Report No: AUS1920 Lao People’s Democratic Republic Maternal Health, Child Health & Nutrition in Lao PDR Evidence from a Household Survey in Six Central and Southern Provinces June 2013 Standard Disclaimer: Copyright Statement: This volume is a product of the staff of the In- The material in this publication is copyrighted. ternational Bank for Reconstruction and Devel- Copying and / or transmitting portions or all of this opment / The World Bank. The findings, inter- work without permission may be a violation of pretations, and conclusions expressed in this applicable law. The International Bank for Recon- paper do not necessarily reflect the views of the struction and Development / The World Bank Executive Directors of The World Bank or the gov- encourages dissemintion of its work and will normal- ernments they represent. The World Bank does not ly grant permission to reproduce portions of the work guarantee the accuracy of the data included in this promptly. work. The boundaries, colors, denominations, and other information shown on any map in this work For permission to photocopy or reprint any part do not imply any judgment on the part of The World of this work, please send a request with complete Bank concerning the legal status of any territory or information to the Copyright Clearance Center, Inc., the endorsement or acceptance of such boundaries. 222 Rosewood Drive, Davers, MA 01923, USA, tele- phone 978-750-8400, fax 978-750-4470, http://www.copyright.com/. All other queries on rights and licenses, including subsidiary rights, should be addressed to the Office of the Publisher, The World Bank, 1818 H Street NW, Washington, DC 20433, USA, fax 202-522-2422, e-mail pubrights@worldbank.org. MATERNAL HEALTH, CHILD HEALTH, AND NUTRITION IN LAO PDR: EVIDENCE FROM A SURVEY IN SIX CENTRAL AND SOUTHERN PROVINCES1 EXECUTIVE SUMMARY Lao PDR has made dramatic improvements in some areas. Unsurprisingly, physical access to health population-level health outcomes over the past facilities was difficult: the mean distance to several decades. For example, life expectancy has the nearest health center and hospital for increased from 46 years in 1970 to 67 years in 2011. households in the sample was 6 km and 34 km However, the country still has some of the worst ma- respectively. Apart from physical access, financial ternal health, child health, and nutrition indicators barriers are also important and were in fact the in the region. The under-five mortality rate is 42 per most frequently reported constraint to the utilization 1,000 live births, while the maternal mortality rate is of health services (by 45% of respondents). This 470 per 100,000 live births. Nutrition indicators are relates to the low coverage of health insurance also alarming, with 32% and 48% of under-fives are schemes: less than 4% of households were covered underweight and stunted respectively. With its high by any such scheme. prevalence of undernutrition, Lao PDR is an outlier when contrasted with regional comparators, Given this context, the utilization of all the basic even after accounting for national income. maternal health services – antenatal care visits, Recently introduced strategies, such as the free institutional deliveries, and postnatal care visits maternal and child health (MCH) policy and the – was extremely low. Only 40% of women with National Nutrition Strategy, aim to address these a child under two years reported at least one issues and to attain health-related MDGs by antenatal care visit; only 14% of births occurred at 2015. Against this backdrop, this report presents findings from a household, village, and health center survey of largely rural communities in six any health facility, and postnatal care visits were ex- ceedingly rare (2%). Even where utilization occurred, this was often inadequate from both a demand-side 1 central and southern provinces of Lao PDR and supply-side perspective. For example, on the conducted in 2010. These communities are the target demand-side, antenatal care visits were often too late of various pilot interventions aimed at addressing in the pregnancy (less than a third had their first visit these poor health-related MDG indicators, for which during the recommended first trimester) and only this survey was designed to contextualize, inform, about half went for the recommended minimum and evaluate. of four antenatal care visits. On the supply-side health facilities lacked important commodities like iron The household survey, which focused on rural orfolate supplements. Importantly, utilization households with at least one living child under varied along key demographic characteristics: for two, confirms the largely rural nature of the sample example, institutional delivery rates were much compared with the national population, with a higher higher in urban communities (30%) compared with proportion of non-Lao Tai ethnic groups, larger rural communities without a road (6%) and were household sizes, and a predominance of agricultural also much higher among mother’s with secondary activities as the primary occupation. Indeed, more education (30%) compared with mother’s with no than 80% of households were resident in rural education (7%). 1 This report was written by a team consisting of Chantelle Boudreaux, Ajay Tandon, and Wei Aun Yap; Data analysis was conducted by Ajay Tandon, Wei Aun Yap, Laurence Lannes, and Chantelle Boudreax; The survey was designed by Magnus Lindelow, Chantelle Boudreaux, and Robert McLaughlin; IndoChina Research Ltd. collected the data; Valuable inputs were provided by Phetdara Chanthala, Sophavanh Thitsy, Anna Lorenza-Pigazzini, Somchit Akkhavong, and Khamseng Philavong; The team would like to thank Yi-Kyoung Lee and Darren Dorkin for excellent comments made on a previous version of the report. Utilization of preventative child health services was only 50% of respondents washed their hands also extremely low, with only 9% of children under before cooking and only 9% did so before feeding two taken for routine well-baby check-ups. For this the baby. The survey also notes that 15% of children reason, it is unsurprising that coverage of under two had an episode of diarrhea in the immunizations was also poor, with only 26% of last two weeks prior to the survey. Symptomatic children aged 12-23 months having received all episodes of diarrhea are not the only nutritionally the Expanded Program on Immunizations (EPI) relevant manifestation of fecal-oral contamination. vaccines. A sharp decline is noted between the first Environmental enteropathy, which is intestinal dose of vaccinations (83% for DPT1 and 83% for damage caused by contaminated water, toxins, Polio1) compared with the second dose of antigens, nutrient deficiencies, and infections, vaccinations (41% for DPT2 and 45% for Polio2) thus is both a contributor to malnutrition (through indicating substantial loss to follow-up. malabsorption and maldigestion), and a result of malnutrition. As 77% of households in this Dietary diversity was limited with almost all families sample in the lacked a toilet, the environment consuming grains and vegetables but less than half of the whole community – not just individual consuming any meat or fish. Household diets lacked households who lack sanitation facilities – would both Vitamin A-and iron-rich foods. Furthermore, only be presumed to be contaminated. Hence, in- 40% of children under two benefitted from timely terventions aimed at arresting this downward initiation of breastfeeding within one hour of delivery. spiral of child undernutrition should be aimed at Anthropometric measurements of children under the whole community, including both adults and two further confirm the severity of undernutrition in children, rather than focusing only on nutritionally these communities. More than a third (36%) of these vulnerable children. children were stunted and 13% were severely stunted. Almost one-third (31%) of these children were The results from this survey thus shed light on underweight and 11% were severely underweight. what it would take to attain the health-related 2 Importantly, undernutrition varied along key de- mographic parameters and household charac- teristics, but remained substantial even in rela- MDGs. In order to improve the level and equity of maternal and child health indicators, interventions would need to address numerous demand-side tively wealthy and better-educated households. barriers, including physical access barriers, financial For example, the prevalence of stunting varied barriers, and cultural, linguistic, and educational from 43% among the poorest economic quintile to barriers. In addition to demand-side measures 24% among the richest; and also varied from 43% aimed at increasing utilization, it is likely that more among children whose mother had no education investments are required on the supply-side to insure to 23% among children whose mother had lower high-quality services are available by adequately- secondary education. Children whose household trained staff and adequately equipped and stocked- lacked access to a toilet were also associated with health facilities. With regards to nutrition indicators, higher rates of stunting (39%) than children with a cross-sectoral approach is required, intervening not such access (26%). just within the health sector (for example, in encour- aging appropriate breastfeeding and complemen- These variations in the prevalence of undernutrition tary feeding practices, providing micronutrients to are further contextualized by water and sanitation both mothers and children, and promoting hygienic indicators generated from this survey. Only 23% practices) but also in sectors beyond health. Inter- of households had access to a sanitation facility ventions which promote access and use of improved and only 40% of households had access to drinking water supply and hygienic sanitation facili- improved drinking water sources. Behavioral ties are needed to reduce the prevalence of diarrhea, indicators are also a concern as even though most while interventions in the agriculture sector will help households had a specific place to wash hands, to address food security and dietary diversity issues. INTRODUCTION Despite being on-track on the child- and PDR. The information in this report localizes MCH & maternal-health MDGs, Lao PDR continues to nutrition-related information that are typical for have some of the worst maternal and child health sampled catchment