Human Resources for Health - WPRO IRISThe designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the

Human Resources for HealthCountry Profiles

Lao People’s Democratic Republic

WHO Library Cataloguing-in-Publication Data

Human resources for health country profiles: Lao People’s Democratic Republic

1. Delivery of healthcare – manpower. 2. Health manpower. 3. Health resources - utilization. I. World Health Organization Regional Office for the Western Pacific.

ISBN 978 92 9061 636 8 (NLM Classification: W 76)

© World Health Organization 2013

All rights reserved.

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Acronyms v

Acknowledgements vi

1. Introduction 1 1.1 Demographic, social and political background 1 1.2 Current economic situation and macroeconomic indicators 1 1.3 Summary of health indicators 2 1.4 Health system 3

2. Health workforce supply and trends 4

3. Health workforce distribution 7 3.1 Gender distribution 7 3.2 Age distribution 7 3.3 Geographical distribution 9 3.4 Distribution of health workers by urban/rural area 9

4. Health professions education 9 4.1 Structure of health education institution 9 4.2 Training of health professionals 10 4.3 Overall cost of training/education per graduate 12 4.4 In-service and continuing professional education 12

5. Human resources for health (HRH) utilization 13 5.1 Recruitment 13 5.2 Deployment and distribution policies and mechanisms 14 5.3 Unemployment 15

6. Financing HRH 15 6.1 Health expenditure 15 6.2 Remuneration to health workers 15 6.3 Health workers incentives 17

7. Governance of HRH 20 7.1 HRH policies and plans 20 7.2 Policy development, planning and managing for HRH 20 7.3 Professional Regulation 20 7.4 HRH information 21 7.5 Health workforce requirements 21

8. Concluding remarks 22

References 23

Annexes 24 Annex A. Gender distribution by professional category/cadre (%), March 2012 24 Annex B. Health workers by age group and cadre, March 2012 25 Annex C. Density of health workers by category and province (per 1000 population) 26 Annex D. Distribution of health workers by urban/rural area 27 Annex E. Number of entrants by year, 2008–2011 28 Annex F. Number of graduates by year, 2008–2011 29

Table of contents

Human Resources for Health Country Profilesiv

List of tables

Table 1. Leading causes of OPD and IPD patients 2 Table 2. Levels of service delivery and types of services in the Lao People’s Democratic Republic, 2012 3 Table 3. Classification of health workers 4 Table 4. Current supply of health workers at national level, March 2012 5 Table 5. Current supply of contractual health staff, March 2012 6 Table 6. Distribution of health workers by group/cadre and province, March 2012 8 Table 7. Number of training institutions by specialty 12 Table 8. Approved HRH quotas, March 2012 14 Table 9. National Health Account summary results, 2009–2010 16 Table 10. Sources of health funds, 2009–2010 16 Table 11. Functional distribution of health care expenditure, 2009–2010 16 Table 12. Expenditure disaggregated by function, 2009–2010 17 Table 13. Entry level groups classification 17 Table 14. Average income by category cadre, March 2012 18 Table 15. Levels of remote, isolated and difficult areas 19 Table 16. Incentives for civil servants working in remote, isolated and difficult areas 19 Table 17. Projections for health workforce requirements, 2013–2020 21

List of f igures

Figure 1. Population trends 1 Figure 2. Gender distribution by professional category/cadre (%), March 2012 7 Figure 3. Health workers by age group and cadre (%), March 2012 7 Figure 4. Geographical distribution of health workforce (% urban vs. % rural), March 2012 9 Figure 5. Number of entrants per year in health professions education institutions, for selected categories (2008-2011) 13 Figure 6. Number of graduates per year in health professions education institutions, for selected categories (2008-2011) 13 Figure 7. Structure of Department of Organization and Personnel 20

Lao People’s Democratic Republic v

Acronyms

GDP gross domestic product

GGE general government expenditure

GGHE general government expenditure on health

HRH human resources for health

IMR infant mortality rate

IPD Inpatient Department

MA medical associate, medical assistant

MDGs Millennium Development Goals

MMR maternal mortality ratio

MNCH maternal, neonatal and child health

MOHA Ministry of Home Affairs

OPD Outpatient Department

PACSA Public Administration and Civil Service Authority

PHC primary health care

PhD Doctorate

PIMS Personnel Information Management System

PPP purchasing power parity

PvtHE private health expenditure

TB Tuberculosis

THE total health expenditure

UHS University of Health Science

Human Resources for Health Country Profilesvi

Acknowledgements

The Human Resources for Health Country Profile for the Lao People’s Democratic Republic was developed by Khampasong Theppanya, Asmus Hammerich and Valeria De Oliveira Cruz, with assistance from Simone Phillips in the Office of the WHO Representative in the Lao People’s Democratic Republic and Inseok Lee, an intern in the Human Resources for Health team at the WHO Regional Office for the Western Pacific.

The Human Resources for Health Country Profiles in the Western Pacific Region are prepared under the logistical and editorial support of the WHO Western Pacific Regional Office Human Resources for Health unit and coordinated by a team composed of Gulin Gedik, Rodel Nodora, Jose Aguin and Dyann Severo.

Lao People’s Democratic Republic 1

1. Introduction

1.1 Demographic, social and political background

The estimated population of the Lao People’s Democratic Republic in 2011 was 6 385 057, according to the Lao Statistics Bureau, with a registered annual population growth in 2010 of 1.44%. The country has a sparse population density (27 people per square kilometre), with large interprovincial variations and an average household size of 5.9 people. The population is young, but there are signs of changes in the demographic structure: the percentage of the population under 15 years of age decreased from 42.3% to 34.5% between 2000 and 2010. The population is mainly concentrated in rural areas, but a rural-to-urban shift is beginning to take place as the estimated percentage of the population living in rural areas decreased from 78% to 67% between 2000 and 2010. The Lao population has a balanced sex ratio of 50% for each sex, and life expectancy at birth increased from 53 in 2000 to 62 in 2010 (see Figure1).

Figure 1. Population trends

0102030405060708090

100

201020052000

Life expectancy at birth (years)

% Population living in rural areas

% Populationunder 15 years old

42 39 35

7873

67

53

N/A

62

N/A, not available.Source: World Bank, 2012.

The Lao People’s Democratic Republic is a single-party, socialist republic with an ethnically diverse population; the official language is Lao. Sixty-seven per cent of the Lao people are Theravada Buddhists, and 1.5% are Christian. The remaining 31.5% follow non-Buddhist local religions (Encyclopaedia Britannica, 2012).

The geography is largely mountainous, with lowland areas along the Mekong River that provide land for paddy rice cultivation and highland areas where upland rice production and the gathering of non-timber forest products are the main sources of livelihoods. The mountainous topography makes the construction of railway system impossible, and as a result, the Mekong River is an important artery for transportation. Because of these geographic conditions, access to hospitals and health services in the Lao People’s Democratic Republic is very difficult, especially for the people living in rural areas.

1.2 Current economic situation and macroeconomic indicators

The Lao People’s Democratic Republic is on an increasingly sustainable growth pathway. Reforms under way have reduced poverty and stimulated growth. The real gross domestic product (GDP) growth rate increased from 6% in 2000 to 9% in 2010, while the registered GDP per capita in 2010 was US$ 1077 (Lao Statistics Bureau, 2012). As a result, the Lao People’s Democratic Republic is now a lower-middle-income economy (World Bank, 2013). The Lao People’s Democratic Republic recommitted in its Seventh Five-Year National Socio-Economic Development Plan (2011–2015) to achieving the Millennium Development Goals (MDGs) by 2015, and graduating from the group of least-developed countries by 2020.

Government revenue collection has been rising slowly in recent years but remains very low, estimated at 14.6% of GDP in 2008. Nonetheless, the budget deficit has declined and the the flexibility of the Government to decide its spending choices has widened. In 2007, the collection of taxes and revenues was recentralized by a decree by the Prime Minister. However, budget and state audit laws still need to be fully enforced (WHO Western Pacific Regional Office, 2011).

The Lao People’s Democratic Republic ranked 138 out of 187 nations on the Human Development Index in 2011, just ahead of Cambodia. Literacy rates have improved in the last decade, attaining 73% in the population above 15 years of age in 2005, compared with 60% in 1995, showing, however, a considerable gap between sexes (83% male, 63% female). School attendance has also improved for children aged 6 to 16 years: 75% of boys and 68% of girls in 2005

Human Resources for Health Country Profiles2

compared with 66% of boys and 56% of girls in 1995 (United Nations Development Programme, 2011). However, boys still have a higher attendance rate than girls.

The population below the poverty line fell from 46% in 1993 to 26% in 2010. Poverty is higher in remote and highland areas and inversely correlates with road or river access. Based on international purchasing power parity (PPP) standards, 24.8% of the population was living on less than US$ 2 a day and 33.9% on less than US$ 1.25 a day in 2008. Inequalities remain significant, with the share of the national economy of the lowest and the highest quintiles being 7.6% and 45%, respectively. Proxy indicators of poverty, such as access to sanitation and electricity, also reflect the population’s vulnerability. The latest Lao Reproductive Health Survey found that, in 2005, 50% of households had no toilet and over 40% had no electricity. Disparities between urban and rural areas are still pronounced. For example, while 90% of urban households have electrical power, only 43% of rural households have access to electricity, and 11% of people living in rural areas have no road access, according to the Lao Statistics Bureau (Central Intelligence Agency, 2012).

1.3 Summary of health indicators

The main causes of mortality in the Lao People’s Democratic Republic are (listed by number of deaths): malaria, pneumonia, diarrhoea, heart failure and injury (World Health Organization, 2011). The most common cause of Outpatient Department (OPD) visits

are common colds, (14.6% of total OPD patients) and tonsillitis and pharyngitis (10.5%), as shown in Table 1. The most frequent causes for Inpatient Department (IPD) cases are gynaeco-obstetrics (15.8% of total IPD patients), followed by diarrhoea (9.9%) and digestive system problems (9.5%) (Ministry of Health, 2012). Tuberculosis (TB) is also one of the most prevalent causes of health problems. In 2008, the TB prevalence rate was estimated at 260 per 100 000 people.

Life expectancy at birth rose from 53 years in 2000 to 67.5 years in 2011. This improvement is due mainly to the decreases in maternal mortality, infant mortality and under-five mortality. The maternal mortality ratio (MMR) plummeted from 1200 maternal deaths per 100 000 live births in 1990 to 357 maternal deaths per 100 000 live births in 2012. In addition, the infant mortality rate (IMR) decreased from 142 to 68 deaths per 1000 live births, and the under-five mortality rate dropped from 213 to 73 per 1000 live births between 1970 and 2010 (Lao Social Indicator Survey, 2011–2012 and the United Nations Inter-Agency for Child Mortality Estimation, 2012). Despite these improvements, there are big geographical disparities in these indicators. As an example, in 2005, while the IMR was 18 per 1000 live births in Vientiane capital, Sekong province recorded an IMR of 122 per 1000 live births.

