Public Health School

Beng District

Dr Bounsuang Khamphouvong, Head of District Health Office

Mr. Khammai, Head of District Hospital

Napa Health Centre

Two HC staff, nurse and midwife

Ban Phiahouanam Village

Village Chief,

Villagers, mothers and their babies

30

Saravan Province

Dr Boualay Senkeomyco Director of Saravan PHO

Director MCH services

Saravan Hospital

Dr Vanthong Bounvilay, Deputy Director, Provincial Hospital

Dr Phoutavanh, Paediatrician, Paediatric Ward.

Dr Nokalya Phommaxay, Obstetrician/Gynaecologist, Maternity Ward

District Health Office of Kongsedone

Kongsedone Hospital

Head of Clinical services and MCH team

Thaluang Health Centre

Nurse in charge.

Muangkao Village

Deputy Village Chief.

Village Health Volunteer.

Mothers and babies in the village.

Partners

UNICEF Lao PDR

Myo-Zin Nyunt, Deputy Representative.

Dr Hendrikus Raaijmakers, Chief, Health and Nutrition Section.

Ms Karen Courtney, Nutrition Specialist.

Dr. Salwa AlEryani, MCH Specialist.

Dr Onevanh Phiahouaphanh, Health Specialist.

WHO Lao PDR

Dr Shogo Kubota, Technical Officer, Maternal and Child Health

Lux Development Project

Mr Peter Heimann, Chief Technical Advisor

Dr Frank Haegeman, Health Systems Advisor

Dr Ruhul Amin, Health Planning and Management Coordinator

JICA

Dr Hiromi Obara, JICA Health Policy Advisor

CARE International

Ms Isabelle Cazottes, Gender and Health Advisor

31

USAID

Ms Kongchay Vongsiya, Development Assistance Specialist, Health Program Advisor

University of Melbourne

Dr Julie Cayrol, Paediatric Clinical Education Fellow, Centre for International Child Health

Dr Marianne Safe, Paediatric Clinical Education Fellow, Centre for International Child Health

Institute Pasteur du Laos

Dr Anthony Black, Head of Lao-Lux Laboratory

32

Principal investigator: Dr Elizabeth Mason, UNICEF Consultant

Assessment Team

MOH

Dr Kaisone Chounramany, Deputy Director General, Department of Hygiene and Health Promotion

Dr. Sommanikhone Phangmanixay, Director, Children Hospital.

Dr. Kopkeo Souphanthong, Deputy Director, Maternal and Child Health Center.

Dr. Sayavone Khounnolath, Head of Child Health Division, Maternal and Child Health Center

Dr. Phengchoi Panyalath, technical staff, Maternal and Child Health Center

Dr. Foukty Phengphakeo, technical staff, Maternal and Child Health Center Dr. Koulap, Children Hospital.

Dr. Douangmala, Children Hospital.

UN

Dr Hendrikus Raaijmakers, Chief Health and Nutrition, UNICEF Lao PDR

Dr Salwa AlEryani, MCH Specialist, UNICEF Lao PDR

Dr Onevanh Phiahouaphanh, Health Specialist, UNICEF Lao PDR

Dr Shogo Kubota, Technical Officer, WHO, Lao PDR

Dr Kaisone Chounramany, Deputy Director General, Department of Hygiene and Health Promotion, Dr.

Sommanikhone Phangmanixay, Director, Children Hospital, Dr. Kopkeo Souphanthong, Deputy Director,

Maternal and Child Health Center, and Dr. Sayavone Khounnolath, Head of Child Health Division,

Maternal and Child Health Center.

Principal investigator: Dr Elizabeth Mason, UNICEF Consultant. Dr Hendrikus Raaijmakers, Chief Health

and Nutrition, Dr Salwa AlEryani, MCH Specialist, and Dr Onevanh Phiahouaphanh, Health Specialist, from

UNICEF/ Lao PDR, and the key Development Partners.