areas of selected health centers (MCH) and nutrition outcome indicators, both in six central and southern provinces of the country.2 globally as well as in the East Asia and Pacific (EAP) In addition, the report summarizes data on service region. Underlying poor levels of MCH and nutrition availability and readiness of health centers in terms outcomes are poor quality and low levels of cov- of their ability to provide key MCH & nutrition-related erage of key MCH utilization indicators such as services. antenatal care (ANC), skilled birth attendance, as well as measles and DPT immunization rates. Physical, financial, and cultural barriers help explain low coverage rates from a demand-side perspective. Poor training of health workers, service readiness deficiencies, and generally inadequate quality of care are some of the key challenges from a supply-side perspective. In recognition of these challenges, the Govern- ment of Lao PDR has recently adopted a health sector reform strategy with the overarching objectives of: (i) attainment of health-related MDGs by 2015; and (ii) achievement of universal health coverage (UHC) by 2025. Key aspects of the reform agenda include increasing domestically-sourced government financing for health, ensuring adequate 3 availability of skilled and motivated health workers, improving access to essential medicines and technology, and bolstering grass-root level service delivery efforts, among others. This report presents results from a household, village, and facility survey on MCH & nutrition in mostly rural areas of six central and southern provinces of Lao PDR. Effective implementation of the government’s health sector reform agenda will require timely and frequently-updated information on the underlying factors determining the low levels of key MCH and nutrition-related outcomes and, in looking forward, what the impact of policy interventions on these outcomes has been. In light of helping provide evidence for informing policy- making and implementation, this report provides some key baseline information on MCH- and nutri- tion related outcomes and their correlates in Lao Photo by Bart Verweij/2013 2 The analysis in this report complements recently compiled national and provincial-level information on MCH & nutrition-related data collected in 2011 as part of the Lao Social Indicators Survey (LSIS). BACKGROUND AND CONTEXT Lao PDR has made steady and significant progress day, PPP) have declined from 56% of the population on several key population health outcomes over in 1992 to 34% in 2008. In the social sectors, adult lit- the past few decades. Life expectancy has steadily eracy rates rose from 60% to 73% between 1995 and increased to almost 67 years in 2011, up from 54 years 2005, while the fertility rate (total births per woman) in 1990 (Figure 1). The under-five mortality rate has declined dramatically from 6.2 in 1990 to 2.7 in 2010. also declined steadily from 148 per 1,000 live births In the health sector, preventative strategies – includ- in 1990 to 42 per 1,000 live births in 2011 (Figure ing expanding access to family planning, immuniza- 1). At current trends, Lao PDR is projected to meet tions, and the reduction of anemia – have been im- the child- and maternal-health related Millennium portant contributors to the improvements seen in Development Goals (MDGs). Under-five and infant child and maternal health indicators. mortality rates in Lao PDR are about average, adult mortality rates are better than average relative to Despite notable progress in health on some fronts, GDP per capita in the newly reclassified lower-middle considerable challenges remain. Despite being income country. on-track on the child- and maternal-health MDGs, Lao PDR continues to have some of the worst MCH Population health indicators for Lao PDR, 1990-2011 and nutrition outcome indicators, both globally as well as in the East Asia and Pacific (EAP) region. 70 100 120 140 Although there is some uncertainty regarding exact numerical values, WHO/UNICEF/UNFPA/World Bank (2012) estimate that, at 470 per 100,000 live births, 65 Lao PDR’s maternal mortality ratio (MMR) is among Life expectancy 80 the highest in the world, and is almost double that of 4 neighboring Cambodia and almost eight times that 60 60 of Vietnam (Table 1).3 More recent estimates from LSIS data indicate an MMR of 357 per 100,000 live births. About a third of all children under five remain 40 55 underweight in the country. At current trends, Lao 1990 2000 2010 Year PDR is off-track on the nutrition MDG, and there are Source: WDI Note: y-scale logged significant urban-rural, socio-economic, geographic, and ethnic-group related inequalities in health out- Figure 1: Key population health indicators for Lao PDR: 1990-2011 comes. Underlying poor levels of MCH and nutri- tion outcomes are poor quality and low levels of The decades between 1990 and 2010 have been a coverage of key MCH utilization indicators such as time of significant economic growth for Lao PDR, antenatal care (ANC) and skilled birth attendance. following economic liberalization reforms which Births attended by skilled personnel only increased began in 1986. Major national infrastructure from14% to 17% between 1994 and 1999,4 while, de- initiatives were active during this period: the spite improvements over time, immunizations rates time period saw the upgrading of highway 13 including measles and DPT remain low relative and a large rural electrification initiative. Poverty to neighboring countries (Table 1). headcounts (based on a poverty line of US$ 1.25 per 3 WHO/UNICEF/UNFPA/World Bank (2012), Trends in Maternal Mortality: 1990-2010, Geneva: World Health Organization. 4 Eckermann, Liz. “Finding A ’safe’ place on the Risk Continuum: a Case Study of Pregnancy and Birthing in Lao PDR.” Health Sociology Review 15, no. 4 (2006): 374–386. Table 1: Key MDG and other indicators for Lao PDR and comparators Country GNI per MMR At Skilled Prevalence Prevalence Under-five Measles DPT3 capita per least 1 birth of of mortality rate immunization immunization (2011) 100,000 ANC attendance underweight stunting per 1,000 live rate rate live visit children<5 children<5 births births (2011) (2010) Cambodia $820 250 69% 57% 29% 41% 43 85% 87% China $4,940 37 92% 98% 4% 9% 15 95% 95% Indonesia $2,940 220 93% 79% 21% 39% 32 82% 78% Lao PDR $1,130 470 35% 29% 32% 48% 42 64% 74% PNG $1,480 230 79% 53% 18% 44% 58 58% 59% Philippines $2,210 99 91% 62% 21% 32% 25 91% 88% Thailand $4,440 48 99% 98% 7% 16% 12 97% 99% Timor-Leste $2,220 300 84% 29% 45% 58% 54 64% 69% Vietnam $1,270 59 91% 88% 21% 31% 22 93% 94% East Asia & $3,257 140 87% 81% 17% 31% 30 82% 84% Pacific Lower-Middle $2,371 215 86% 79% 15% 31% 49 83% 85% Income Countries 5 Lower-Income $553 452 76% 53% 23% 40% 99 75% 77% Countries Note: Unweighted averages for country groupings; average or latest available year 2005-2011 where year not noted. In recognition of these challenges, the Lao PDR Scaling-Up Nutrition (SUN) initiative, and a dedicated government has recently adopted a health sec- national nutrition center housed within the Ministry tor reform strategy with the overarching objectives of Health has recently opened. The 7th Nation- of: (i) attainment of health-related MDGs by 2015; al Socioeconomic Development Plan highlights and (ii) achievement of universal health coverage “sustainable health financing” as one of the priority (UHC) by 2025. Key aspects of the reform agenda in- areas for 2011-2015, with a focus on increasing clude increasing domestically-sourced government the government budget for health, expanding financing for health, ensuring adequate availability prepayment schemes, and developing mechanisms of skilled and motivated health workers, improving for ensuring the poor have access to health services.6 access to essential medicines and technology, and The government has made a commitment to increase bolstering grass-root level service delivery efforts, health’s share of the government budget to 9%, up among others.5 In addition, Lao PDR has recently from current allocations that have been in the 3% signed on to become an “early riser” in the global range.7 5 Ministry of Health (2012), National Health Sector Reform Strategy: 2013-2025, Vientiane: Ministry of Health. 6 Ministry of Planning and Investment (2011), The Seventh Five-year National Socio-Economic Development Plan (2011-2015), Vientiane: Ministry of Planning and Investment, Government of Lao PDR. 7 Lindelow et al, World Bank (2011), “Government Spending on Health in Lao PDR: Evidence and Issues,” World Bank, Washington, DC. In order to improve the utilization of MCH services, of micronutrients by community-based distributors and to reduce the burden of associated out-of- are also included. These interventions are intended pocket payments, the government is in the process to increase the demand for and utilization of of beginning the implementation of a Ministerial basic health services. The first intervention is decree aimed at incentivizing the supply as well as also intended to improve financial protection demand of MCH and other related services at all public from catastrophic health expenditure. Both health facilities. The decree - referred to as the “free interventions contain nutrition-sensitive and MCH policy” - is a form of results-based financing nutrition-specific interventions on enabling (RBF) that will remove user fees and charges for the distribution of micronutrients, encouraging medicines, provide beneficiaries with small incentive appropriate exclusive breastfeeding and payments, and reimburse health facilities for complementary feeding, and hygiene and provision of MCH-related care. The free MCH policy sanitation messaging. The survey described in builds on the relatively positive experience of several this report was conceived both to inform the smaller-scale donor-financed pilots that have implementation of these interventions and to implemented similar interventions in selected regions act as a baseline for an embedded impact and of Lao PDR over the past few years.8 In addition, the process evaluation. The complementary endline government will soon complete the piloting of the survey is currently in progress in the same panel Community Nutrition Project, which utilized village of villages and health centers. health volunteers, village heads, and Lao Women’s Union representatives to provide key messaging related to MCH and nutrition in addition to providing