According to the Lao Reproductive Health Survey 2007, only 28.5% of women sought antenatal care and 18.5% of deliveries were being attended by trained birth attendants during the reference year. Eighty-four per cent of women were still delivering at home.

Table 1. Leading causes of OPD and IPD patients

Top 10 causes of OPD patients Percentage Top 10 causes of IPD patients Percentage

Common cold 14.6% Gynaeco-obstetricts 15.8%

Tonsillitis, pharyngitis 10.5% Diarrhoea, no blood, no severe dehydratation

9.9%

Digestive system 7.7% Digestive system 9.5%

Nervous system, non-psychiatric 6.0% Otitis 6.4%

Pneumo-bronchitis 5.4% Pneumo-bronchitis 5.3%

Diarrhoea, no blood, no severe dehydratation

5.4% Common cold 4.2%

Minor surgery 4.6% Road traffic injury 4.1%

Road traffic injury 3.5% Urology 3.0%

Gynaeco-obstetrics 2.7% Trauma, all other 2.6%

Trauma, all other 2.6% Nervous system, non-psychiatric 2.1%

Others 39.7% Others 37.1%

Source: National Health Statistic Report, 2010–2011.


Compounding this is that only 32% of children aged 12 to 23 months were fully immunized. This has improved compared to 2000, but there is a need to step up efforts to resolve this issue (Somchith, 2009).

1.4 Health system

The main health-care delivery system of the Lao People’s Democratic Republic is a government-owned, public system that operates health centres and district and provincial hospitals. The Lao People’s Democratic Republic’s public health system has a strong vertical structure and is divided into three main arms:• health care;• prevention, promotion and disease control; and• health management and administration.

The public health system is organized into three administrative levels (Ministry of Health, 2007):• Central level: Ministry of Health Steering Commit-

tee (Department of Hygiene and Prevention, Depart-ment of Finance, Department of Planning and Inter-national Corporation, Department of Inspection, Cabinet, Department of Organization and Personnel, Department of Education and Research, Department of Curative Service, Food and Drug Department,

Department of Communicable Disease Control, Uni-versity of Health Science);

• Provincial level: Provincial Health Offices, regional hospitals, provincial hospitals, provincial nursing schools;

• District level: District Health Offices, district hos-pitals, health centres.

Under the Ministry of Health, there are four central hospitals, four regional hospitals, 12 provincial hospitals, 130 district hospitals, 894 health centres and around 5000 village drug dispensaries (see Table 2). There are around 5000 hospital beds in the country. Each health centre covers about 7000 people, but many centres serve fewer than 1000 (Ministry of Health, 2011).

Although there are no private hospitals in the Lao People’s Democratic Republic, the private sector for health is expanding, mainly in urban areas, with 1993 private pharmacies, 222 private clinics and 600 traditional medicine practitioners (Ministry of Health, 2011). There are some regulations on private health facilities and the involvement of health personnel in the private sector. However, the implementation and enforcement face typical challenges, including conflicts of interest, as most of the senior public

Table 2. Levels of service delivery and types of services in the Lao People’s Democratic Republic, 2012

Facility Number Characteristics

Public sector Village drug dispensaries 5000 Provide maternal, neonatal and child health (MCNH) package of

essential services: health information, including family planning and nutrition supplements.

Provide outreach package of MCNH interventions, including immunization, deworming, vitamin A supplementation, health promotion with a focus on nutrition, and skilled delivery care.

Health centres 894 Provide MNCH services, as well as community and outreach services.

District hospitals 130 Provide health promotion, disease prevention, diagnosis and treatment.

Provincial hospitals 12 Provide treatment and rehabilitation services.

Regional hospitals 4 Provide curative health-care services at the regional level as well as health care for the entire population of the region.

Central hospitals 4 Provide tertiary curative care.

Special treatment centres 3 Provide dermatology, ophthalmology and rehabilitation.

Private sector Clinics 222 Mainly in urban areas. There are 647 applications waiting for

approval.

Pharmacies 1993 Mainly in urban areas.

Hospitals 0 No private hospitals.

Source: Ministry of Health, 2010.


health personnel are directly or indirectly involved in private health practice after official working hours.

Since the introduction of a market economy two decades ago, the national health sector has gradually made good progress in terms of the quantity and quality of service. However, the health sector still has some constraints and faces great challenges that must be addressed. A majority of the Lao population, particularly in rural, remote and mountainous areas, lacks adequate access to basic health care. Therefore, it is of critical importance to solve these problems by reforming the national health system to make it more effective, efficient, equitable and sustainable. Since early 2012, the Ministry of Health, under the

leadership of the Prime Minister and with support from World Health Organization and other development partners, has undertaken a series of consultations to discuss how the Lao health sector needs to be reformed to achieve the health-related MDGs by 2015 and universal health coverage by 2025. Following these consultations and discussions, a reform strategy has been developed to set out short-, middle- and long-term visions, strategies and milestones for further developing the national health sector in the Lao People’s Democratic Republic.

In December 2012, the National Assembly approved the National Health Sector Reform Strategy.

2. Health workforce supply and trends

An understanding of the local health worker classification system is necessary in discussing the health professions education system in the Lao People’s Democratic Republic. Lao health workers are separated into four major levels: postgraduate level, bachelor level, high level and middle level. Table 3 shows detailed classification of health professions in the Lao People’s Democratic Republic. The fact that

different titles are used to refer to the same profession creates a source of confusion in classifying health professionals within the Lao system. For instance, seven different titles designate the role of nurse: bachelor-level nurse, high-level nurse, middle-level nurse, graduate nurse, associate nurse, registered nurse and technical nurse. However, in reality there

are only three different types of nurses based on educational background. For example, a bachelor-level nurse and graduate nurse both have bachelor’s degrees after four years of training and therefore have the same professional standing. Likewise, high-level nurses, associate nurses and registered nurses all have equivalent credentials and need not be distinguished professionally.

In the Lao People’s Democratic Republic, education for low-level workers has been discontinued. However, a number of low-level health workers still exist. Current low-level workers should upgrade their credentials through continuing education. The Lao People’s Democratic Republic suffers from a critical shortage of health workers, with 2.17 health workers per 1000

Table 3. Classification of health workers

Medical related Nurse Midwife Dental staff Pharmacy

staffLaboratory

staff Others

Postgraduate level Specialist level 1*, Specialist level 2**, Master level, PhD

Bachelor level Medical doctor

Graduate nurse

Graduate midwife Dentist Pharmacist Laboratory

technicianPhysical Therapist

High level Medical associate

Associate/registered nurse

Registered midwife

Hygienist, physical therapist, X-ray

Middle level Medical assistant

Technical nurse

Community midwife

Dental assistant

Pharmacist assistant

Laboratory assistant

Primary health care worker

* Two/three years training course after bachelor’s degree (i.e. specialist level 1 in internal medicine, in cardiology…).** Two/three years training course after specialist level 1 degree (i.e. specialist level 2 in internal medicine, in cardiology…). Source: Department of Organization and Personnel, Ministry of Health, March 2012.


population density (see Table 4). Compared with 2008 data (2.00 health workers per 1000 population), there has been a small increase in the number of health workers in the public health sector, which serves as the major implementer of health services.

Low-level nurses (auxiliary nurses) made up the largest group of health providers from 2008 to 2012 (see Table 4). Education for low-level health workers, however, was discontinued and as a result, the number of low-level workers has decreased. The Government of the Lao People’s Democratic Republic requests that low-level workers upgrade their level of education

Table 4. CurrentCurrent supply of health workers at national level, March 2012

Health professional category/cadre

2008 2012

NumberHealth

workers/1000population

NumberHealth

workers/1000population

PhD (physician) 35 0.01 35 0.01

PhD (pharmacist) - - 3 0

Master (physician) 391 0.07 381 0.06

Master (dentist) - - 31 0

Master (pharmacist) - - 46 0.01

Master (laboratory) - - 8 0

Master (nurse/midwife) - - 13 0

Master (other*) - - 8 0

Specialist 2 (physician) 9 0 20 0

Specialist 1 (physician) 206 0.03 312 0.05

Medical doctor 1169 0.2 1233 0.19

MA (Medical associate, medical assistant) 1496 0.25 1375 0.21

Bachelor/high-level nurse 113 0.02 166 0.03

Technical nurse 738 0.12 1774 0.27

Community midwife 0 0 338 0.05

Midwife 388 0.06 120 0.02

Laboratory (bachelor) 31 0.01 70 0.01

Laboratory assistant 466 0.08 490 0.07

Pharmacist (bachelor) 357 0.06 473 0.1

Pharmacist assistant 586 0.1 667 0.1

Dentist (bachelor) 171 0.03 194 0.03

Dentist assistant 109 0.02 96 0.01

Hygienist 321 0.05 482 0.07

Physiotherapist 272 0.05 284 0.04

X-ray technician 0 0 32 0

Low-level nurse and nurse-midwife 3948 0.66 3629 0.56

Middle-level primary health care worker 0 0 132 0.02

Low-level primary health care worker 244 0.04 320 0.05

Support and logistic staff 963 0.16 1434 0.22

Public health (high) N/A N/A 23 0

Total 12 013 2 14 189 2.17* Non-health profession related masters. Source: Department of Organization and Personnel, Ministry of Health, March 2012.


through continuing education. This explains the decreasing trend in the number of low-level nurses and low-level midwives.

From 2004, the Ministry of Home Affairs (MOHA) officially stopped hiring contractual health staff. However, currently, there are four different kinds of contractual staff in the health sector (see Table 5):

official contractual workers hired before 2003, paid hospital workers, workers paid by donor funds, and volunteers. The central, provincial and district hospitals continue to have a workforce shortage problem, so they continue to hire contractual workers directly. Most of the contractual staff are hoping to become permanent staff.