33

Annex 3 Documents Reviewed

1. Lao PDR Five year National Socio-Economic Development Plan VIII. 2016-20

2. Health Sector Development Plan 2016-2020

3. Government Expenditure on Health in Lao PDR: Overall Trends and Findings from a Health Center

Survey. World Bank, Vientiane Office, Laos May 2015

4. Lao National Health Accounts Report. Fiscal Year 2010-2011 and 2011-2012. MOH/WHO 2012

5. Health Sector Reform Framework Lao PDR to 2025. Vientiane 2013

6. Lao People’s Democratic Republic Health System Review Asia Pacific Observatory on Health

Systems and Policies. Health Systems in Transition Vol. 4 No.1 2014

7. Health Information System Strategy 2009 – 2016

8. Health Sector Reform Strategy and Health Sector Reform Framework

9. MOH/DPIC Roadmap for DHIS2/HMIS strengthening in the framework of Health Sector Reform

10. Draft eHealth strategy 2016 – 2030

11. Health Personnel Development Strategy by 2020. Ministry of Health, November 2010

12. Human Resources for Health, Lao PDR Country Profile. WHO Western Pacific Region 2013

13. Analyses of Health Workforce Retention and Attraction Policies in Lao PDR. Vientiane May 2015

14. Human Resources for Health in Lao PRD. Analysis of a nationally representative Health Centre

and Health Centre Worker Survey. World Bank Vientiane, 2015

15. Social Health Protection (SHP) towards UHC in Lao PDR. National Health Insurance Bureau (NHIB)

16. Ministry of Health. Ministry of Planning and Investment, Vientiane February 2015

17. Evaluation of Lao PDR’s Strategy and Planning Framework for Integrated Package of Maternal, Neonatal and Child Health Services 2009-2015. April 2015

18. National Strategy and Action Plan for Integrated Services on Reproductive, Maternal, Newborn

and Child Health 2016-2025. Ministry of Health Lao PRD 2015.

19. Early Essential Newborn Care Action Plan for Lao PDR, 2014-2020 MOH, Family Health Office.

DRAFT November 29, 2013

20. Midwives in Lao PDR: Scaling up Skilled Birth Attendance: Putting midwives at the community-level towards achieving MDGs for Mothers and Children Report 2012. UNFPA 2012

21. Service Availability and Readiness Survey Assessment Report 2014. Lao PDR. Ministry of Health 22. Final Report: Stock Availability Study – Insights INDOCHINA RESEARCH LTD. Laos 2016

23. Key Findings from Reproductive Health Commodities and Services 2013 Facility Assessment.

UNFPA Vientiane 2013

24. Facility Assessment for Reproductive Health Commodities and Services in Lao PDR. UNFPA 2014

Survey Report

25. Community Health System Strengthening in the Lao People’s Democratic Republic Situation

Report, Mapping and Qualitative Inquiry. WHO Lao PDR December 2013

26. Building an Accessible and Sustainable Community-Level Health Worker System in Lao PDR. A

Position Paper 2013.UNJP Support to MOH to develop a Phased Approach to a Community

Health Worker As part of the 8th HSDP and RMNCH strategy and Action Plan 2016-2025

27. Preliminary Report. Evaluation of the Community based Management of Acute Malnutrition in 2

Southern Provinces (Attapeu, Saravane) Lao Peoples’ Democratic Republic 11th – 24th March

2013

28. WHO Technical Paper 1: Analysis of the Scope and investments in ongoing community‐based

health worker initiatives.

29. WHO Technical paper 2: Village Health Volunteers (VHVs) in Lao PDR: An assessment of their

sociodemographic profile, recruitment, training, incentive, and job performed. 2014.

34

30. Technical Paper 3: Cost Projections for establishing a two‐tier Community‐Based Health Worker

System

31. Technical Paper4: Projected Impact and Cost‐Effectiveness Analysis of establishing a two‐tier one

National CHW Program targeting rural villages in Lao PDR

32. Presentation Comprehensive Integrated community services By: Dr. Viengvilay Chanthavong

Head of Primary Health Care Division Department of Hygiene and Health Promotion. Ministry of

Health

33. Report on an integrated approach to improving care for children in Nambak District Hospital

Centre for International Child Health, University of Melbourne, August 2016

34. By the book: improving paediatric hospital care in Lao PDR. Women and Children’s Health Knowledge Hub. February 2013

35. Implementing WHO hospital guidelines improves quality of paediatric care in central hospitals in Lao PDR. Tropical Medicine and International Health 2014

35

Annex 4 – Semi-Structured questionnaires

Questions for National-level informants 1. Firstly I would like to look at the main lessons from IMNCI implementation as you see them, when thinking about how future child health strategies should be designed?

• What is your understanding of IMNCI in Laos – what components/activities does it cover?

• What in your view has been the relevance of IMNCI implementation in Laos? Has the integrated approach changed the landscape of child health programming?