Given this backdrop, this report presents results conditional cash transfers to mothers and pregnant from a household, village, and facility survey on women for the use of services (Box 1). MCH and nutrition in mostly rural areas of six central and southern provinces of Lao PDR. 6 Box 1: The Community Nutrition Project (CNP) The Community Nutrition Project was conceived Effective implementation of the government’s health sector reform agenda will require timely and frequently-updated information on the underlying as an emergency pilot project to protect and factors determining the low levels of key MCH and improve nutritional outcomes in the context of high nutrition-related outcomes and, in looking forward, and volatile food prices. It aimed to expand the what the impact of policy interventions on these utilization of key health services, which may outcomes has been. In helping to provide evidence be under pressure due to food price and other for informing policy-making and implementation, macro shocks. The project piloted two key this report provides some key baseline information demand-side interventions: (1) a conditional cash on MCH- and nutrition-related outcomes and their transfer (CCT) scheme for all pregnant women and correlates in Lao PDR. mothers of children under two, conditional on utilizing key maternal and child health services The remainder of the report is organized as follows: such as antenatal visits, facility-based deliveries, the next section provides a brief overview of the and regular child growth monitoring visits; socio-economic characteristics of households and (2) a community-based health and nutrition included in the survey sample. The report then behavior change program, which trains village highlights key findings related to general nutrition facilitators to conduct regular village meetings and health indicators, followed by outcomes and where health and nutritional messages are correlates related to MCH and nutrition outcome discussed. Additional activities for training and and coverage indicators. The report concludes with supervising health workers, and the distribution a summary overview and some discussion of policy implications. 8 Pilots include the World Bank-supported Health Services Improvement Project (HSIP) as well as projects financed by Lao-Lux, WHO, and Medicine du Monde. SOCIO-ECONOMIC CHARACTERIS- TICS OF HOUSEHOLDS Using a multi-level cluster sampling meth- were Hmong-Mien (Table 2). As can be seen in Table odology, the survey sampled 2,741 house- 2, the proportion of non-Lao-Tai ethnic groups in the holds living in 193 villages across 21 survey was higher than in the national population, high-priority and/or poor districts in the prov- again reflecting the greater proportion of rural and inces of Borikhamxay, Khammuane, Savan- remote communities included in the sample. nakhet, Saravane, Champasack, and Attapeu. The data span the catchment areas of 38 health centers in these six provinces.9 These included both health centers and villages which were the intended target of CNP and matched control health centers and villages. Figure 2 shows the location of sampled districts, villages, and health centers. The sampled villages cover a population of approximately 112,000, from a national population of 6.2 million10, in 21 out of 142 districts, and 6 out of 17 provinces. The household data, which is the main focus of this report, is complemented by facility audits and questionnaires conducted at each of the 38 health centers and surveys conducted at the village level. At health centers, facility personnel answered questions, while village heads were the respondents for the village questionnaire. This survey focuses on the results of the household survey, for which mothers 7 or the primary caretaker was interviewed in randomly selected households having at least one living child less than two years of age. 80.4% of respondent households lived in rural ar- eas (42.6% in rural areas with road access plus 37.8% in rural areas without road access) and the remaining 19.6% lived in urban areas. This contrasts with the national population, where 67% of the population is rural.11 The average household size among the sample was 6.4, higher than the national average of 5.2, and 95.0% of households were headed by men.12 A slight majority (51%) of household heads were Lao-Tai, followed by 44% who were Mon-Khmer and 3% who Photo by Bart Verweij/2013 9 The survey was conducted in April-June 2010 to provide baseline information for the World Bank and European Union-financed Com- munity Nutrition Project currently being implemented by the Department of Hygiene and Prevention of the Ministry of Health of the Government of Lao PDR; The full list of the 38 health centers is reported in Annex A. 10 WDI 2010 11 WDI 2010 12 Ministry of Health and Lao Statistics Bureau (2012), Lao Social Indicator Survey 2011-2012, Vientiane, Lao PDR: Ministry of Health and Lao Statistics Bureau. 8 Figure 2: Survey map: sampled districts (orange), villages (blue dots), and health centers (red crosses) Table 2: Distribution of households by ethno-linguistic group13 Ethno-linguistic group Percent of sample Percent of Lao PDR national population Lao-Tai 51% 68% Mon-Khmer 44% 22% Hmong-Mien 3% 7% Chinese-Tibetan 0.2% 3% Other 2% 0.6% Total 100% 100% Among individuals aged 14 and above, 87% are only primary education. About 18% of household reported as being self-employed in agriculture. heads had completed secondary schooling, with In the same age group, 3% are as reported to be the remaining 7% having had some post-secondary students, 4% are employed by the public sector, education. Respondent mothers (those that had and 3% are retired, sick, or disabled. In 36% of given birth most recently in the household) had even households, the head had no formal education lower educational attainment levels, with more than whatsoever; and a similar proportion had completed half reporting no schooling (Figure 3). Educational attainment 9 Household head Respondent mother 50 50 40 40 Percent Percent 30 30 20 20 10 10 0 0 n y y y er n y y y er ar r r ar r r tio tio da da da da gh gh im im ca ca n on n on hi hi Pr Pr co co u u nd nd ec ec ed ed se se rs rs ya ya No No er er pe pe r r w w da da Up Up Lo Lo n n co co e e t-s t-s s s Po Po Source: CNP Baseline Survey Figure 3: Educational attainment of household heads and respondent mothers 13 The national ethnic-group distribution is from the Lao Social Indicator Survey report. Almost all (98%) households reported owning washing their hands after using the toilet and 17% their own home. Most households accessed drinking reported washing their hands after cleaning the water using a protected well, followed by surface baby’s bottom. Where the place and process of hand water, and an unprotected well (Table 3). In all, about washing was observed, the following items were 40% of households had access to improved drinking observed: bar soap (39%), detergent (24%), liquid water sources.14 More than three-fourths of the soap (3.2%), and ash/mud/sand (0.11%). Observations households reported sometimes boiling the water of respondent hand washing note that water was before drinking to make it safer, although this was frequently (93%) used but soap was less frequently consistently practiced by less than half of those (45%) used. Only 89% washed both hands, rubbed reporting boiling the water. About 77% of households their hands at three times (75%), and dried it with did not have a sanitation facility; the remaining a clean cloth or allowed it to air dry (45%). reported having a flush toilet (22%) or a pit latrine (0.8%) (Table 3). Among households which reported Only 41% of households in the sample reported having a toilet, most (93%) appeared to have been having access to electricity from the grid. About used, and 83% were very clean or moderately clean. 11% reported using electricity from generators or Despite the relatively higher availability of toilets, few batteries, and 36% reported using kerosene lamps as households used them to dispose of child waste. More their primary source of light. Most (>90%) households than 80% of families left child feces in the open (54%) in the sample had wood and bamboo flooring and or in a ditch or drain (27%). Slightly less than 20% of walls. families disposed of the feces safely, with 14% burying the waste, and 4% using toilets or pit latrines. Approximately 50% of households reported having a motorcycle, 21% had bicycles, 30% owned Table 3: Water source and sanitation facilities two-wheeled tractors, and 4% had a four-wheeled tractor and 3% had a car, van or truck (Figure 4). Water and sanitation Distribution 10 Water source Piped water 0.7% About 30% of households reported having a mobile phone. There was a strong relationship between educational attainment of household head and economic status, the latter estimated by means of Protected well 34% an asset index. Household heads had no education Unprotected well 18% in 58.3% of households in the bottom economic Spring water 16% quintile, whereas the head in only 19.6% of households in the top economic quintile reported Rain water 0.4% having no education (Table 4). Surface water 28% Proportion of households owning assets Bottled water 3% Sanitation Facilities .5 Flush toilet 22% .4 Proportion Pit latrine 1% .3 No toilet 77% .2 .1 Most (83%) households had a specific place where 0 household members usually wash their hands. r r cle e le r Ca to on to yc cy ac ac ph oc Bi Tr Almost all (94%) respondents reported washing Tr ot ile el el M he ob he r-W M W their hands before eating but only 50% did so before o- u Tw Fo cooking, and only 9.3% did so before feeding the Source: CNP Baseline Survey baby. Furthermore, only 20% of respondents reported Figure 4: Selected asset ownership 14 Access to improved drinking water sources is defined as year-round access to water from a piped source, protected well, rain water, and/ or bottled water. Table 4: Distribution of household head’s educational attainment by economic status Economic quintile Educational attainment of household head No education Primary Lower secondary Upper secondary Post-secondary Total and higher Poorest 58.3% 30.5% 3.5% 5.2% 2.5% 100% Second 38.4% 41.9% 6.9% 5.8% 7.1% 100% Middle 32.3% 42.7% 6.7% 9.7% 8.7% 100% Fourth 31.2% 41.6% 11.3% 8.1% 7.7% 100% Richest 19.6% 42.0% 16.8% 13.0% 8.6% 100% In terms of access to health services, the mean households had better access to