Table 5. Current supply of contractual health staff, March 2012

Province

Spec

ialis

t 1

Spec

ialis

t 2

Med

ical

doc

tor

Phar

mac

ist

(bac

helo

r)

Den

tist

(bac

helo

r)

Labo

rato

ry (b

ache

lor)

Nur

se (h

igh/

bach

elor

)

Med

ical

ass

ista

nt

Com

mun

ity

mid

wif

e (m

iddl

e)

Tech

nica

l nur

se (m

iddl

e)

Phar

mac

ist

Phar

mac

ist

assi

stan

t

Labo

rato

ry a

ssis

tant

Hyg

ieni

st

Phys

ioth

erap

ist

Prim

ary

heal

th c

are

wor

ker

(low

)

Mid

wif

e (lo

w)

Nur

se (l

ow)

Nur

se-m

idw

ife

(low

)

Supp

ort

and

logi

stic

sta

ff

Tota

l

Attapue - - 2 - - - - - - 48 1 - - - 1 7 - 11 - 13 83

Bokoe - - 4 2 - - - - - 31 1 - - 3 - 2 - 1 - 50 94

Bolikhamsay - - 6 1 2 - - - - 17 13 - 1 4 2 8 - 4 - 13 71

Central level 1 1 88 35 44 3 2 2 1 257 25 - 45 31 35 - 1 4 - 294 869

Champasack - - 7 3 2 - - 2 1 134 10 - 7 3 4 24 4 76 6 63 346

Huaphan - - 4 2 - - 2 5 - 18 5 - - 10 2 - - 13 - 16 77

Khammuane - - 11 5 1 - - - - 133 6 - 4 2 1 15 - 25 36 24 263

Luangnamtha - - - - - - - - - 9 1 - 1 - - - - - - 14 25

Luanprabang - - - 1 - - - - - 2 - - - - - - - 18 - 38 59

Oudomsay - - 1 3 1 - - 6 - 61 6 - 1 6 - - - 10 - 24 119

Phonsaly - - - - - - - - - - - - - - - - - - - 10 10

Saiyabury 1 - 5 8 2 - - 4 - 127 10 - 9 10 2 2 - 16 - 39 235

Salavan - - - - - - - - - 2 - - - - - 21 - 9 - 8 40

Sekong - - 1 - - - - - - 19 4 - 2 - - - - 1 - 16 43

Svannakhet - - 4 5 - - - - 3 173 - 4 2 13 - 17 5 18 - 8 252

Vientiane - - 3 5 - - - - - 49 6 - 2 4 3 - - - - 32 104

Vientiane capital

- - 14 2 4 - - 2 3 20 7 - 9 39 9 - - 3 - 24 136

Xiengkhuang 1 2 16 6 5 - - - 4 42 9 - 6 18 10 3 - 10 - 38 170Total 3 3 166 78 61 3 4 21 12 1142 104 4 89 143 69 99 10 219 42 724 2996Source: Department of Organization and Personnel, Ministry of Health, March 2012.


3. Health workforce distribution

This section looks at the health workforce by gender, age and geographical distribution.

3.1 Gender distribution

There are more women (59%) than men in the health workforce due to a large number of nurses and midwives. In these categories, women are more numerous than men (see Figure 2). Women tend to make up more than half of the personnel among the low- and middle-level workers, including laboratory specialists, pharmacists and dental assistants.

However, in all postgraduate categories, male health workers make up the larger proportion (see Annex A).

3.2 Age distribution

Overall, nurses and midwives are a young workforce, with 45% of them below 30 years of age. Dentists also represent a young group, with those aged 30–39 years making up almost half (46%) of the total number of dentists. The largest share of other categories displayed in Figure 3 (physicians, pharmacists and

0%

10%

20%

30%

40%

50%

60%

>60

50–59

40–49

30–39

<30 Yrs

DentistLaboratoryspecialist

PharmacistNurse/midwifePhysician

8

23

39

28

3 30

2428

45

20

3135

13

14

54

29

10

3

12

46

29

10

2

Figure 3. Health workers by age group and cadre (%), March 2012

Note: Physician: Phd, Master, Specialist 1 and 2 and medical doctors; Nurse/midwife: Master Nurse/midwife, Bachelor Nurse, Technical Nurse and Community Midwife; Pharmacist: Master; Dentist: Master; Laboratory specialist: Master, Bachelor. Source: Department of Organization and Personnel, Ministry of Health, March 2012.

Figure 2. Gender distribution by professional category/cadre (%), March 2012

Note: Physician: PhD, Master, Specialist 1 and 2 and medical doctors; Nurse/midwife: Master Nurse/midwife, Bachelor Nurse, Technical Nurse and Community Midwife; Pharmacist: Master; Dentist: Master; Laboratory specialist: Master, Bachelor. Source: Department of Organization and Personnel, Ministry of Health, March 2012.

0% 10% 20% 30% 40% 50% 60% 70% 80%

% Male

% Female

Nurse/midwife

Pharmacist

Dentist

Physician

Laboratory specialist

2929

465454

4657

4363

37


laboratory specialists) belongs to the 40–49 years age group.

The compulsory retirement age for civil servants in the Lao People’s Democratic Republic is 60 for males and 55 for females. However, there continues to be a number of medical associates and low-level nurses over 60 still employed, as it is very hard to recruit

health workers in rural areas (see Annex B). In fact, some health workers cannot retire even if they want to.

3.3 Geographical distribution

Geographical maldistribution of staff in the Lao People’s Democratic Republic is a problem (see Table 6 and Annex C). Only 22% of medical doctors are based

Table 6. Distribution of health workers by group/cadre and province, March 2012

Health professional group/cadre

Vien

tian

e Ca

pita

l

Phon

saly

Luan

gnam

tha

Oud

omsa

y

Boko

e

Luan

gpra

bang

Hua

phan

Saiy

abur

y

Xien

gkhu

ang

Vien

tian

e

Bolik

ham

sai

Kham

mua

ne

Sava

nnak

het

Sala

van

Seko

ng

Cham

pasa

ck

Att

apue

Tota

l

PhD (physician) 33 – – – – – – – – – – – 1 – – 1 – 35

PhD (pharmacist) 3 – – – – – – – – – – – – – – – – 3

Master (physician) 214 7 5 8 4 21 6 11 20 2 12 7 32 4 5 21 2 381Master (dentist) 28 – – – – – 1 – 1 – – – 1 – – – – 31

Master (pharmacist) 39 – – 1 – 1 – 1 1 1 – – 1 – – 1 – 46

Master (labolatory) 7 – – – – – – – – – – – – – – 1 – 8

Master (nurse/midwife) 11 – – 1 – 1 – – – – – – – – – – – 13

Master (other) 8 – – – – – – – – – – – – – – – – 8

Specialist 2 (physician) 15 – – 1 – – – – – – – – – – – 4 – 20

Specialist 1 (physician) 173 2 7 10 3 11 7 16 8 6 8 12 4 8 5 28 4 312Medical doctor 511 19 32 41 25 34 20 53 37 100 45 55 87 40 23 71 40 1233MA (medical associate, medical assistant) 151 46 27 46 24 176 57 93 23 85 50 73 207 65 32 180 40 1375

Bachelor/Higher nurse 83 1 3 6 2 8 8 3 6 3 1 14 6 4 4 12 2 166Technical nurse 413 59 56 74 66 84 69 72 73 151 59 82 170 83 65 84 114 1774Community midwife 40 7 10 14 12 23 20 22 24 22 21 19 33 17 11 29 14 338Midwife 26 – 6 2 – – – – 3 – 2 24 1 – 1 52 3 120Laboratory (bachelor) 39 1 – 3 1 2 1 2 4 3 1 3 1 2 1 5 1 70Laboratory assistant 148 8 19 14 19 16 19 23 24 34 22 30 33 18 9 38 16 490Pharmacist (bachelor) 167 8 9 18 12 21 14 25 17 12 13 46 30 16 9 37 19 473

Pharmacist assistant 176 18 27 26 23 22 41 27 34 49 28 28 49 24 12 72 11 667Dentist (bachelor) 71 1 8 8 6 7 7 11 8 10 8 8 20 3 4 11 3 194Dentist assistant 23 – 1 4 2 3 1 6 4 12 4 5 15 2 1 12 1 96Hygienist 149 16 24 19 21 16 52 25 43 21 15 14 14 12 14 9 18 482Physiotherapist 125 6 3 5 3 13 12 8 12 11 11 13 21 13 3 21 4 284X-ray technician 15 – 1 3 1 1 1 1 1 – – 6 1 1 – – – 32Low-level nurse and nurse-midwife 217 141 88 183 94 365 152 236 150 271 149 337 541 212 96 326 71 3629

Middle-level primary health care worker 1 7 12 11 1 1 12 13 15 1 3 10 2 3 15 11 14 132

Low-level primary health care worker – 20 43 45 34 43 30 13 24 – 2 2 17 46 – – 1 320

Support and logistic staff 623 40 36 40 24 35 49 51 58 65 51 58 82 51 39 60 72 1434Public health (High) 5 1 2 4 1 – 4 – 1 1 3 – – – – – 1 23

Total 3514 408 419 587 378 904 583 712 591 860 508 846 1369 624 349 1086 451 14 189Source: Department of Organization and Personnel, Ministry of Health, March 2012.


in rural areas. Bachelor- and high-level health workers are centralized in urban areas; only 5% of bachelor/higher nurses, 4% of bachelor laboratory workers, 22% of pharmacists and 28% of dentists work in rural areas.

3.4 Distribution of health workers by urban/rural area

As seen in Figure 4, the majority of highly skilled workers are located in urban areas, while rural

areas have the largest share of low-level nurses and midwives. The vast majority of medical specialists (91%) are based in urban areas, as are similar percentages of bachelor/high-level nurses (93%) and bachelor-level laboratory workers (94%). Only 26% of medical doctors are working in rural areas. Overall, the density of medical doctors, bachelor/high-level nurses, pharmacists and dentists found in rural areas is one-tenth of the density in urban areas (see Annex D).

4. Health professions education

4.1 Structure of health education institution

The Department of Training and Research of the Ministry of Health is primarily responsible for education in the health professions. This department supervises all education and in-service training. Therefore, all health-related educational facilities are under the control of this department (Ministry of Health, 2007).

Until 2007, there were three education providers for health workers: the Faculty of Medical Science, the College of Health Technology and nursing schools. At that time, the Ministry of Education was responsible

for the Faculty of Medical Science of the University of the Lao People’s Democratic Republic, which became part of the National University of the Lao People’s Democratic Republic in 1996. Since 2008, however, the Faculty of Medical Science and the College of Health Technology have been combined under the University of Health Science (UHS) under the Ministry of Health. Therefore, in 2012, there were two education providers for health workers: UHS and nursing schools.

UHS produces seven training programmes: basic science, dentistry, medical technology, medicine, nursing, pharmacy and postgraduate studies. There

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Laboratory (bachelor)

Bachelor/high-level nurse

Medical specialist

Pharmacist

Medical doctor

Dentist

Technical nurse (middle)

Low-level nurse and nurse-midwife

% Rural% Urban

39 61

94 6

67 33

78 22

47 53

93 7

74 26

91 9

Figure 4. Geographical distribution of health workforce (% urban vs. % rural), March 2012

Source: Department of Organization and Personnel, Ministry of Health, March 2012.


are eight provincial nursing schools located in Champasack, Khammuane, Luang Prabang, Oudomsay, Salavane, Savannakhet, Vientiane and Xien Khung. Nursing schools provide nursing and midwifery training programmes.