• How would you characterize strengths of implementation of the three main components/activities covered under IMNCI? (Health Worker Training, Health Systems Strengthening and Community Component)

• How would you characterize the extent and limitations of IMNCI implementation, considering the different components and activities?

• What lessons have you learnt from IMNCI implementation to date? • What are your perceptions about the overall feasibility of delivering IMNCI at scale and

ensuring integrated service delivery with quality?

2. Implementing programs at scale requires a programmatic approach that includes evidence-based planning, strengthening of health system functions such as training, distribution and retention of health work force, supportive supervision, supply chain management, health information, and monitoring and evaluation

• Was the programmatic approach adopted for IMNCI? Please describe why or why not.

• How has IMNCI been linked with programming in other areas that are relevant for child survival and health, such as immunization, nutrition, prevention and control of malaria and of HIV?

• What have been the main benefits of IMNCI compared to other child health strategies or health policies?

• What was the value of the integrated approach? What might be alternatives?

3. What are some support systems and challenges for child health in terms of governance, policy and investment?

• How are newborn and child health programme activities coordinated at the nation level? Who is responsible for child health, including newborn health?

• Is there a National IMNCI or child health working group?

• What are challenges in coordinating among actors, either within government or with other partners? (PROBE: private sector, civil society, partners)

• What have been the greatest support systems for IMCI and other child health efforts in recent years? Have actors ever been in conflict over these issues?

• Tell me about the financing for IMNCI and child health more generally. Was scaling-up of IMNCI strategy ever costed? Has funding been adequate to meet the needs? Has funding been directed to all IMNCI components in a balanced way? Have there been instances in which some activities have been prioritized and received more funding than others? Where are there gaps? Would you say that allocation of funds for IMNCI is sustainable?

• How has the introduction and scale up of iCCM affected IMCI?

4. What are the greatest supports and challenges for child health within the health system?

• Can you tell me about some of the biggest health systems issues that limit the achievement of child health goals? (e.g. Stock outs, referral pathways, supervision, HR shortages)

• KEY QUESTION: What works well to make the health system responsive to child health strategies?

• Describe any organizational & management issues affecting scaling up & sustainability.

• What innovations have been either piloted or implemented widely that have worked well? Does it make sense to scale these up? (e.g. ICT, mHealth) If so, how would this happen? What do you anticipate are the biggest obstacles to scale up?

36

• How are regional differences (in epidemiology, service implementation) within your country being addressed?

• Tell me about training & supervision of providers of child health in your country. What works well and what could work better? (PROBE: Supportive Supervision, training, in-service and pre-service)

• How is the National Health Information System functioning? Are indicators relating to IMCI included?

• What is the situation with respect to Monitoring and Evaluation? What works well and what could work better?

• How much care for sick children is provided by the private sector? In what ways do MOH and other actors work with the private sector?

• What other health systems issues may have limited the impact of IMNCI and other child health programs. How do you think these could be overcome?

• Over the years we have seen a lot of global initiatives launched to support countries accelerate action. These include A promise renewed, GAPPD, ENAP, etc. Have these helped in scaling up IMNCI?

5. What are the most important future actions to improve child survival & health in Laos?

• How is Laos addressing changing epidemiology in child health?

• What do you see as the future link between activities to strengthen actions for child survival and health overall in communities, facilities and the health system?

• What should be done to generate demand and increase utilization of effective treatment interventions?

• What innovations should we be thinking about as we strive for increasing access to quality care at all levels?

• Do you think IMNCI has a role to play in the future landscape of national child health policy? Why or why not? What would you do differently in the implementation of IMCI?

• What aspects of the IMNCI strategy should be preserved as the national child health policy is updated and re-positioned? What aspects can be modified and how?

6. Is there anything else about IMNCI or future child health strategies that we have not discussed that you would like to add?

******************************************** Questions for the Provincial and District Health Management Team 1. Introductory questions

• What role does the PHMT/DHMT play in oversight of IMNCI? • Are there other child health programmes being implemented in your district?

2. Organization and management

• What plans/programmes do you have for capacity building and skills reinforcement, team-building, management skills, incentives, monitoring and audit processes.

• Who is responsible for IMNCI implementation and is it part of the district health plan? Integrated funding? Separate funding? By whom?

• Are partners’ activities part of the district health plan? • Do partners regularly report activities to PHMT/DHMT? How often?