health facilities as distance to a health center for households in the compared to households in rural areas without access sample was 5.5 km, and the mean distance to the to a road (Table 5). Respondents generally reported closest hospital (provincial or district) was 34.1 km. a very positive perception of the quality of care Households reported taking approximately 35 received at health centers. More than 40% of minutes to reach a health center during dry months, respondents described the quality of their health and almost double that time during the rainy season center as “excellent”, with most of the remaining (Table 5). The average time to a hospital was 1 hour describing it as “good” (30%) or “okay” (22%). Only 3% and 42 minutes during the dry months and almost described HCs as “not very good” or “bad”, and 5% did 3 hours during the rainy season. As expected, urban not know or refused to answer. Table 5: Distance and time to nearest health facility Distance and time to nearest health facility Health center Hospital 11 Residence Distance Time Time Distance Time Time (dry season) (rainy season) (dry season) (rainy season) Urban 3.0 km 0.3 hrs 0.4 hrs 23.5 km 0.6 hrs 0.8 hrs Rural with road 5.2 km 0.4 hrs 0.8 hrs 34.5 km 1.6 hrs 2.6 hrs Rural without road 7.0 km 0.9 hrs 1.7 hrs 39.0 km 2.3 hrs 4.2 hrs All 5.5 km 0.6 hrs 1.1 hrs 34.1 km 1.7 hrs 2.8 hrs GENERAL DIETARY AND HEALTH-RELATED INDICATORS Respondents reported a diet heavy in grains, and Many women and children were not consuming were largely self-sufficient in the main foods eaten. essential micronutrients. Only 69% of respondents The survey asked a number of questions related to reported a diet rich in Vitamin A, and only 55% report- household dietary diversity. Specifically, respondents ed consuming foods rich in iron. Dietary habits were were asked to report on consumption of twelve not clearly associated with the ethnicity of the family, broad food groups in the 24 hours prior to the sur- although there was a notable trend toward higher vey. While most families consumed grains (98%) and dietary diversity with increasing education of the vegetables (92%), the percentage of families who ate head of the household, as well as with wealth. For fruits (32%) was much lower, as was the proportion example, 57% of households in the lowest quintile eating red meat (43%) or fish (46%). On average, fami- reported a diet rich in Vitamin A compared with 67% lies ate from four to five of the available categories. among the highest quintile. Likewise, only 40% of Table 6 provides an overview of what families were respondents in the lowest quintile reported a diet rich consuming, as well as what types of foods were in iron compared with 64% for the highest quintile. self-produced and which were purchased. More than 68% of households reported that there Table 6: Household dietary diversity had been one or more shocks causing a large negative impact on living conditions in the two Type of Food Number of Proportion families who years prior to the survey. A health shock – involving consumed purchased the serious illness, injury or death of any member of this food that household – affected 26% of all households in Grains 98% 13% the two years prior to the survey. Weather-related 12 Roots and Tubers Vegetables 28% 92% 4.8% 2.9% shocks (drought, floods, mudslides, or strong winds) affected 42%, and livestock or crop diseases affected Fruits 32% 27% 35% of all households in the two years prior to the Red or White Meat 43% 24% survey. Eggs 12% 62% The burden of sickness and injury is significant, Fish 46% 17% with more than 77% of households reporting Legumes, Nuts or Seeds 2.6% 63% that someone in the household had been sick or Dairy or Insects 19% 99% injured in the last three months, and just under Oils or Fats 11% 86% half (42%) of these cases being serious or somewhat Sugar or Honey 15% 96% serious. Advice or treatment was sought in 75% of Coffee, Tea, Alcohol 58% 96% cases. This typically involved going to a health center Total 100% 100% (57%), district hospital (25%) or seeing the village health volunteer (16%) as detailed in Figure 5. Where help was wanted but not sought, reasons include physical access barriers (23%) and financial considerations (20%). Health Utilization Health Care Agent Reasons for Not Utilizing (among those that utilized) (among those that did not utilized) .8 .8 .6 .6 Proportion Proportion .4 .4 .2 .2 0 0 He t H er in lun l l H er ct ar al Th st nd Ce al H er l H ler l h ed pe e M ve e To ent sy Qu er No lity n Pr h V pita ta r lf T icin g pe it in aci ly oo The t te on th oo th Bu ed nsi pi ea to ou la en p a m tO O O ai t os os os or m Se ed o D th C n at T et cu s E o re d Ne Ex G Do Ph u al cia ra c io ge istri He nt iti tG al er lt ad ov To ot S No Tr N Di On lla o Vi Source: CNP Baseline Survey Figure 5: Utilization among families experiencing a health shock Less than 4% of households had any form of Table 7: Barriers to seeking treatment among women health insurance scheme. For those who did, the main schemes used were the social security scheme (1.1%) and health equity funds (0.7%). 4% of all house- Barriers Getting the money needed for treatment? (%) 45% 13 holds reported having to borrow for financing a de- Finding someone to go with you/Not wanting to 39% livery in the last two years, and 6% reported having to go alone? borrow to cover the costs of health care for the respondent or their children. The median amount The distance to the health center or hospital? 31% borrowed was US$50 (400,000 kip) but a quarter of Means of transportation to the health center or 29% these were US$125 (1,000,000 kip) or more. About hospital? 45% of these borrowers remain in debt at the time of Concern there may not be a health worker? 22% survey, with half of them owing US$50 (400,000 kip) or more, and a quarter owing US$125 (1,000,000 kip) Getting permission to go? 21% or more.15 Concern about having to read? 20% Financial factors were the most-reported con- Concern that the health worker cannot help? 20% straint to utilization health services by women. Concern that there are no supplies or drugs? 20% 45% of all women reported that “getting money for treatment” was a barrier to obtaining medical advice Concern that health worker does not speak your 13% or treatment. Not wanting to go alone and physical language? access were additional problems reported. Language Concern that there may not be a female health 13% and communication concerns were reported by worker? 13% of women. The full list of reported constraints is summarized in Table 7. 15 According to the most recent Lao Expenditure and Consumption Survey (LECS 2007), households in the survey provinces had an average monthly consumption of US$251 (2,089,000 LAK). Respondents scored well in recognizing danger- these are self-report statements, they need to be ous symptoms, and many noted the appropriate interpreted with caution as they may not correlate responses to these symptoms. Most respondents with what respondent actually do when such reported knowing that with high fever and diarrhea, symptoms occur. Responses to health-seeking one should seek advice from health centers (HCs), attitudes are summarized in Table 8 below. hospitals, or village health volunteers. However, as Table 8: Health seeking knowledge and attitudes Health Issue Survey Question Response (%) Dengue fever You just learned that your friend’s four-year - Go to health center (61%) old child is not feeling well. She has a fever, - Go to district hospital (18%) chills and a headache and isn’t sure it’s just - Go to village health volunteer (12%) a minor illness or if it could be dengue fever. - Self-treatment or traditional treatment (3.3%) What would you advise her to do FIRST? Diarrhea You just learned that your friend’s two-year - Go to health center (60%) old son has diarrhea that has lasted for a few - Go to district hospital (17%) days. She wants to know what she should do. - Go to village health volunteer (12%) What would you advise her to do FIRST? - Self-treatment or traditional treatment (4.2%) Diarrhea warning symptoms* Children often get diarrhea. Can you tell me - Ongoing vomiting (53%) what signs indicate diarrhea so dangerous - Blood/mucous in stool (dysentery) (30%) that medical attention is required? - Pass watery stools 10 times a day (19%) - Fever (16%) - Unable to eat or drink (10%) - Child not better in three days (3.9%) 14 Diarrhea treatment* What should you do to care for diarrhea at home? (for normal cases) - Traditional treatment (39%) - Give ORS (29%) - Give medicine (25%) - Increase fluid intake (10%) - Don’t know (7.7%) - Watch for dangerous signs (6.1%) - Continue feeding as normal (2.9%) - Reduce fluid intake (0.25%) Severe illness warning symptoms* Sometimes children have severe illnesses - Child develops fever (61%) and should be taken immediately to a health - Child becomes sicker (46%) center or hospital. What types of symptoms - Child has diarrhea and vomiting (44%) would cause you to take your child to a - Child has cough/cold (32%) health center or hospital right away? - Child as difficult breathing (5.7%) - Child has blood in stool (3.2%) - Child has fast breathing (3.1%) - Child not able to drink/breastfeed (2.3%) - Child is drinking poorly (0.48%) Pregnancy warning symptoms* What are the dangerous signs that you know? - Pain in abdomen (39%) - Don’t know (35%) - Strong headache/blurred vision (30%) - Fever (12%) - Swollen limbs (8.1%) - Decrease in fetal movement (4.9%) - Vaginal bleeding (3.3%) - Water breaking (0.48%) *Multiple responses allowed More than three-fourths of respondents Table 10: Health education by source (last 6 months) reported having received health information on Source of information (%) immunizations, insecticide-treated bed nets, and hand washing. Far fewer reported receiving Health staff at health center? 81% information regarding growth monitoring, treatment Village Health Volunteer? 70% of tuberculosis, respiratory infections, HIV/AIDS, or the importance of iron or folate for pregnant women. Village Chief? 68% The primary sources of health messages were from Outreach health worker during community visits? 61% HCs (81%), village health volunteers (70%), and village chiefs (68%). Table 9 and Table 10 summarize Friends/relatives? 54% these findings. Doctor/nurse in hospital? 38% Table 9: Health education by topic (last 6 months) Lao Women’s Union? 30% Have you heard the following health message (%) Radio? 