4.2 Training of health professionals

Specialists (Postgraduate level)There are nine specialty training programmes: anesthesia/intensive and emergency care, cardiology, family medicine, general surgery, internal medicine, medical imaging and radiology, obstetrics and gynaecology, ophthalmology and paediatrics. UHS in Vientiane provides educational preparation for professionals to enter all programmes. Entry requirements include: a graduate degree (bachelor of medicine), under 45 years of age, more than three years of experience, passing an entrance examination and a recommendation. The specialist training programme lasts for three years and graduates receive a postgraduate degree upon completion (specialist 1 or specialist 2).

Medical relatedMedical doctors (bachelor level): Medical doctors are trained at UHS in Vientiane. The training of doctors began in 1968. Only the upper-secondary school graduates who qualify in the entrance examination can begin training. The training course lasts for six years and graduates receive a bachelor’s degree in medicine.

Medical associate (high level): The education of medical associates (high level) is provided at any one of three institutions (Health Science College in Champasack, Luangprabang and Savannakhet provinces) and lasts for three years for direct entry and two years for continuing education. Entry requirements of direct entry are upper-secondary school diploma and passing an entrance examination, and for continuing education, medical assistant level, under 40 years of age and more than three years of experience. Graduates get a high-level diploma.

Medical assistant (middle level): This group is trained at the school of public health in Salavane and Savannakhet provinces, and the course lasts two years for direct entry and 18 months for continuing education. Entry requirements for direct entry are upper-secondary school diploma and passing an entrance examination. For continuing education the entry enrollees can be low-level medical staff,

primary health care workers, upper-secondary school graduates and must pass an entrance examination. Graduates get a middle-level diploma.

Nurse: There are multiple categories of nurses in the Lao People’s Democratic Republic. Auxiliary (low-level) nurses are the largest group and may have been trained anywhere from three months to two years. However, there have been no training courses for auxiliary (low-level) nurses since 2003. The two-year nursing schools have been upgraded to two and a half years of training and their graduates are now considered technical, or middle-level, nurses.

Graduate nurse (bachelor-level nurse): Graduate (bachelor-level) nurses are trained at the Faculty of Nursing at UHS in the Vientiane capital. Applicants for direct entry need to be upper-secondary school graduates and should pass the entrance examination. Training lasts for four years and graduates receive a bachelor’s degree. Applicants for continuing education face more requirements than direct entry. They should be under 45 years of age, with more than three years of experience as a registered nurse. Training for continuing education lasts for two years, including four months for a “bridge” course. All graduates get a bachelor’s degree.

Associate nurse/registered nurse (high-level nurse): Education for associate/registered (high-level) nurses is provided at one of four provincial nursing schools: the Faculty of Nursing at UHS in the Vientiane capital and the College of Health Science in Champasack, Luangprabang and Savannakhet provinces. All applicants are upper-secondary school graduates and should pass the entrance examination. This course lasts for three years and graduates receive a diploma.

Technical nurse (middle-level nurse): Technical (middle-level) nurses are trained at one of eight provincial nursing schools for two and half years: the Faculty of Nursing at UHS in Vientiane capital, College of Health Science in Champasack, Luangprabang and Savannakhet provinces and the Public Health School in Khammuan, Oudomxay and Xiengkhuang provinces, and the Vientiane Nursing School). Entry requirements call for completion of upper-secondary education and passing an entrance examination.

MidwifeGraduate midwife (bachelor-level midwife): Training for graduate (bachelor-level) midwives is provided at the Faculty of Nursing at UHS in Vientiane. Training


lasts four years after upper-secondary school and the successful completion of an entrance examination. Graduates receive a bachelor’s degree.

Registered midwife (high-level midwife): Registered (high-level) midwives are trained at the Faculty of Nursing at UHS in Vientiane. Training for direct entry lasts for three years and continuing education for one and a half years. Entrance requirements of direct entry are upper-secondary graduation and the successful completion of an entrance examination. Technical (middle-level) nurses and community (middle-level) midwives can apply via continuing education. They should be younger than 40 years and have at least three years of experience, with a recommendation. Graduates receive a high-level diploma.

Community midwife (middle-level midwife): Community (middle-level) midwives are trained at one of six provincial schools (College of Health Science in Champasack, Luangprabang and Savannakhet provinces, the Public Health School in Khammuan and Xiengkhuang provinces, and Vientiane Nursing School). Training for direct entry lasts for two years and continuing education for a year. Entry requirements of direct entry include graduation from an upper-secondary school and an entrance examination. Applicants to continuing education must be auxiliary (low-level) nurses, under the age of 40 years, with more than three years of experience and a recommendation.

Dental staffDentist (bachelor-level): Dentists are trained at the Faculty of Dentistry at UHS in Vientiane for six years after upper-secondary school and the completion of the entrance examination. Graduates receive a Bachelor of Dental Surgery degree.

Pharmacy staffPharmacist (bachelor level): Pharmacists are trained at the Faculty of Pharmacy at UHS in Vientiane for five years after upper-secondary school and completion of the entrance examination. Graduates get a bachelor’s degree in pharmacy.

Pharmacy assistant (middle level): The Faculty of Pharmacy at UHS in Vientiane oversees the training of pharmacy assistants. The programme provides training for three years after upper-secondary school and an entrance examination. Graduates get a middle-level diploma.

Laboratory staffLaboratory technician (bachelor level): Laboratory technicians are trained at the Faculty of Medical Technology at UHS in Vientiane for four years for direct entry and two and a half years via continuing education. Entry requirements for direct entry are completion of upper-secondary school and an entrance examination. Requirements for continuing education are a high-level degree in medical laboratory studies for Government employees with at least five years of experience and an entrance examination. Graduates receive a bachelor’s degree in medical laboratory studies.

Laboratory assistant (middle level): Training of laboratory assistants takes place at the Faculty of Medical Technology at UHS in Vientiane for three years after upper-secondary school and an entrance examination. Graduates receive a middle-level diploma.

OthersPhysical therapist (bachelor level): Physical therapists are trained via continuing education at the Faculty of Medical Technology at UHS in Vientiane for two years. High-level physical therapists with at least five years of experience can enter this course. Graduates receive a bachelor’s degree in physical therapy.

Physical therapist (high level): Training via direct entry is offered at the Faculty of Medical Technology at UHS in Vientiane for three years after upper-secondary school and an entrance examination. Graduates receive a high-level degree.

Primary health care workers: The training of primary health care workers began in 2002 in the northern part of the country. There are five schools offering training in Champassak, Oudomxay, Khammuane, Luangprabang and Savannakhet provinces. Primary health care workers are lower-secondary school graduates who train for three years. They are selected from rural and remote locations, with the intention that they will provide services in their home areas. Saravane and Xieng Xhuan provinces also have training centres for primary health care workers. They are assigned to health centres in priority northern provinces. Table 7 provides an overview of the public health professions training institutions. There are no private health professions institutions providing training in the Lao People’s Democratic Republic.


Table 7. Number of training institutions by specialty

PhD 1

Master 1

Specialist 2 1

Specialist 1 1

Medical doctor 1

MA (medical associate, medical assistant)

Associate 3Assistant 2

Bachelor/high-level nurse Bachelor 1high-level 4

Technical nurse 8

Community midwife 6

Midwife (low) 0

Laboratory (bachelor) 1

Laboratory assistant 1

Pharmacist (bachelor) 1

Pharmacy assistant 1

Dentist (bachelor) 1

Dentist assistant 0

Hygienist 1

Physiotherapist 1

X-ray technician 1

Low-level nurse and nurse-midwife 0

Middle-level primary health care worker 5

Low-level primary health care worker 0

Support and logistic staff 0

Public health (high) 1

Total 9


The number of entrants has decreased in recent years (2008–2011) for medical doctors and pharmacists, while it has increased quite remarkably in the case of medical assistants and nurses (see Figure 5).

The popularity of nursing can be also seen in Figure 6, where the same categories are shown in terms of number of graduates per year (2008–2011).

Annexes E and F show the total number of entrants and graduates per category (2008–2011).

4.3 Overall cost of training/education per graduate

The Department of Organization and Personnel at the Ministry of Health estimates the training cost at UHS (medicine, dentistry, nursing, pharmacy, medical technology, basic science and postgraduate studies) at around US$ 1500 per year. Training costs in the eight provincial nursing schools (nursing and midwifery training programmes) are around $1200 per year.

4.4 In-service and continuing professional education

According to the Lao People’s Democratic Republic Law on Health Care—Article 34, In-service Training, all health-care professionals in the Lao People’s Democratic Republic are required to continuously improve their knowledge and skills and take part in training activities and evaluation of their professional practices in order to improve the quality of their consultations, diagnoses and care, and to keep abreast of the latest scientific progress, for the interests and safety of patients. Also, the Medical Profession Council has the right and duty to assess and evaluate in-service training at least once every two years, in accordance with the instructions of the Ministry of Health.

Although the Lao People’s Democratic Republic regulates continuing professional education by law, it has not yet been implemented. However, the Government is developing guidelines and is determined to implement continuing professional education.


5. Human resources for health (HRH) utilization

5.1 Recruitment

Every April and October, an HRH quota is fixed by the Prime Minister’s Cabinet, the Ministry of Home Affairs and the Ministry of Finance (see Table 8). The Division of Personnel at Department of Organization and Personnel then requests that Ministry of Home Affairs allocate a number of health workers and non-medical workers to fill needed positions. After Department of Organization and Personnel receives a number of employees as designated by the quota, Department of Organization and Personnel is responsible for the allocation of this quota at all administrative levels: central, provincial and district, as well as health centres.

However, currently the quotas are not sufficient to address the shortage of health workers and are not even enough to absorb those already trained. An increase of the quotas by the Government would allow the recruitment of the available health workforce into

the system and would help to some extent solve the shortage of the staff in the health sector. There have been positive signs of commitment from Ministry of Home Affairs to increase significantly the quotas in the next few years to meet the needs of service delivery.

All persons eligible for recruitment should meet the following criteria (Prime Minister’s Office, 2003):

Lao nationals or those who have acquired and held Lao citizenship for three or more years; are 18 to 35 years of age; comply with the law and the Decree on civil service; are good citizens with no criminal record and no history of dismissal; submit an accurate description of personal and family details; are physically fit and healthy as certified by state hospitals; have qualification awarded by recognized educational institutions; meet all the criteria required by the workplaces concerned.