3. Supports & challenges in executing national health strategies

• What are the policy, systems and programme characteristics affecting coverage & system readiness to provide care under IMNCI? (Health worker training, Health System and Community, plus IMNCI/iCCM linkages)

• Have you undertaken specific adaptations & innovations (e.g. newborn component) in your district?

• Do you use the pocket book in the district hospital?

37

• What gaps are there to successful implementation of IMNCI in the hospital? In the health facilities?

• Staff mobility – how often do HW rotate and how do you keep them updated? (Hospital, Health Facilities)

• Do you undertake supportive supervision in the district, how often? Can you describe? • How is monitoring done (HMIS, separate forms etc) • What are the policy, systems and programme issues affecting scaling-up

4. Do you have other proposals for the future?

• E.g. updating of guidelines, formats (paper, electronic, etc.), number of guidelines, communication, etc

• What do you think your future priorities in child health for this district will be?

5. Is there anything else that we should understand about IMNCI or future child health strategies that we have not discussed that you would like to add?

***********************************************

Questions for Providers at facility or community levels

• What are the most important issues in this community related to child health? • Have you been trained in IMNCI?

o If yes what was good/bad about the IMNCI training. o If no have you heard of IMNCI? o Are you regularly supervised? o What are the issues related to supervision?

• What are the problems related to implementation/practicing IMNCI? E.g. lack of medicines, stockouts, payment, referral etc

• Integration – how has this helped or hindered your workload? • Community component & iCCM delivery – describe any links between curative care & health

promotion • Do you have suggestions to improve IMNCI?

Questions for Village Chief/Village Health Committee

• What are the most important issues in this community related to child health? • What are the problems related to access to services? E.g. lack of medicines, payment of fees,

health worker absence, referral etc • Have you heard of IMNCI?

o If yes what was good/bad about IMNCI. • Are there any other programmes for children in the village/district (e.g. nutrition programme,

immunization). Do they work together? • Can you tell me about any links between curative care & health promotion • Do you have suggestions to improve IMNCI?

Questions for Child Caretakers – Focus Group Discussion

• What are the most important issues in this community related to child health? • Are there any programmes for children in the village/district (e.g. IMNCI, nutrition programme,

immunization). • What are the problems related to access to services? E.g. lack of medicines, payment of fees,

health worker absence, referral etc • Do you have suggestions to improve the health of children in your community?

38

Annex 5: Total Number of IMCI-trained staff (clinical training) 2007

Name of Province

Source: MOH and JICA smile project summary of IMCI training 2007.

Number of trained Health Workers 2011

Province Facilitator trainees

Number of health centre

HC trained on IMCI 5-day course

Remarks

Central level 47 46 0 16 facilitators trained on 5-day course

Xiengkhouang 4 54 54 10 HCs have >1 staff trained on IMCI

Houaphan 3 55 12 All HC will be covered by Dec 2012

Oudomxay 3 44 0 26 HC will be covered by October 2012

Phongsaly 3 31 0 11 HC will be covered by Oct 2012

Louangnamtha 5 38 0 2 facilitators trained on 5-day course

Bokeo 5 30 10 3 facilitators trained on 5-day course

Xayabouly 5 74 45 3 facilitators trained on 5-day course

Louangprabang 3 62 17

Vientiane province 3 50 0 No facilitator trained on 5-day course

Bolikhamxay 3 40 5

Khammouane 3 76 68

Savannakhet 5 116 0 3 facilitators trained on 5-day course

Champasack 4 67 19 25 more HC by the end of Sept. 2012

Saravan 4 48 0 One facilitator trained on 5-day course

Xekong 3 19 0 One facilitator trained on 5-day course

Attapeu 2 24 0 No facilitator trained on 5-day course

Source: WHO IMCI report 2012

Provincial District Health Center

Level Level Level

Phongsaly 10 12 39

Luangnamtha 5 11 38

Oudomxay 14 56 76

Bokeo 19 41 60

Luangprabang 8 29 47

Huaphanh 8 21 63

Xayabury 18 76 127

Xiengkhuang 6 18 68

Vientiane 6 65 75

Borikhamxay 2 12 18

Khammuane 4 2 0

Savannakhet 4 5 6

Saravane 5 6 0

Sekong 3 5 7

Champasack 4 2 2

Attapeu 5 10 0

39

Annex 6

Human Resources for Health Country Profiles: Lao PDR 2012