22% in the last 6 months? Television? 18% Bringing your children for immunization? 90% Traditional Birth Attendant (TBA)? 16% Sleeping in a mosquito net soaked with mosquito 81% repellant? Pharmacist? 13% Washing hands? 78% Village PA system? 10% Using clean water? 73% Traditional Healer? 9% How to prevent or treat diarrhea? 63% Newspapers? 3% The benefits of having children take Vitamin A? Maintaining a sanitary toilet? 54% 47% Doctor/nurse at clinic? Monk/Nun? 2% 2% 15 Good ways to nourish children 45% Given this background on household Using iodized salt? 45% characteristics as well as general diet- and health Monitoring your child’s height and weight? 39% -related indicators, subsequent subsections report findings with regard to key MCH and How to prevent or treat tuberculosis? 38% nutrition-related indicators. How to prevent or treat respiratory infection? 32% How to prevent or treat HIV/AIDS? 31% Women, especially when pregnant, taking iron 27% or folate? MATERNAL HEALTH Table 11: Percent reporting at least one ANC visit during last pregnancy The survey asked mothers that had a child in the Antenatal care (%) two years prior to the time of survey to provide information on key aspects of their antenatal, Residence delivery, and postnatal periods for their most Urban 58.5% recent pregnancy. Findings from the survey Rural with road 43.6% responses related to maternal health are summarized below. Rural without road 25.4% Age of mother Fertility and Contraception Less than 20 36.3% Women had, on average, given birth 3.3 times 20-34 years 41.5% prior to the survey.16 Approximately half of women 35-49 years 34.7% reported having ever used family planning to try to Mother’s education prevent pregnancy, with injections (42.8%) and the pill (40.3%) being the two most popular methods. None 29.1% Primary 43.9% Antenatal Period Lower secondary 68.1% Upper secondary 68.7% Only about 40% of women reported at least one antenatal care (ANC) visit during their most Post-secondary and higher 58.2% recent pregnancy. ANC visits were significantly Economic quintile higher among urban residents, those mothers that 16 had secondary education and higher, those from richer households, and those belonging to the Lao-Tai Poorest Second 22.8% 26.2% ethnic group (Table 11).17 ANC utilization rates were Middle 38.9% particularly low among Mon-Khmer and Hmong-Mien Fourth 48.3% ethnic group households, and among poorer households and households where the mother had Richest 64.1% received no formal education. Ethno-linguistic group of household head Lao-Tai 54.0% Mon-Khmer 29.0% Hmong-Mien 10.5% Other 14.4% Total 40.0% 16 Although the survey included a module on contraceptive use, the sampling methodology does not permit an adequate estimation of contraceptive use and fertility. Only households with at least one living child two were included in the survey. 17 The levels of ANC utilization are similar in magnitude to those found by other studies in Lao PDR; For example, Manithip et al (2011) found that about 51% of women in their sample in Khammouane and Champasack provinces received ANC during their most recent pregnancy in the past 12 months; See Manithip, C, A Sihavong, K Edin, R Wahlstrom, and H Wessel (2011), “Factors Associated with Antenatal Care Utilization Among Rural Women in Lao People’s Democratic Republic,” Maternal and Child Health Journal, 15: 1356-1362. Only about half of those utilizing ANC visits had During ANC visits, the most common services four or more of the recommended visits. Among received were weighing (82%) and counseling on those who did not attend an ANC visit, more than early and exclusive breastfeeding (76%). Other two-thirds reported not doing so because they did common services during ANC included counseling not perceive having any antenatal problems; 17% did on maternal nutrition (59%), iron distribution (56%), not utilize because of financial considerations; and blood pressure measurement (50%), family planning 11% because of physical access issues (Table 12).18 counseling (48%), blood tests (23%), and tetanus Health center staff were the most-frequently reported vaccination (33%). Urine pregnancy tests were persons seen for ANC care with visits occurring both available at only 20% of HCs, and only 19% of women at the health center as well as in villages during reported receiving one. Nearly 85% of women re- outreach services. ported ever receiving at least one tetanus toxoid (TT) vaccination, and 37% reported having the rec- Table 12: ANC utilization ommended five or more vaccines required to be Antenatal care Percent (%) considered fully immunized. Tetanus vaccination is an important element of the ANC services and is Received any ANC 40% commonly documented in the maternal vaccination Reasons for not receiving ANC card, which 36% of women reported owning (although the card was seen in only 7.1% of cases).19 No problems 71% Slightly more than a third (39%) of women utilizing No money 17% ANC reported having been counseled on danger Health center too far 11% signs during their visit. Decreased fetal movement and headache or blurry vision were the most Person seen for ANC (among those receiving ANC) commonly discussed issues. Health staff 93% Traditional birth attendant Village health volunteer 3.5% 2.6% From a supply-side perspective, facility surveys indicated that basic ANC care services were gen- erally available in all 38 health centers included 17 Most common locations of ANC in the sample. Most health centers reported Health center 73% providing weight checks, blood pressure checks, fundal height, abdomen checks, and fetal heartbeat In the village 64% checks. Iron or folate supplements were provided District hospital 27% in 76% of facilities, however, only 55% provided Home 11% deworming medicine, and less than 20% provided hemoglobin or any urine test (Table 13). Furthermore, Timing of First ANC Visit 15 of the 38 health centers did not have even one First trimester 31% staff member who had received training in ANC Second trimester 52% services in the two years prior to the survey, raising concerns about the quality of ANC services provided. Third trimester 17% In spite of intensive national campaigns, only half of Total number of ANC visits health centers report discussing early and exclusive 1 visit 14% breastfeeding during ANC, and only 55% discussed 2-3 visits 35% 4+ visits 52% 18 Manithip et al (2011) found that that 49% of women not utilizing ANC care in their sample in Lao PDR did so because they felt normal and did not perceive any antenatal problems and 48% reported difficulty accessing health centers. 19 Within a given pregnancy, a woman is considered immunized if she has had two doses during that pregnancy or at least five doses in her lifetime. danger signs.20 Although most health centers report Table 14: Assistance at delivery discussing maternal nutrition and self-care, many miss the opportunity to discuss birth and emergency Assistance at delivery Percent (%) planning and the need for follow-up care. About 20% None 55% of all mothers reported practicing food restrictions Traditional birth attendant 22% during their last pregnancy, the proportion being Health staff 18% the same whether or not they had received any ANC care. Village health volunteer 4% Traditional healer 0.30% Table 13: Provision of ANC services at health Total 100% centers Provision of ANC service Percent (%) Only 14% of births among surveyed women took place at health facilities (Figure 6). While Is the following ANC service provided? national trends suggest that facility-based delivery is Fundal height 95% increasing in prevalence, it remains relatively rare Abdomen check 95% in our sample. Traditions surrounding delivery vary substantially around the country. In some rural Fetal heartbeat check 95% communities, child birth is traditionally conducted Other physical exam 92% in a forested area outside of the village, while other Weight check 87% communities build separate birthing structures which are used only once. Home births remain the Blood pressure check 87% most common location of delivery, even in relatively Iron or folate 76% more developed areas of the country. More women Any Tetanus toxoid 66% reported delivering in birth structures or in the 18 Deworming 55% village than did at the health center, and all facility-based deliveries (including health centers, Any urine test 18% district hospitals, and provincial hospitals) accounted Hemoglobin test 11% for only 14% of deliveries. Reasons for delivering outside of health facilities included convenience (43%), tradition (22%), and a lack of money (10%).21 Deliveries Place of delivery 80 Only 18% of births among surveyed women were attended by skilled birth attendants. With 22% of 60 Percentage (%) women seeking the assistance of a traditional birth 40 attendant (TBA), these local resources seem to assist somewhat more frequently than the formal health 20 sector, who were reported to be present in only 18% of deliveries (Table 14). 0 e ge er l l r ta ita he m nt pi lla sp Ho Ot ce os vi ho e/ th th ur e al ric nc ct He st i ru ov Di st Pr hrt Bi Source: CNP Baseline Survey Figure 6: Place of delivery 20 A study of four district hospitals and 18 health centers in Khammouane and Champasack provinces by Manithip et al (2012) found that the average encounter time for an ANC visit was very brief (only about 5 minutes) and of poor quality; See Manithip, C, K Edin, A Sihavong, R Wahlstrom, and H Wessel (2012), “Poor Quality of Antenatal Care Services – Is Lack of Competence and Support the Reason?” Midwifery, doi:10.1016/j.midw.2011.12.010. 