1000

900

800

700

600

500

400

300

200

100

02008

624 646

203

17160

150100

2009

Medical doctor Medical assistant Nurse

Midwife Pharmacist

2010 20110

280

669

897

364

160

63

20219212440

Figure 6. Number of graduates per year in health professions education institutions, for selected categories (2008-2011)

Note: “Nurses” comprehends bachelor nurse, technical nurse and higher nurse. “Pharmacists” comprehends pharmacists and pharmacy assistants. Source: Department of Organization and Personnel, Ministry of Health, March 2012.

1400

1200

1000

800

600

400

200

02008

693

638

370290

275

397

318

2009

Medical doctor Medical assistant Nurse

Midwife Pharmacist

2010 2011

086

0

761

1214

666

16912659

464

190114

0

Figure 5. Number of entrants per year in health professions education institutions, for selected categories (2008-2011)

Note: “Nurses” comprises bachelor nurse, technical nurse and high-level nurse. “Pharmacists” comprises pharmacists and pharmacist assistants. Source: Department of Organization and Personnel, Ministry of Health, March 2012.


Table 8. Approved HRH quotas, March 2012

Category 2008 2009 2010 2011 Grand Total

Master 0 3 9 0 15

Specialist 1 18 15 1 4 38

Medical doctor 30 40 47 106 223

MA (medical associate, medical assistant) 12 18 9 28 67

High-level nurse 0 0 0 2 2

Technical nurse 127 152 180 408 867

Laboratory (bachelor) 0 0 1 0 1

Laboratory assistant 18 20 34 48 120

Pharmacist 27 17 31 47 122

Pharmacist assistant 29 37 38 56 160

Dentist 11 15 16 17 59

Dentist assistant 2 0 0 0 2

Hygienist 32 33 41 62 168

Physiotherapist 12 16 17 19 64

Low-level nurse 61 39 42 14 156

Low-level primary health care worker 101 72 16 0 189

Midwife (low) 0 72 15 0 87

Nurse-midwife (low) 48 0 28 54 130

Middle-level primary health care worker 0 0 0 63 63

Support and logistic staff 81 85 104 133 403

Total 612 634 629 1061 2936


5.2 Deployment and distribution policies and mechanisms

The Lao People’s Democratic Republic has a critical shortage and a maldistribution in its health workforce. There are 0.6 qualified health workers (physicians) per 1000 population, according to 2011 Ministry of Health data. The main challenges that contribute to the shortage and maldistribution of health workers in the Lao People’s Democratic Republic are limited posts allocated by the Government to recruit health workers; the preference of health workers to work in urban areas with better salaries; the lack of professional career development opportunities; and graduates with inadequate preparation to work in rural areas, which may be attributable to insufficient training. The shortage of middle- and high-level health workers at primary and secondary health-care facilities leads to a major gap in the quality of health-care services between urban and rural areas.

To solve the above problems and to provide incentives to health workers to work in rural areas

(district and health-centre levels), the Ministry of Health and the Government have developed and endorsed a number of policies, decrees and regulations, starting in 2002:• 2002: The Ministry of Health’s Health Strategy

to the Year 2020 indicated a significant need to provide appropriate incentives for health workers in rural areas.

• 2003: The Civil Service decree No. 82/PM stated that during the first five years, newly recruited health workers should work at least two years in rural areas. However, implementation of this decree has been insufficiently enforced.

• 2010: Financial Incentive decree No. 468/PM was intended to provide salary bonuses of 30%, 40% and 50% of the regular salary to civil servants working in rural areas, including health workers. The implementation has not started due to delays in defining and classification of rural areas.

• 2010: The Ministry of Health’s Health Personnel Development Strategy by 2020 addressed five main areas for improvement: preparation of health personnel, utilization of health personnel, health


personnel management, equity and quality, and incentives for health personnel.

• 2011: The Ministry of Health’s Ministerial Decree No. 103/MOH called for newly graduated medical students to agree to three years of compulsory service in rural health facilities. The decree also indicated the provision of non-financial incentives such as: direct promotions for permanent staff, eli-gibility for continuing education, and eligibility for the licensing examination.

Including the latest decree, a number of policies, decrees and regulations have been endorsed. However, enforcement, implementation, monitoring and evaluation of these policies using updated, accurate HRH databases remain weak. Also, low salaries and low levels of motivation decrease health system efficiency. In rural and remote areas in particular, there is low motivation among health workers and a lack of career development opportunities (Thome and Soulivanh, 2008).

5.3 Unemployment

Even though the Lao People’s Democratic Republic has a shortage of health workers, the country also faces the challenge of providing positions to trained professionals. This is a direct result of small quotas for recruiting health workers due to financial constraints in recent years. Thus, some graduates are not recruited and some of them offer their services as volunteers until they get a position. This period of unemployment may last up to a few years. Except for those positions that the Government no longer offers training (low-level nurses and primary health care workers), almost all of these groups have a large recruitment gap. Therefore, there are high levels of unemployment, especially among technical nurses, laboratory technicians and hygienists.

6. Financing HRH

6.1 Health expenditure

According to the National Health Account 2009–2010, total health expenditure (THE) was 2.5% of GDP, US$ 27.10 per capita (see Table 9). Private health expenditure (PvtHE) as a percentage of THE in 2009–2010 was 59.3%, while out-of-pocket expenditure on health comprised the majority of health spending (46.4% of THE). The general government expenditure on health (GGEH) amounted to 40.7% of THE and 4.1% of the general government expenditure (GGE).

As Table 10 demonstrates, about 32% of health expenditure in the Lao People’s Democratic Republic derives from nongovernmental organizations and donors; this reflects a high dependence on foreign aid and makes the Lao people vulnerable to shifts in aid spending.

Table 11 shows a breakdown of THE by function and indicates that almost 50% is spent on curative services. Fourteen per cent of this amount is spent on inpatient care.

As shown in Table 12, the expenditure for education and training of health personnel makes up only 2.6% of THE.

6.2 Remuneration to health workers

The salary of civil servants, including health workers, is regulated by Prime Minister’s Decree No. 82/PM. The starting salaries of new staff are allotted according to their educational and professional qualifications. An initial proposal for the starting level and step—each level has several steps based on accumulated experience—is made by the selection board at the central, provincial or district level—depending on who is recruiting. This proposal has to be approved by the Department of Organization and Personnel at the Ministry of Health and by the Ministry of Home Affairs. There is a probation period for all new staff, which increases with the level of posting, for instance, three months for low-level, six months for middle-level and 12 months for high-level professionals. A final evaluation is made after this period. Based on this evaluation, a proposal for nomination is made to the Minister of Health by the recruitment committee of the corresponding professional level.

Civil servants in the Lao People’s Democratic Republic are classified by a five-level system (1, 2, 3, 4 and 5), and each level has 15 steps. Table 13 shows the entry levels classification. Table 14 shows the average monthly salary by health profession in the local currency.


Table 9. National Health Account summary results, 2009–2010

Key indicators Kip (in billions)

US$ (in millions)

US$ per capita at average

exchange rate% of

Total health expenditure (THE) 1398.95 169.87 27.1 2.5% GDP Private health expenditure (PvtHE) 829.56 100.74 16.1 59.3% THE

Out-of-pocket expenditure on health 649.10 78.82 12.678.2% PvtHE 46.4% THE

Non-profit institutions serving households (e.g. donors not channelled through Government, nongovernmental organizations)

180 459.05 21.91 3.5

21.8% PvtHE

12.9% THE

General Government Expenditure on Health (GGEH) 569.30 69.13 11.0

4.1% GGE 40.7% THE

1.0% GDP

Ministry of Health expenditure 510.46 61.99 9.9 89.7% GGHE

Social expenditure on health (SSHE) 39.54 4.80 0.8 6.9% GGHE

Domestic government expenditure on health 278.87 33.86 5.4

3.0% Domestic GGE

19.9% THE

0.5% GDP

Domestic government recurrent expenditure on health 244.30 29.67 4.7 4.2% Domestic

recurrent GGE

Domestic government non-wage recurrent expenditure on health 71.03 8.63 1.4 2.9%

Domestic non-wage

recurrent GGE

External resources for health 445.56 54.11 8.6 31.9% THE Source: National Health Account 2009–2010, 2011.

Table 10. Sources of health funds, 2009–2010

Sources of health funds Kip (in billions) % US$

(in millions) US$ per capita

Ministry of Finance 278.87 19.9% 33.86 5.41Other private funds 3.84 0.3% 466.45 0.07Households 670.58 47.9% 81.43 13.01Nongovernmental organizations and donors 445.56 31.9% 54.11 8.64Total 1398.85 100% 169.87 27.14Source: National Health Account 2009–2010, 2011.

Table 11. Functional distribution of health care expenditure, 2009–2010

Function Kip (in billions) % US$ (in millions) US$ per capita

Services of curative care 677.35 48.4% 82.25 13.14 Ancillary services to health care 33.50 2.4% 4.07 0.65 Medical goods dispensed to outpatients (including pharmaceutical products) 306.80 21.9% 37.25 5.95

Prevention & public health services 70.04 5.0% 8.50 1.36 Health administration & health insurance 53.68 3.8% 6.52 1.04 Health-related Functions1 257.49 18.4% 31.27 5.00 Total 1398.85 100% 169.87 27.14 Source: National Health Account 2009–2010, 2011.

1 Health-related functions include: capital formation for health-care provider institutions; education and training for health personnel; research and development in health, food, hygiene and drinking-water control; and environmental health.


Table 12. Expenditure disaggregated by function, 2009–2010

Function Kip (in billions) % US$ (in

millions) US$ per capita

Inpatient curative care 315.16 22.5% 38.27 6.11

Outpatient curative care 315.25 22.5% 38.28 6.12

Clinical laboratory 1.61 0.1% 0.19 0.03

Diagnostic imaging 0.46 0.0% 0.05 0.01

Patient transport and emergency rescue 31.43 2.2% 3.81 0.61

Traditional healers 46.94 3.4% 5.70 0.91

Medical goods dispensed to outpatients 306.79 21.9% 37.25 5.95

Maternal and child health, family planning and counselling 38.95 2.8% 4.73 0.76

School health services 10 0.7% 1.21 0.19

Prevention of communicable diseases 8.85 0.6% 1.08 0.17

Prevention of noncommunicable diseases 9.93 0.7% 1.21 0.19

All other miscellaneous public health services 2.31 0.2% 0.28 0.04

Health administration and health insurance 53.68 3.8% 6.52 1.04

Capital formation of health-care provider institutions 190.64 13.6% 23.15 3.70

Education and training of health personnel 36.25 2.6% 4.40 0.70

Research and development in health 27.52 2.0% 3.34 0.53

Food, hygiene and drinking-water control programme 2.53 0.2% 0.30 0.05

Others 0.55 0.0% 0.068 0.01

Total 1398.85 100% 169.87 27.14

Source: National Health Account 2009–2010, 2011.

Average monthly salaries of other civil servants such as lawyers, teachers or police are also calculated based on their education level. Therefore, for instance, the average monthly salary for both a bachelor-level medical doctor and bachelor-level teacher is 1 165 216 kip (see Table 14).

6.3 Health workers incentives

The Government of the Lao People’s Democratic Republic is trying to implement both financial and non-financial incentive schemes to retain and promote health workers. The Ministry of Health’s consideration

of the incentive system is detailed in the Health Personnel Development Strategy by 2020. The following are financial and non-financial incentives that the Ministry of Health is committed to provide to health workers.

• Improve and implement remuneration of health workers in keeping with the cost of living, socioeconomic development, knowledge and skills, better performance and work achievement.

• Benefits may include higher salary, health insur-ance, pension and other social benefits; gasoline expenses, house rental fee, nursery care fee, trans-

Table 13. Entry level groups classification

No education Level 1Low-level education (e.g. high school) Level 2Mid-level education certificate (minimum three-year course) Level 3 step 3 (3/3)High-level certificate (minimum three-year course) Level 4 step 1 (4/1)Bachelor’s degree certificate Level 4 step 2 (4/2)Intermediate graduate diploma Level 4 step 3 (4/3)Master’s degree or equivalent Level 4 step 5 (4/5)Higher-level graduate diploma (higher than Master’s but not PhD) Level 4 step 6 (4/6)Doctorate (PhD) Level 4 step 7 (4/7)Senior high-ranking staff (e.g. Minister) Level 5



Table 14. Average income by category cadre, March 2012

Professional category Average monthly salary (Kip)

PhD* 1 293 869

Master** 1 257 312

Specialist level 2 1 293 869

Specialist level 1 1 257 312

Medical doctor 1 165 216

MA (medical associate, medical assistant) 896 568

Bachelor/high-level nurse 1 165 216

Technical nurse 896 568

Community midwife 896 568

Midwife 790 435

Laboratory (bachelor) 1 165 216

Laboratory assistant 896 568

Pharmacist (bachelor) 1 165 216

Pharmacist assistant 896 568

Dentist (bachelor) 1 165 216

Dentist assistant 896 568

Hygienist 896 568

Physiotherapist 896 568

X-ray technnician 896 568

Low-level nurse and nurse-midwife 790 435

Middle-level primary health care worker 896 568

Low-level primary health care worker 790 435

Support and logistic staff 896 568

Public health (high) 896 568* Includes physicians and pharmacists. ** Includes physicians, dentists, pharmacists, laboratory specialists, nurses/midwives and other. US$ 1 = 8000 kip


portation fee for home visits; payment for better performance and a budget to promote professional development such as scholarships, loans for educa-tion and others.

• Improve and implement appropriate non-financial incentives for health workers, such as improve-ment of the work environment to ensure it is clean, safe and stable, without violence including sexual violence; improve flexibility of work such as working hours and work leave plans; develop professionals and skills of health workers such as supervision, teaching, accessibility to training and educational leave; improve accessibility to social services such as health services, school, nursery school, housing, and transportation; improve appropriate rewards directed to boost staff’s motivation.

The Ministry of Health prioritizes health workers working in rural and remote areas. The Ministry of

Health developed a Decree on Financial Incentives for Rural Civil Servants. The decree defines remote, isolated and difficult areas; levels of each area; and ways of measuring incentives. Tables 15 and 16 explain more about the Ministry of Health’s incentive plan for health workers working in rural areas.

Even though the Ministry of Health understands the importance of incentives and has developed incentive-related decrees, there has been minimal action. Reasons include low levels of funding for the health sector, low absolute rates of pay, and limited capacity to administer and evaluate targeted incentive schemes. However, more positively, several other projects have been implemented within the Lao People’s Democratic Republic that have incorporated the implementation of incentives for health workers. These movements will expedite implementation.


Table 15. Levels of remote, isolated and difficult areas

Level one Level two Level three

1. Geographic and natural condition

• Mountainous village located more than 50 kms from a city

• Rainfall shortage/natural disaster

• Mountainous village located more than 30 km from a city

• Rainfall shortage

• Mountainous district/village located more than 20 km from a city

• Rainfall shortage

2. Infrastructural condition

• No road access• No post office/telephone• No electricity/water supply• No market

• Poor road access/access by car in only some areas or access only in dry season

• Post office/telephone coverage in only some areas

• No electricity/water• Have simple market

• Improved road access but difficult to access during rainy season

• Have post office/telephone but not convenient

3. Education and health condition

• More than 50% of children not enrolled in school; there is no school or the school is substandard

• Limited access to health service; have only drug kits

• More than 40% of children not enrolled in school; school is below standard

• Only access to health centre with insufficient resources

• More than 30% of children not enrolled in school

• May be able to access district hospital and health centre with insufficient resources

4. Living and environmental condition

• Majority of people rely on natural resources for their livelihood

• Ethnic minority area, difficult in terms of language and communication

• Area vulnerable to disease outbreaks; poor environment at high risk for living and working

• Some people rely on natural resources for their livelihood

• Ethnic minority area, difficult in terms of language and communication in some areas

• Some areas still have outbreaks of infectious diseases, poor environment, and present difficulties for living and working

• Some people rely on natural resources for their livelihood

• Challenging environment for development and living

Source: Financial Incentive decree No. 468/PM, 2010.

Table 16. Incentives for civil servants working in remote, isolated and difficult areas

Level one Level two Level three

1. For rural civil servant

• Receive a salary increase of 50%

• Be a priority candidate for continued study

• Receive appropriate recognition based on performance

• Receive a salary increase of 40%


• Receive appropriate recognition based on performance

• Receive a 30% salary increase• Be priority candidate for

continued study• Receive appropriate

recognition based on performance

2. For civil servants who are temporarily assigned to work in rural areas (less than 12 months)

• Receive a 50% salary increase• Receive additional money for

resettlement (equivalent of two months of salary)


• Receive appropriate admiration based on performance









Source: Financial Incentive decree No. 469/PM, 2010.


7. Governance of HRH

7.1 HRH policies and plans

The latest HRH-related strategy, Health Personnel Development Strategy by 2020, was developed in order to effectively and efficiently train and recruit a sufficient number of qualified health personnel representing all categories of staff, mix of professions, levels of seniority, gender, ethnicity and age groups who could lead, manage and deliver quality health services in different health settings to the entire Lao population. There are five pillars of the strategy: health personnel capacity-building; utilization of health personnel; equity and equality of opportunity; health personnel management; and health personnel incentives. The Health Strategy to the Year 2020 also includes measures to improve HRH; it addresses human resources under a number of different health issues (University of New South Wales, 2011).

7.2 Policy development, planning and managing for HRH

The Department of Organization and Personnel (see Figure 7) and the Ministry of Health develop all policies, laws, decrees, regulations and strategies related to HRH. The Prime Minister’s Office, the National Assembly, health-related nongovernmental organizations and development partners contribute feedback and provide support. The Lao People’s

Democratic Republic’s health system is mainly centralized, so the central Government is responsible for staffing, budget, planning and evaluation of central, provincial, and district health centres.

7.3 Professional regulation

Requirements of health workers are regulated in the Law on Health Care No.139/PM.

First, health workers are required to complete at least a middle-level professional education and possess a diploma from a health professions education institution in the Lao People’s Democratic Republic or in a foreign country recognized by the Ministry of Education and the Ministry of Health of the Lao People’s Democratic Republic.

Second, health workers must obtain authorization from the Ministry of Health to practise, after verification and proposal from the Medical Profession Council.

Third, for physicians and dentists, practitioners must have at least five years of professional experience in health care in public or private hospitals. Medical assistants, dentist assistants, nurses, midwives, and physiotherapists and other medical technicians must

Figure 7. Structure of Department of Organization and Personnel

Department of Training and

Research

Department of Health Personnel

Department of Organization and

Personnel

Adminis-tration

Graduate Studies Division

Under-graduate Studies Division

Research Division

Adminis-tration

Personnel Division

Organiza-tion

DivisionParty Office

Staff Welfare Division

Source: Ministry of Health, 2012.


have at least three years of experience in public or private hospitals.

Fourth, health workers must be in good physical and mental health and possess a certificate indicating they are free of communicable diseases.

Fifth, health workers must show that they have never been disciplined, professionally punished or punished for offences.

Lastly, they must also have Lao nationality and reside in the Lao People’s Democratic Republic, except if otherwise provided by a separate decision.

Currently there is no relicensing requirement. A process is under way to introduce a national exam for a license to practise.

7.4 HRH information

In 2006, the Division of Personnel in the Department of Organization and Personnel, and the Ministry of Health in coordination with the Public Administration and Civil Service Authority (PACSA) began to use an electronic system for monitoring personnel-related information. The Personnel Information Management System (PIMS) was created to standardize the gathering of personnel information from different sectors of the

Government. In addition, the Ministry of Health used PIMS to further classify health personnel according to profession, activity history and qualification for salary increases (Bañez, 2011).

PIMS has the ability to create reports on the following:• predetermined quota per province regarding the

number of needed personnel• salary grade of civil service personnel• classification according to educational attainment• classification according to age• classification according to ethnicity• report of civil service termination• report of additional civil service recruitment and

transfer to other region• report of new recruitment• reports from the central office• retirement• report of civil service per province, district• summary report.

7.5 Health workforce requirements

The Lao People’s Democratic Republic also began projecting HRH requirements based on the services that are being targeted by each different type of health facility nationwide. Table 17 is the result of WHO guidance to support planning of HRH requirements for the Lao People’s Democratic Republic.

Table 17. Projections for health workforce requirements, 2013–2020

CategoriesYear

2013 2014 2015 2016 2017 2018 2019 2020PhD 46 50 54 57 61 65 69 72Master 494 514 534 553 573 593 613 633Specialist level 2 80 102 124 146 168 190 211 233Specialist level 1 435 480 525 570 615 660 705 750Medical doctor 1412 1490 1568 1645 1723 1801 1878 1956Medical assistant/nurse practitioner 1376 1353 1330 1307 1284 1260 1237 1214Bachelor/high-level nurse 188 210 233 255 278 300 323 345Middle-level nurse 2335 2778 3222 3666 4110 4554 4998 5442Low-level nurse 2944 2646 2347 2048 1750 1451 1153 854Community midwife/Midwife 1017 1161 1306 1450 1594 1739 1883 2027Laboratory (bachelor) 104 123 142 161 180 199 218 237Laboratory assistant 469 482 496 509 523 536 550 563Pharmacist (bachelor) 397 406 416 425 434 443 452 461Pharmacist assistant 639 654 669 684 699 715 730 745Dentist (bachelor) 217 227 237 248 258 268 278 288Dentist assistant 148 165 183 200 218 235 252 270Hygienist 417 447 478 508 538 568 599 629Physiotherapist 342 360 378 396 414 433 451 469X-ray technician 88 118 147 176 206 235 265 294Primary health care worker 581 642 704 765 826 887 948 1009Support and logistic staff 1306 1355 1404 1453 1502 1551 1599 1648

Totals 15 035 15 764 16 494 17 223 17 952 18 682 19 411 20 140Source: Department of Organization and Personnel, Ministry of Health, March 2012.