21 Convenience, cost, comfort, and tradition were the reasons cited for not using health facilities for deliveries in a qualitative study of rural Laotians; See Sychareun, V, V Hansana, V Somphet, S Xayavong, A Phengsavanh, and R Popenoe (2012), “Reasons Rural Laotians Choose Home Deliveries over Delivery at Health Facilities: A Qualitative Study,” BMC Pregnancy and Childbirth, 12: 86 doi:10.1186/1471-2393-12-86. As with ANC, there are clear socio-economic More than a quarter (28%) of responding mothers gradients with regard to skilled birth attendance reported giving birth to a child who later died. and institutional delivery rates. Both skilled birth Consistent with global patterns, the majority of and institutional delivery rates were four to five deaths occurred in the first several months of life times higher among those women who had received and 78% of these children died within the first year ANC during their latest pregnancy (Table 15). Village of birth. More than a third of mothers did not know remoteness was a key factor with those in rural the cause of death for their child; among those that villages without road access having very low skilled knew, fever and diarrhea were among the leading birth attendance and institutional delivery rates causes (Table 16). as was maternal education and economic status. Lao-Tai ethnic group households had higher rates Table 16: Cause of child death compared with those from other ethno-linguistic Leading Causes of Death Among Children (%) groups (Table 15). Fever (excluding Malaria & Dengue) 26% Table 15: Skilled birth and institutional Diarrhea 9.2% delivery rates Dengue 5.3% Respiratory infection 2.7% Skilled birth Institutional Malaria 2.0% attendance deliveries Accident 1.2% (%) (%) Other 17% Received any ANC Unknown 37% No 7.5% 6.3% Total 100% Yes 34.5% 26.0% Residence Urban 37.0% 30.3% From a supply-side perspective, most (87%) of Rural with road 18.2% 14.0% health centers in the sample provided some Rural without road Age of mother Less than 20 8.6% 24.1% 6.0% 20.9% delivery services for pregnant women; however, the range of delivery services was generally 19 20-34 years 18.3% 13.5% limited. Among those health centers providing 35-49 years 13.3% 12.6% delivery services, many lacked capacity to actively Mother’s education manage the third stage of labor. Only 24% had None 10.3% 7.2% Primary 20.1% 16.8% partographs, and just under half offered oxytocin, Lower secondary 41.7% 30.2% injectable antibiotics, or neonatal resuscitation. Upper secondary 40.1% 29.8% Magnesium sulfate is still rare in rural Lao PDR, and Post-secondary and higher 34.0% 31.9% was available at only 17% of the health centers Economic quintile surveyed (Table 17). Of the 33 health centers provid- Poorest 6.0% 4.6% Second 12.7% 9.7% ing delivery services, 29 (88%) offer these services Middle 14.7% 8.4% during evenings and weekends. Fourth 20.5% 15.6% Richest 37.3% 32.9% Table 17: Delivery service availability at health Ethno-linguistic group of household head centers Lao-Tai 26.3% 21.5% Mon-Khmer 11.0% 7.7% Are the following delivery services available? Percent (%) Hmong-Mien 16.3% 11.7% Any 87% Other 1.9% 1.5% Among those who provide any services: Total 18.2% 14.2% Partograph 24% Injectable antibiotics 45% Oxytocin 42% Magnesium sulfate 17% Neonatal resuscitation (with mask and bag) 45% Postnatal Period Food taboos were very prevalent during the postnatal period, and were reported by 76% of Post-natal care (PNC) check-ups within one week women. Meats were very commonly avoided, with of delivery were rare, and were reported by only 77% of women avoiding buffalo meat and 63% of 2% of women.22 The most common reasons for not women avoiding beef. 58% of women had returned to seeking PNC included not having any problems their normal diet within one month of delivery, while (75%), no money (11%), inability due to the 24% restricted their diets for more than six months. post-delivery “roasting” period (8%), and the distance from the health center (5%). Almost all women (99%) reported ever breastfeeding their child, with 40% of all women initiating breastfeeding within one hour of delivery. However, about 40% reported waiting 1-3 days before breastfeeding, and nearly half 49% fed the infant something prior to breastfeeding. Three-quarters of women reported giving their child colostrum. Among those who delayed breastfeeding, 77% had no milk, while an additional 19% reported that the child would not suck. CHILD HEALTH & NUTRITION Well-baby and routine check-ups for children under two were reported by only 8.9% of households in the survey. Well-baby visits that did take place were 20 generally provided through outreach (55%); 33% took place at the health center and 15% were at a hospital. Immunizations Only one-quarter (26%) children aged 12-23 months have received all of the vaccines included in the standardized Expanded Program on Immunizations (EPI) and one in ten children aged 12-23 months have not received any vaccinations at all. This data was obtained from a combination of vaccination cards (in the 30% of cases where vaccination cards were available) and verbal recall. The percentage of children aged 12-23 (i.e. those who are old enough to be fully vaccinated) months who have been immunized are summarized in Table 18 Photo by Bart Verweij/2013 22 The low levels of PNC check-ups may be a result of the way in which the question was asked as PNC check-ups may have occurred during the same time as deliveries occurred and not as separate visits. Table 18: Vaccination rates among children 12-23 Consistent with national policy emphasizing months of age quarterly outreach visits, most children are vaccinated in the village through outreach. Vaccine Vaccination Card Mother’s Report Either According to the survey respondents, vaccines were BCG 28% 56% 84% DPT1 28% 54% 83% mainly provided in villages (78%), although health DPT2 25% 15% 41% centers (16%) and hospitals (5%) were also important DPT3 22% 20% 42% venues for the delivery of vaccinations. This trend Polio 1 27% 56% 83% was even more prominent when limiting the analysis Polio 2 27% 18% 45% to fully immunized children; among these children, Polio 3 21% 20% 41% Measles 15% 37% 51% an even higher proportion of vaccinations being All 14% 12% 26% delivered in villages (83%) at the expense of hospitals None 0.0% 11% 11% (1.4%). The role of health centers is unchanged at HepB 9.3% 0.0% 9.3% 16%. Micronutrient Vaccination Card Mother’s Report Either Vitamin A 19% 56% 75% Child Illnesses While nearly 90% of children receive at least one More than a third of children less than two years vaccination, the data suggest substantial loss to of age had a fever in the two weeks prior to the follow-up. Mothers reported many reasons for not survey; 24% had had a cough and 15% had had fully vaccinating their children, with a lack of time or diarrhea. Among children with a cough, fast breath- knowledge about the vaccination event being the ing was noted in 64% of cases, which was attributed most common. Table 19 provides a summary of the to a blocked or runny nose (75%), problems inside reasons given. the chest (11%), or both (14%). Children were most likely to receive treatment for fever (65%, compared Table 19: Reasons for not receiving all vaccinations (multiple possible) 49% of children with a cough and 63% of children with diarrhea). Treatment patterns were similar across the three illnesses, with the health center most 21 Reason (%) commonly sought for advice, followed by village Not notified 25% No time 17% health volunteers, district hospitals and pharmacies Makes baby sick 6.0% in that order, regardless of illness type (Table 20). For Baby gets fussy 2.1% fevers, caretakers typically waited until the day after Not useful 1.1% the onset of the illness to seek advice or treatment Afraid it is harmful 1.0% illness; 32% seek care on the same day, and 97% Expensive 0.5% Other 10% seeking care within three days of the onset of illness. The pattern was similar for coughs, with 33% seeking care on the same day, and 96% seeking care within three days of the onset of illness. Table 20: Treatment patterns for childhood illnesses Illness Incidence in the Any Health Village District Pharmacy Health staff Health staff Friends/ last two weeks treatment center health hospital (outside (at village) family volunteer village) Fever 39% 65% 52% 23% 11% 9.3% 6.3% 2.3% 1.6% Cough 24% 49% 55% 16% 11% 11% 9.1% 6.4% 1.4% Diarrhea 14% 63% 46% 29% 12% 6.0% -- -- 2.2% Most children ill with a fever (82%) were given a water sources did not correlate with diarrhea drug during the illness, most frequently on the prevalence in the sample. Approximately two-thirds same day (43%), the next day (26%) or two days of children with diarrhea received ORS. During the after the fever (20%). Relatively few respondents episode of diarrhea, approximately 29% of children were aware of the treatments given to their children; were given about the same amount of fluids, with 77% of drugs given for febrile episodes unspecified. 0.1% given none, 10% given much less and 28% Among children who were sick the two weeks before given somewhat less to drink. Only 33% were given the survey, and 31% were still sick with a fever, 39% more liquids. Fluids given included a form of ORS in still had a cough. Drugs were somewhat less likely 66% of cases, reconstituted from a “special packed to be given for a cough (70%). Treatment times were called ORS” (47%), or a government-recommended similar, with treatment most frequently initiated on homemade fluid (22%), or a pre-packaged ORS liquid the same day (45%), the next day (20%) or two days (18%). after the cough appeared (21%). The most common drug used is cough medicine (69%) followed by Table 22: Diarrhea prevalence among children less paracetamol (38%) (Table 21). None of the children than two years of age sick with a cough (n=238) were reported to receive antibiotics. Diarrhea prevalence two weeks prior to survey Percent (%) Residence Table 21: Treatment regimens for ill children Urban 8.7% Rural with road 17.6% Treatment (%) Rural without road 15.3% Fever Sanitation Paracetamol 39% No toilet 16.6% 22 Antimalarials 3.2% Flush toilet/pit latrine 8.8% Antibiotics 1.7% Hygiene No designated handwashing area 18.3% Unspecified 77% Designated handwashing area with soap/ash 13.9% Cough Water source Cough Medicine 69% No access to improved water source 15.2% Paracetamol 38% Access to improved water source 15.1% Total 15.2% The prevalence of diarrhea among children under two in rural areas was double that in urban households. Not unexpectedly, diarrhea rates were significantly higher in households that lacked or did not use a flush toilet/pit latrine and in households that lacked a designated place and did not have soap/ ash for handwashing (Table 22). Access to improved Anthropometrics Anthropometric data confirms the high rates of undernutrition among children under two years of age. Almost one-third (31%) of children under two were underweight while more than one-tenth (11%) were severely underweight.23 The prevalence of stunting was even more extreme, with 36% of the same population stunted and 13% severely stunted. Wasting was also prevalent: 14% of children less than two were wasted, and 2.9% severely wasted. These parameters of