8. Concluding remarks

The shortage and maldistribution of the health workforce in the Lao People’s Democratic Republic, together with the inadequate skills of the health staff, pose serious challenges to achieving the health-related Millennium Development Goals (MDGs). In response to these challenges, Health Strategy to the Year 2020 gives priority to improving employment capacity, increasing deployment of skilled health workers to rural and remote areas, and enhancing the capacity of health professionals through improved education and training in order to achieve the MDGs by 2015.

Recent years have witnessed an increase of graduates in health professions who have not been fully absorbed by the health system and have remained unemployed or working voluntarily. Improving employment capacity is one of the key ways to strengthen the health workforce. On a biannual basis, the Prime Minister’s Cabinet, the Ministry of Home Affairs and the Ministry of Finance fix a quota for new placements of civil servants, including the number of health workers. The Division of Personnel in the Department of Organization and Personnel then receives a number of employees as designated by the quota. The Department is responsible for the allocation of this quota at all administrative levels: central, provincial and district, as well as health centres.

The quota, however, rarely meets the actual need for health workers, and as a result there is a shortage of employed health workers around the country. In addition, there remains qualified but unemployed health workers who do not receive positions under the current quota system. Increasing quotas in order to recruit the available health workforce into the system will help, to some extent, solve the shortage of health staff. But until quotas are increased, the most promising way to increase the health workforce is to develop innovative ways to recruit existing health workers into the system.

The tendency for health workers to prefer urban over rural settings poses a significant challenge to ensure that the health workforce is evenly distributed according to needs and population levels across the country. Likewise, over half of the existing health workers in rural health centres are low-level health workers. To remedy this problem, the capacity of

existing health workers at health centres should be improved and upgraded through accelerated in-service training and ‘bridge’ courses. In addition, more middle- and high-level professionals are needed to serve rural communities. In response, the Health Strategy to the Year 2020 prioritizes staffing of health centres with middle-level/community midwives. Short-term solutions include enhancing service delivery through outreach activities at the community level. For remote villages where the regular outreach from health centres is difficult, posting village health workers is a method piloted to provide health promotion and preventive health services.

The urgent need to scale up the health workforce calls for a more rigorous education system for health professionals in the Lao People’s Democratic Republic. To achieve this, issues related to educational capacity for training health professionals, such as training approaches and methods, faculty development, infrastructure, and teaching resources and materials must be addressed. The Education Development Centre for Health Professionals, which has been established in some provinces, provides an excellent opportunity to update educational approaches and build and strengthen faculty capacity. Besides addressing these key issues related to the development of the health workforce in the country, HRH governance capacities are critically important to the implementation of HRH strategies, including strengthening the capacities of relevant departments in the Ministry of Health.

In addition, financial limitations remain a major obstacle to increasing the quantity and quality of the health workforce. Domestic government expenditure accounts for only 19.9% of total health expenditure, while out-of-pocket spending makes up 46.4% of the total. The heavy reliance on international aid makes long-term planning and employment of health workers tenuous. Moreover, the generally low level of compensation, especially in rural areas, may explain part of the difficulty of attracting and retaining competent health workers. The correlation is clear: low levels of overall financial investment in health directly translate to inadequate human resources for health. An increased financial commitment will serve to improve the competency, reliability and quantity of the health workforce.


References

Bañez R (2011). Improvement of the Personnel Information Management System. City, Publisher.

Central Intelligence Agency (2012). The World Factbook. Washington, DC (https://www.cia.gov/library/publications/the-world-factbook/, accessed on 15 April 2012)

Prime Minister’s Office (2003). Decree on Civil Service of the Lao People’s Democratic Republic. [Civil Service Decree No. 82/PM]. Vientiane Capital, Lao People’s Democratic Republic.

Prime Minister’s Office (2010). Decree on Financial Incentive for Rural Civil Servants [Financial Incentive decree No. 468/PM]. Vientiane Capital, Lao People’s Democratic Republic.

Department of Organization and Personnel (March 2012). Data on Health Workers Stock and Distribution. Vientiane Capital, Ministry of Health, Lao People’s Democratic Republic.

Encyclopaedia Britannica (2013). Laos . City, Publisher (http://global.britannica.com/EBchecked/topic/330219/Laos, accessed on January 2013).

Lao Statistics Bureau (2012). GDP per capita. Vientiane Capital, Lao People’s Democratic Republic (http://www.nsc.gov.la/, accessed on 15 January 2012).

Lao Statistics Bureau (2012). Lao Social Indicator Survey (LSIS) 2011–2012. Vientiane Capital, Lao People’s Democratic Republic.

Ministry of Health (2012). National Health Statistic Report, 2010–2011. Vientiane Capital, Lao People’s Democratic Republic.

Ministry of Health (2011). National Health Account 2009–2010. Vientiane Capital, Lao People’s Democratic Republic.

Ministry of Health (2010). Health Personnel Development Strategy by 2020. Vientiane Capital, Lao People’s Democratic Republic.

Ministry of Health (2007). Human Resources for Health: Analysis of the situation in the Lao People’s Democratic Republic. Vientiane Capital, Lao People’s Democratic Republic.

Somchith A (2009). Infant Mortality and Maternal Mortality in the Lao People’s Democratic Republic [lecture]. Vientiane Capital, Department of Hygiene and Prevention, Ministry of Health, Lao People’s Democratic Republic.

Thome J-M and Soulivanh P (2008). Lao People’s Democratic Republic: Health Financing Reform and Challenges in Expanding the Current Social Protection Schemes. In: UNESCAP, eds. Promoting Sustainable Strategies to Improve Access to Health Care in the Asian and Pacific Region. Bangkok, United Nations Economic and Social Commission for Asia and the Pacific.

United Nations Inter-Agency for Child Mortality Estimation (2012). Child Mortality Estimates. (www.childmortality.org, accessed on 15 January 2012). City.

University of New South Wales (2011). HRH profile of the Lao People’s Democratic Republic. Sydney, UNSW HRH Knowledge Hub.

WHO Western Pacific Regional Office (2011). Western Pacific Country Health Information Profiles: Lao People’s Democratic Republic, 2011 revision. Manila.

World Bank (2012). Data: Lao PDR. Washington, DC (www.databank.worldbank.org, accessed on 14 February 2013).


Annexes

Annex A. Gender distribution by professional category/cadre (%), March 2012

Professional category/cadre Total Female % Female

PhD (physician) 35 10 28.57%

PhD (pharmacist) 3 1 33.33%

Master (physician) 381 133 34.91%

Master (dentist) 31 5 16.13%

Master (pharmacist) 46 13 28.26%

Master (laboratory) 8 2 25.00%

Master (nurse/midwife) 13 9 69.23%

Master (other) 8 3 37.50%

Specialist 2 (physician) 20 2 10.00%

Specialist 1 (physician) 312 112 35.90%Medical doctor 1233 600 48.66%

MA (medical associate, medical assistant) 1375 813 59.13%

Bachelor/high-level nurse 166 139 83.73%

Technical nurse 1774 1302 73.39%

Community midwife 338 285 84.32%

Midwife 120 103 85.83%

Laboratory (bachelor) 70 30 42.86%

Laboratory assistant 490 290 59.18%

Pharmacist (bachelor) 473 254 53.70%

Pharmacist assistant 667 394 59.07%

Dentist (bachelor) 194 89 45.88%

Dentist assistant 96 53 52.21%

Hygienist 482 254 52.70%

Physiotherapist 284 176 61.97%

X-ray technician 32 6 18.75%

Low-level nurse and nurse-midwife 3629 2450 67.51%

Middle-level primary health care worker 132 45 34.09%

Low-level primary health care worker 320 116 36.25%

Support and logistic staff 1434 694 48.40%

Public health (high) 23 3 13.04%

TOTAL 14 189 8385 59.10%Source: Department of Organization and Personnel, Ministry of Health, March 2012.


Annex B. Health workers by age group and cadre, March 2012

Professional category/cadre <30 30–39 40–49 50–59 >60 Total

PhD (physician) 0 3 10 18 4 35

PhD (pharmacist) 0 1 0 1 1 3

Master (physician) 3 65 143 161 9 381

Master (dentist) 0 11 10 8 2 31

Master (pharmaciat) 1 13 20 11 1 46

Master (laboratory) 0 2 2 3 1 8

Master (nurse/midwife) 0 2 8 2 1 13

Master (other) 0 1 4 3 0 8

Specialist 2 (physician) 0 0 2 13 5 20

Specialist 1 (physician) 7 98 111 77 19 312Medical doctor 146 288 497 281 21 1233

MA (medical associate, medical assistant) 94 156 766 321 38 1375

Bachelor/high-level nurse 9 51 94 11 1 166

Technical nurse 979 425 321 46 3 1774

Community midwife 42 171 120 5 0 338

Midwife 13 65 34 8 0 120

Laboratory (bachelor) 3 21 40 5 1 70

Laboratory assistant 117 143 178 48 4 490

Pharmacist (bachelor) 102 148 163 56 4 473

Pharmacist assistant 174 199 224 66 4 667

Dentist (bachelor) 28 94 55 15 3 195

Dentist assistant 1 5 63 25 1 95

Hygienist 178 175 111 17 1 482

Physiotherapist 53 73 134 22 2 284

X-ray technician 8 19 2 3 32

Low-level nurse and nurse-midwife 212 1041 1735 590 51 3629

Middle-level primary health care worker 87 43 2 0 0 132

Low-level primary health care worker 216 99 5 0 0 320

Support and logistic staff 334 471 388 208 33 1434

Public health (high) 0 3 16 4 0 23

TOTAL 2799 3875 5275 2027 213 14 189Source: Department of Organization and Personnel, Ministry of Health, March 2012.


Annex C. Density of health workers by category and province (per 1000 population)

Professional category/cadre

Vien

tiane

Cap

ital

Phon

saly

Luan

gnam

tha

Oud

omsa

y

Boko

e

Luan

gpra

bang

Hua

phan

Saiy

abur

y

Xien

gkhu

ang

Vien

tiane

Bolik

ham

sai

Kham

mua

ne

Sava

nnak

het

Sala

van

Seko

ng

Cham

pasa

ck

Atta

pue

Tota

l

1 PhD (physician) 0.04 - - - - - - - - - - - 0.00 - - 0.00 - 0.01

2 PhD (pharmacist) 0.00 - - - - - - - - - - - - - - - - 0.00

3 Master (physician) 0.25 0.04 0.03 0.03 0.02 0.05 0.02 0.03 0.08 0.00 0.04 0.02 0.03 0.01 0.05 0.03 0.01 0.06

4 Master (dentist) 0.03 - - - - - 0.00 - 0.00 - - - 0.00 - - - - 0.00

5 Master (pharmaciat) 0.05 - - 0.00 - 0.00 - 0.00 0.00 0.00 - - 0.00 - - 0.00 - 0.01

6 Master (labolatory) 0.01 - - - - - - - - - - - - - - 0.00 - 0.00

7 Master (nurse/midwife) 0.01 - - 0.00 - 0.00 - - - - - - - - - - - 0.00

8 Master (other) 0.01 - - - - - - - - - - - - - - - - 0.00

9 Specialist 2 (physician) 0.02 - - 0.00 - - - - - - - - - - - 0.01 - 0.00

10 Specialist 1 (physician) 0.20 0.01 0.04 0.03 0.02 0.02 0.02 0.04 0.03 0.01 0.03 0.03 0.00 0.02 0.05 0.04 0.03 0.05

11 Medical Doctor 0.60 0.11 0.19 0.13 0.14 0.08 0.06 0.14 0.14 0.21 0.16 0.14 0.09 0.10 0.21 0.10 0.29 0.19

12 MA (medical associate, medical assistant) 0.18 0.26 0.16 0.15 0.14 0.40 0.18 0.25 0.09 0.17 0.18 0.19 0.22 0.17 0.30 0.26 0.29 0.21

13 Bachelor/high-level nurse 0.10 0.01 0.02 0.02 0.01 0.02 0.03 0.01 0.02 0.01 0.00 0.04 0.01 0.01 0.04 0.02 0.01 0.03

14 Technical nurse 0.49 0.33 0.32 0.24 0.38 0.19 0.22 0.19 0.27 0.31 0.21 0.21 0.18 0.22 0.61 0.12 0.84 0.27

15 Community midwife 0.05 0.04 0.06 0.04 0.07 0.05 0.06 0.06 0.09 0.05 0.08 0.05 0.03 0.04 0.10 0.04 0.10 0.05

16 Midwife 0.03 - 0.03 0.01 - - - - 0.01 - 0.01 0.06 0.00 - 0.01 0.07 0.02 0.02

17 Laboratory (bachelor) 0.05 0.01 - 0.01 0.01 0.00 0.00 0.01 0.02 0.01 0.00 0.01 0.00 0.01 0.01 0.01 0.01 0.01

18 Laboratory assistant 0.17 0.05 0.11 0.04 0.11 0.04 0.06 0.06 0.09 0.07 0.08 0.08 0.03 0.05 0.08 0.05 0.12 0.08

19 Pharmacist (bachelor) 0.20 0.05 0.05 0.06 0.07 0.05 0.05 0.07 0.06 0.02 0.05 0.12 0.03 0.04 0.08 0.05 0.14 0.07

20 Pharmacist assistant 0.21 0.10 0.16 0.08 0.13 0.05 0.13 0.07 0.13 0.10 0.10 0.07 0.05 0.06 0.11 0.10 0.08 0.10

21 Dentist (bachelor) 0.08 0.01 0.05 0.03 0.03 0.02 0.02 0.03 0.03 0.02 0.03 0.02 0.02 0.01 0.04 0.02 0.02 0.03

22 Dentist assistant 0.03 - 0.01 0.01 0.01 0.01 0.00 0.02 0.02 0.02 0.01 0.01 0.02 0.01 0.01 0.02 0.01 0.01

23 Hygienist 0.18 0.09 0.14 0.06 0.12 0.04 0.17 0.07 0.16 0.04 0.05 0.04 0.01 0.03 0.13 0.01 0.13 0.07

24 Physiotherapist 0.15 0.03 0.02 0.02 0.02 0.03 0.04 0.02 0.05 0.02 0.04 0.03 0.02 0.03 0.03 0.03 0.03 0.04

25 X-ray technician 0.02 - 0.01 0.01 0.01 0.00 0.00 0.00 0.00 - - 0.02 0.00 0.00 - - - 0.00

26 Low-level nurse and nurse-midwife 0.26 0.79 0.51 0.58 0.54 0.82 0.49 0.63 0.56 0.56 0.54 0.86 0.56 0.55 0.89 0.47 0.52 0.56

27 Middle-level PHC workers 0.00 0.04 0.07 0.04 0.01 0.00 0.04 0.03 0.06 0.00 0.01 0.03 0.00 0.01 0.14 0.02 0.10 0.02

28 Low-level PHC workers - 0.11 0.25 0.14 0.20 0.10 0.10 0.03 0.09 - 0.01 0.01 0.02 0.12 - - 0.01 0.05

29 Support and logistic staff 0.74 0.23 0.21 0.13 0.14 0.08 0.16 0.14 0.22 0.13 0.18 0.15 0.09 0.13 0.36 0.09 0.53 0.22

30 Public health (high) 0.01 0.01 0.01 0.01 0.01 - 0.01 - 0.00 0.00 0.01 - - - - - 0.01 0.00

Total 4.150 2.300 2.431 1.871 2.181 2.041 1.878 1.887 2.221 1.763 1.830 2.148 1.424 1.623 3.252 1.554 3.316 2.17Source: Department of Organization and Personnel, Ministry of Health, March 2012.


Annex D. Distribution of health workers by urban/rural area

Professional category/cadre Total number % Urban % Rural

Health workers/

1000 Popu-lation in

urban areas

Health workers/

1000 Popu-lation in

rural areas

PhD (physician) 35 100.00% 0.00% 0.02 0.00

PhD (pharmacist) 3 100.00% 0.00% 0.00 0.00

Master (physician) 487 92.81% 7.19% 0.28 0.01

Master (dentist) 381 91.34% 8.66% 0.22 0.01

Master (pharmacist) 31 96.77% 3.23% 0.02 0.00

Master (laboratory) 46 97.83% 2.17% 0.03 0.00

Master (nurse/midwife) 8 100.00% 0.00% 0.00 0.00

Master (other) 13 100.00% 0.00% 0.01 0.00

Specialist 2 (physician) 8 100.00% 0.00% 0.00 0.00

Specialist 1 (physician) 312 90.71% 9.29% 0.18 0.01Medical doctor 1233 74.05% 25.95% 0.57 0.06MA (medical associate, medical assistant) 1375 54.33% 45.67% 0.47 0.12Bachelor/high-level nurse 166 93.37% 6.63% 0.10 0.00Technical nurse 1774 46.73% 53.27% 0.52 0.18Community midwife 338 16.86% 83.14% 0.04 0.05Midwife 120 25.83% 74.17% 0.02 0.02Laboratory (bachelor) 70 94.29% 5.71% 0.04 0.00Laboratory assistant 490 54.69% 45.31% 0.17 0.04Pharmacist (bachelor) 473 77.59% 22.41% 0.23 0.02Pharmacist assistant 667 51.42% 45.58% 0.21 0.06Dentist (bachelor) 194 67.01% 32.99% 0.08 0.01Dentist assistant 96 51.04% 48.96% 0.03 0.01Hygienist 482 52.28% 47.72% 0.16 0.04Physiotherapist 284 73.94% 26.06% 0.13 0.01X-ray technician 32 90.63% 9.38% 0.02 0.00Low-level nurse and nurse-midwife 3629 39.27% 60.73% 0.89 0.42Middle-level primary health care workers 132 13.64% 86.36% 0.01 0.02Low-level primary health care workers 320 14.69% 85.31% 0.03 0.05Support and logistic staff 1434 76.36% 23.64% 0.68 0.06Public health (high) 23 56.52% 43.48% 0.01 0.00

TOTAL 14 189 55.23% 44.77% 4.88 1.22Note: ‘Urban’ includes the capital of each district. ‘Rural’ includes all the places that are not considered urban under that definition. Population: Estimated population from Population Census 2005.Source: Department of Organization and Personnel, Ministry of Health, March 2012.


Annex E. Number of entrants by year, 2008–2011

Professional category/cadreNumber of entrants

2008 2009 2010 2011

PhD 10 3 0 2

Master 22 19 37 41

Specialist 2 0 0 0 0

Specialist 1 167 156 162 171

Medical doctor 397 290 114 169

MA (medical associate, medical assistant) 86 370 464 666

Bachelor nurse 24 32 35 130

High-level nurse 117 115 284 321

Technical nurse 552 491 442 763

Low-level nurse 0 0 0 0

Community midwife 24 92 101 247

Midwife 0 0 0 59

Laboratory technician 22 23 21 16

Laboratory assistant 141 137 145 130

Pharmacist 185 140 64 78

Pharmacist assistant 133 135 126 48

Dentist 124 126 72 53

Dentist assistant 0 0 0 0

Hygienist 143 132 168 159

Physiotherapist 98 35 76 188


Primary health care worker (low and middle level) 29 (low) 118 125 164

Primary health care worker (high level) 0 352 339 502

Support and logistic staff 0 0 0 0

Total 2263 2780 2775 3934Source: Department of Organization and Personnel, Ministry of Health, March 2012.


Annex F. Number of graduates by year, 2008–2011

Professional category/cadreNumber of graduates

2008 2009 2010 2011

PhD 3 0 0 0

Master 22 19 18 24



Medical doctor 100 171 202 160

MA (medical associates, medical assistant) 28 60 124 160

Bachelor nurse 24 32 35 130

High-level nurse 0 0 0 30

Technical nurse 600 614 634 737

Low-level nurse 0 0 0 0

Community midwife 0 0 140 167

Midwife 0 0 40 63

Laboratory technician 19 21 26 24

Laboratory assistant 124 140 137 144

Pharmacist 29 77 52 237

Pharmacist assistant 121 126 130 127

Dentist 45 15 56 37

Dentist assistant 0 0 0 0

Hygienist 141 127 124 226

Physiotherapist 81 34 67 76


Primary health care worker (low level) 156 29 0 0

Primary health care worker (middle level) 0 29 180 154

Support and logistic staff 0 0 0 0

Total 1548 1564 2032 2589Source: Department of Organization and Personnel, Ministry of Health, March 2012.

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