malnutrition generally worsen with increasing age: for example, the prevalence of stunting increases from 22% among children aged 0–5 months, to 50% among children those aged 11–23 months, highlighting the importance of interventions aimed at adoption of appropriate complementary feeding patterns at the right times. Malnutrition rates were substantially higher among males than females. For example, the prevalence of underweight was 35% among males and 27% for females. Likewise, the prevalence of stunting was 40% among male children versus 27% among female children. Undernutrition was significantly higher among rural, socio-economicaly marginalized house- 23 holds lacking access to basic infrastructure. Malnu- trition rates were much higher among those in rural areas, those without access to toilet, and in house- holds where the mother was older and less educated. Some of the highest malnutrition prevalence rates were observed among households that were in the lower economic quintiles. Households headed by the Mon-Khmer and Hmong-Mien ethnic groups also tended to have higher rates of malnutrition among children less than two years of age. Photo by Bart Verweij/2013 23 Underweight and stunting areas defined as two standard deviations below the median of the WHO Child Growth Standards adopted in 2006; severely underweight and severely stunted are defined as three standard deviations below the same. Table 23: Malnutrition prevalence among children less than two years of age24 Malnutrition prevalence Underweight (%) Stunted (%) Wasted (%) Residence Urban 21.3% 26.7% 12.7% Rural with road 39.7% 40.4% 14.4% Rural without road 31.3% 35.7% 13.4% Sanitation No toilet 37.5% 39.1% 15.6% Flush toilet/pit latrine 18.7% 26.2% 8.4% Hygiene No designated handwashing area 33.8% 35.7% 16.1% Designated handwashing area with soap/ash 27.5% 32.7% 9.3% Water source No access to improved water source 35.6% 38.5% 14.1% Access to improved water source 29.8% 32.6% 13.0% Age of mother Less than 20 23.5% 36.2% 9.8% 20-34 years 33.8% 36.0% 14.2% 35-49 years 38.9% 37.8% 14.0% Mother’s education None 40.5% 42.8% 15.4% Primary 28.1% 31.4% 12.8% 24 Lower secondary Upper secondary 23.4% 21.6% 22.9% 26.8% 12.3% 11.2% Post-secondary and higher 21.9% 30.0% 7.1% Economic quintile Poorest 42.7% 42.6% 17.0% Second 38.8% 41.4% 17.1% Middle 34.9% 39.0% 12.1% Fourth 29.4% 33.9% 11.9% Richest 20.9% 24.2% 10.1% Ethno-linguistic group of household head Lao-Tai 24.5% 29.1% 11.0% Mon-Khmer 43.9% 43.4% 16.9% Hmong-Mien 15.0% 39.7% 12.7% Other 21.3% 33.3% 3.3% Total 33.4% 36.3% 13.8% 24 The table reports household-level prevalence of malnutrition, i.e., it reports the percentage of households that had at least one child under the age of two that was malnourished. Wasting, which is associated with greater child mortality, is less prevalent than either underweight or stunting, suggesting a dominance of chronic undernourishment rather than acute undernourishment. SUMMARY & POLICY trition, with over a third of all children less than two years of age being underweight or stunted. One IMPLICATIONS consistent finding relates to the socio-economic gradients in key MCH and nutrition-related This report has presented results from a indicators. Across the board, those living in rural, household survey on MCH & nutrition in mostly remote communities, poorer households, households rural areas of six central and southern provinces of headed by non-Lao-Tai ethnic groups, and those Lao PDR. The information is complemented in some wherein the mothers were not educated tended places with data collected at health facilities. Survey to have some of the worst MCH and nutrition results confirm and complement existing information outcomes. from other sources (such as the LSIS and MICS3) on the state of MCH- and nutrition-related output and Service utilization rates remain exceedingly low, outcome indicators in the country. In addition, the far lower than rates observed in comparable survey sheds new light on some of the health risks countries. The reasons provided by women for the and challenges faced by the population in central low levels of ANC, institutional deliveries, PNC, and and southern Lao PDR, especially in rural and remote well-baby visitation rates indicate that, in addition areas. On the positive side, the survey documents to physical and financial barriers, lack of knowledge important gains in preventive MCH services. and awareness of the benefits of contacts with the Coverage of several different vaccines, including BCG, are approaching or have met coverage targets formal health system in the country is widespread. of 80%, and coverage of the measles vaccine is now In addition to demand-side considerations, the slightly over half (up from 35% in 2006). At 40%, ANC findings from the facility audits which complemented coverage is has increased by 5 percentage points the household surveys highlight some key deficien- since 2006.25 cies with regard to service readiness, especially with regard to provision of key MCH services such as Despite some modest gains in health service coverage outcomes, the survey results underscore the fact that MCH- and nutrition- delivery-related care in the more rural and remote parts of the country. These findings will be documented in more detail elsewhere, but are 25 related challenges continue to plague Lao PDR. presented in brief in Box 2 below. The survey More than a quarter of the mothers interviewed re- makes clear that important constraints continue ported having at least one child who had died, and to exist in the supply of basic health services. The more than a quarter of households had at least one complementary system of outreach can be leveraged serious illness, injury, or death in the two years prior and enhanced in order to expand the coverage of to the survey. The data suggest that health shocks basic health services, especially to remote areas. are among the most common (and most expensive) Careful attention will need to be paid to rationalizing shocks facing rural residents. Additional detailed use of care and institutionalizing a robust referral analysis of out-of-pocket expenditure related to system as efforts are made to increase service access to maternal health services based on the utilization. Going forward, a key challenge will be to same survey is in progress and is expected later in find the right balance of investments in underutilized 2013. Anthropometric measurements of children health facilities vis à vis investments in the referral confirm recent reports of serious levels of undernu- and outreach systems. 25 Estimates for 2006 are taken from the 2006 Multiple Indicator Cluster Survey (MICS) 3. Box 2: Facility Audits The CNP survey included facility and village level offering urine pregnancy tests. Even the most basic data collection in addition to the household equipment was often lacking: adult scales were surveys. In all, 38 health centers were visited. At missing in 20% of health centers and stethoscopes the facilities, data was collected on catchment area were missing in 15%. details and utilization; staffing, training and management; infrastructure and equipment; and Following methodology developed by the WHO, drugs, tests, and supplies. simple indices of facility service readiness were created by measuring the percentage of key Facility audits highlight serious gaps in the Lao equipment and drugs available at health centers. medical supply systems. While a small number of Figure 7 shows the distribution of service readiness commodities – notably contraceptives, saline, and scores – divided into quintiles – by both location pain relievers – were routinely available, many (urban, rural with road, and rural without road) essential supplies were missing in most health and local poverty. These results highlight declines centers. BCG vaccine, which should be provided in health facility service readiness as one moves within three days of birth, was available at less than from urban to more remote or to poorer regions. 40% of facilities visited, and infant antibiotics were Complementary analyses suggest that women available in only approximately 30% of facilities living in the catchment areas of relatively better surveyed. Diagnostic capacity was nearly non- resourced health facilities are nearly two times existent in the health centers visited, with only 40% as likely to utilize ANC services as those in the of facilities able to provide a malaria test and 20% catchment areas of less resourced facilities. 26 Urban Service Readiness by Location Wealthiest Service Readiness by Catchment Area Poverty Second Wealthiest Rural with Road Middle Next to poorest Rural no Road Poorest 0 20 40 60 80 100 0 20 40 60 80 100 percent percent Lowest quintile Second quintile Lowest quintile Second quintile Middle quintile Fourth quintile Middle quintile Fourth quintile Highest quintile Highest quintile Figure 7: Health center service readiness scores by location and poverty status Increasing uptake of services is of little value if challenges. These results highlight the need to the services received offer no benefit to patients, invest more in insuring that high-quality services and serious attempts to increase the utilization of are available when contact is made with the health services must address these basic supply-side system. The need for accelerating improvements in MCH- services among the population as a whole, there is a and nutrition-related outcomes has not gone danger that the policy will exacerbate existing health unnoticed by the government. Efforts aimed at inequalities if relatively wealthier families – with increasing uptake of MCH services are steadily better access to health infrastructure and services gaining momentum in the country, and the – disproportionately utilize the free services. In government has committed itself to making key addition, implementation will need to be MDG-related health services accessible to the complemented by improvements in the capacity population as part of its new reform agenda. Al- of health facilities, not just in clinical and service though the planned increases in government health availability terms, but also in terms of their ability to spending are welcome, challenges remain. These manage and allocate revenues appropriately. Current include ensuring that the additional resources are weaknesses include inconsistent implementation used to improve access to and quality of health of user fee regulations and revenue management, services – especially in more remote areas – and variation in management practices, weak progressively making additional domestically- procurement practices for drugs, and inadequate financed resources available to reduce both service provision levels. dependence on external funding and out-of-pocket spending for health. To attain these objectives, It is important to note that the planned removal the government should consider an appropriate mix of user fees, as envisioned under the free MCH of both demand-side and supply-side incentives. policy, may not be sufficient to improve utilization Instead of, or in addition to, setting a target for and inequalities across the country. To achieve budgetary outlays for health, the government needs this, the government should consider additional to improve the efficiency of existing outlays, the supply-side and community-focused demand-side measurement of which requires the monitoring of interventions, especially in rural areas building key population health outputs. These should include on the lessons of the Ministry of Health’s pilot focus on the level and equity of basic immunization rates, of skilled birth attendance, of institutional delivery rates, of need-based outpatient and Community Nutrition Project. If successful, the free MCH policy is likely to have its greatest impact on facility-based delivery rates. Alternative strategies 27 inpatient utilization rates, and on adequate levels of will likely be needed to increase utilization of financial protection from adverse health shocks. antenatal care, postnatal care, or vaccination, as each of these service categories are officially free of charge The planned implementation of the free MCH and have been so for decades. Strategies aimed at policy, which will be implemented to scale this increasing coverage of these interventions should year, is a welcome step in the right direction. This focus on a combination of demand-side interven- policy seeks to remove user fees at the point of service tions, aimed at behavior change and education for key MCH services and to provide utilization-based campaigns, and supply-side interventions aimed reimbursements to health facilities. Notably, the at improving the quality of services that are proposed package of services included in the delivered. One potentially important supply-side free MCH Policy includes facility-based delivery. intervention is the expansion and improvement Experience from a recent World Bank-funded pilot of integrated outreach. During routine outreach, eliminating user fees suggests that this policy may health workers visit villages in their catchment offer important gains in this area. A two-year World areas to provide free-of-charge vaccination services, Bank-funded project piloted free deliveries in two ANC, and PNC and some limited curative care. districts in the same region. It found that facility While these visits remain an important point of based deliveries increased by 300% in the districts care for many living in rural areas, there is evidence in which user fees were eliminated; this compares that these visits are not currently offering access to a much smaller 40% increase in neighboring to a basic package of services. Although outreach control health districts. However, implementation of guidelines provided by the Ministry of Health the policy must be carefully monitored. As with all stipulate that several antenatal and postnatal such strategies aimed at increasing the utilization of services be available at outreach, the survey results suggest that less than 5% of ANC visits took place in the village. Improving nutrition outcomes poses a particular the survey finds a strong correlation of diarrhea policy challenge in the country. Poor nutritional incidence and improved facilities. Table 23 highlights outcomes in Lao PDR have complex causes. Food a consistent decrease in diarrheal incidence with the insecurity remains a problem. However, the issue goes increase in the local availability of flush toilets. The beyond a shortage of food. Malnutrition is caused by National Nutrition Strategy (NNS) was released inappropriate breastfeeding and complementary in 2009, and followed up with a National Plan of feeding practices, food taboos associated with preg- Action for Nutrition (NPAN) the same year. nancy and the postpartum period, high incidence Together, the NPAN and NNS have helped to create a of vector and food-borne disease, and myriad other motivated coalition of actors seeking progress on factors. Many of these causes are only weakly what has been an especially intransigent challenge related to the availability of and access to food, as is in Lao PDR. Fifteen ministries and organizations are evidenced by the relatively high rates of malnutrition held to be accountable for nutrition outcomes and, observed even in better-off segments of the following the release of the NPAN, government population. According to an earlier World Bank- and development partners rallied around the issue. supported study of infant and young child feeding However, implementation of the plan has been slow in Lao PDR, there remains a widespread belief in Lao and better prioritization of critical interventions PDR that young children know when and how much is needed. The existing NPAN contains 44 priority to eat; this results in the absence of engaged and in- interventions requiring immediate action, and teractive feeding behavior, and low overall quantity of include increasing the coverage of exclusive dietary intake for vulnerable children. Development breastfeeding and scaling up immunization to partners such as UNICEF have been supporting the introducing conditional cash transfers for ANC, Ministry of Health in developing the capacity of the PNC, and deliveries. The annual budget for the 44 Center for Information and Education for Health interventions was estimated at US$25 million: while (CIEH). Following the successful implementation of a the targeted budget is substantial, there is little 28 national exclusive breastfeeding campaign in 2010, the center has more recently begun to tackle the challenge of building a broad engagement with na- guidance on where the funds should come from and whether the planned increases in domestically- sourced government financing would specifically tional and local stakeholders- including government target these interventions. agencies, development partners, non-governmental organizations (NGOs), and civil society organizations The response to nutrition issues will need coordi- (CSOs) – in order to ensure appropriate and consis- nated action across sectors. Leadership has been tent messaging. The team has also been active in a challenge in Lao PDR. Even within the national expanding the availability of materials appropriate health sector, leadership around nutrition is only in multi-ethnic/multi-language and low literacy recently beginning to arise, and a designated center environments. for nutrition was only created at the Ministry of Health in 2012. While the goal of facing this multi-sectoral Improvements in nutritional outcomes will challenge with a multi-sectoral response was laid out require a multi-sectoral response aiming to in the Ministry of Health’s NNP, early calls to introduce educate families on appropriate feeding prac- a coordinating committee at the level of the Cabinet tices, especially for infants and young chil- – with ties to the Ministries of Health, Education, dren; increasing access to improved water and Agriculture and others that were initially envisaged sanitation facilities to reduce the prevalence of to participate – have only recently been initiated. water, food and vector-borne diseases; and im- Attacking the persistently high levels of malnutrition proving access to health care services for those in Lao PDR will require a high-level emergency in need. Consistent with international studies, multi-sectoral policy response. 26 Gillespie, A, H Creed-Kanashiro, D Sirivongsa, D Sayakoumanne, and R Galloway (2004), “Consulting with Caregivers: Using Formative Research to Improve Maternal and Newborn Care and Infant and Young Child Feeding in the Lao People’s Democratic Republic,” HNP Working Paper, World Bank, Washington, DC. ANNEX A: LIST OF SURVEYED HEALTH CENTERS No Province District Health Center Status27 1 Attapeu Phouvang Nachuak Intervention 2 Attapeu Xaysetha Kengmakeua Intervention 3 Savannakhet Thapangthong Xekeu Intervention 4 Savannakhet Xepon Dongsavanh Control 5 Savannakhet Xepon Phabang Control 6 Savannakhet Xepon Ladhor Intervention 7 Savannakhet Xepon Manchi Intervention 8 Savannakhet Nong Danvilay Intervention 9 Savannakhet Nong Nakong Control 10 Savannakhet Vilabouly Nayom Intervention 11 Savannakhet Phalanxay Nasai Control 12 Salavane Samuoi Amin Control 13 Salavane Samuoi Asok Control 14 Salavane Samuoi Kimae Control 15 Salavane Taoi Tahouark Intervention 16 Salavane Taoi Photang Intervention 17 Salavane Taoi Kokbik Control 18 Salavane Toomlarn Nadou Control 19 Khammouane Nakai Natane Intervention 20 Khammouane Yommalad Hai Control 21 22 Khammouane Khammouane Yommalad Xaybouathong Phid Kengchone Control Intervention 29 23 Khammouane Xaybouathong Naphao Intervention 24 Khammouane Xaybouathong Nanoithong Control 25 Khammouane Boualapha Sobpheng Control 26 Khammouane Boualapha Sok Control 27 Khammouane Mahaxay Panam Intervention 28 Champasak Sukhuma That Control 29 Champasak Pathoomphone Sanod Control 30 Champasak Pathoomphone Lak 24 Intervention 31 Champasak Bachiang Kuangsy Intervention 32 Champasak Bachiang Kengkia Control 33 Bolikhamxay Khamkheuth Phamoeung Intervention 34 Bolikhamxai Khamkeut Khammuane Control 35 Bolikhamxai Xaychamphone Nam one Control 36 Bolikhamxai Borlikhan Ban Bo Intervention 37 Bolikhamxai Borlikhan Nakoun Intervention 38 Champasak Sukhuma Nachan Intervention 27 The survey was conducted in preparation for the impact evaluation of CNP and matched paired health centers are included in the survey. Control health centers are not implementing project activities were surveyed together with intervention health centers which are. The World Bank Group The World Bank Lao PDR Country Office Patouxay Nehru Road P.O Box: 345 Vientiane, Lao PDR Tel: (856-21) 266 200 Fax: (856-21) 266 299 Websites: www.worldbank.org/lao The World Bank 1818 H Street, NW Washington, D.C. 20433, USA Tel: (202) 4731000 Fax: (202) 4776391 Website: www.worldbank.org Photo by Stan Fradelizi/2011