This document has a restricted distribution and may …documents.worldbank.org/curated/en/298581584324067365/...HIV Human Immunodeficiency Virus HNP Health, Nutrition, and Population

FOR OFFICIAL USE ONLY

Report No: PAD3533

INTERNATIONAL DEVELOPMENT ASSOCIATION

PROJECT APPRAISAL DOCUMENT

ON A

PROPOSED CREDIT

IN THE AMOUNT OF SDR 16.8 MILLION (US$23 MILLION EQUIVALENT)

AND

PROPOSED GRANT

IN THE AMOUNT OF

US$3 MILLION FROM THE INTEGRATING DONOR FUNDED HEALTH PROGRAMS MULTI DONOR TRUST FUND

TO THE

LAO PEOPLE’S DEMOCRATIC REPUBLIC

FOR A

HEALTH AND NUTRITION SERVICES ACCESS PROJECT February 20, 2020

Health, Nutrition and Population Global Practice East Asia and Pacific Region

This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

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The World Bank Health and Nutrition Services Access Project (P166165)

CURRENCY EQUIVALENTS

(Exchange Rate Effective January 31, 2020)

Currency Unit = Lao Kip (LAK)

LAK 8,884.94 = US$1

US$ 1.3770= SDR 1

FISCAL YEAR

January 1 – December 31

Regional Vice President: Victoria Kwakwa

Acting Country Director: Gevorg Sargsyan

Regional Director: Daniel Dulitzky

Acting Practice Manager: Daniel Dulitzky

Task Team Leader(s): Somil Nagpal


ABBREVIATIONS AND ACRONYMS

ADB Asian Development Bank

AF Additional Financing

ANC Antenatal Care

ART Antiretroviral Therapy

CCM Country Coordination Mechanism

CPF Country Partnership Framework

CRI Corporate Results Indicator

CSO Civil Society Organization

DA Designated Account

DALY Disability‐Adjusted Life Year

DCDC Department of Communicable Disease Control

DFAT Department of Foreign Affairs and Trade, Government of Australia

DHHP Department of Hygiene and Health Promotion

DHIS2 District Health Information System version 2

DHO District Health Office

DHPE Department of Health Professional Education

DHR Department of Health Care and Rehabilitation

DLI Disbursement‐linked Indicator

DOF Department of Finance

DPC Department of Planning and Cooperation

DPT Diphtheria, Pertussis, and Tetanus

DPT‐HepB‐Hib Diphtheria, Pertussis, and Tetanus, Hepatitis B, and Hemophilus Influenzae Vaccine

ECE Early Childhood Education

ECOP Environmental Code of Practice

EEP Eligible Expenditure Program

EGDF Ethnic Group Development Framework

EHSP Essential Health Service Package

EPI Expanded Program for Immunization

EMF Environmental Management Framework

FDD Food and Drug Department

FM Financial Management

FMM Financial Management Manual

FSW Female Sex Worker

Gavi Gavi‐ the Vaccine Alliance (formerly the Global Alliance for Vaccines and Immunization)

GDP Gross Domestic Product

GF Global Fund

GGE General Government Expenditure

GGHE General Government Health Expenditure

GOL Government of Lao PDR

GRS Grievance Redressal Service


HANSA Health and Nutrition Services Access Project

HCWM Health Care Waste Management

HGNDP Health Governance and Nutrition Development Project

HIV Human Immunodeficiency Virus

HNP Health, Nutrition, and Population

HSDP Health Sector Development Plan

HSRS Health Sector Reform Strategy

IAI Independent Academic Institution

IDFHP Integrating Donor‐Financed Health Programs

IEC Information, Education, and Communication

IUFR Interim Unaudited Financial Report

IPC Infection Prevention and Control

IPD Inpatient Department

IPF Investment Project Financing

JICA Japan International Cooperation Agency

KAP Knowledge, Attitude, and Practices

LDC Least Developed Country

LiST Lives Saved Tool

LMIC Lower Middle‐Income Country

LSIS Lao Social Indicators Survey

M&E Monitoring and Evaluation

MCH Maternal and Child Health

MDG Millennium Development Goal

MDR Multi Drug‐Resistant

MDTF Multi‐Donor Trust Fund

MIS Management Information System

MOF Ministry of Finance

MOH Ministry of Health

MPA Multiphase Programmatic Approach

MPI Ministry of Planning and Investment

MR Measles and Rubella

MSM Men Having Sex with Men

NA National Assembly

NERI National Economic Research Institution

NHI National Health Insurance

NHIB National Health Insurance Bureau

NNC National Nutrition Center

NNSAP National Nutrition Strategy and Plan of Action

NPCO National Program Coordination Office

OOP Out‐of‐Pocket

OPD Out‐Patient Department

PDO Project Development Objective

PFM Public Financial Management

PHO Provincial Health Office


PHRD Policy and Human Resource Development

PLHIV People Living With HIV/AIDS

PMU Project Management Unit

PNC Postnatal Care

PPSD Project Procurement Strategy for Development

PRF Poverty Reduction Fund

QHC Quality of Health Care

QPS Quality and Performance Scorecard

RMNCAH Reproductive, Maternal, Neonatal, Child, and Adolescent Health

SAO State Audit Organization

SARA Service Availability and Readiness Assessment

SBCC Social and Behavioral Change Communication

SCD Systematic Country Diagnostic

SDG Sustainable Development Goal

SHGs Self Help Groups

SOP Standard Operating Procedure

STEP Systematic Tracking of Exchanges in Procurement

STI Sexually Transmitted Infection

TA Technical Assistance

TB Tuberculosis

TOR Terms of Reference

UFGE Umbrella Facility for Gender Equality

UHC Universal Health Coverage

UN United Nations

UNAIDS United Nations Programme on HIV and AIDS

UNFPA United Nations Population Fund

UNICEF United Nations Children's Fund

WASH Water, Sanitation, and Hygiene

WFP World Food Programme

WHO World Health Organization


TABLE OF CONTENTS

DATASHEET ............................................................................................................................. 1

I. STRATEGIC CONTEXT ........................................................................................................ 8

A. Country Context ................................................................................................................................ 8

B. Sectoral and Institutional Context .................................................................................................... 9

C. Relevance to Higher Level Objectives ............................................................................................. 20

II. PROJECT DESCRIPTION ................................................................................................... 23

A. Project Development Objective ..................................................................................................... 23

B. Project Components ....................................................................................................................... 24

C. Project Beneficiaries ....................................................................................................................... 32

D. Results Chain .................................................................................................................................. 32

E. Rationale for Bank Involvement and Role of Partners ................................................................... 32

F. Lessons Learned and Reflected in the Project Design .................................................................... 34

III. IMPLEMENTATION ARRANGEMENTS .............................................................................. 35

A. Institutional and Implementation Arrangements .......................................................................... 35

B. Results Monitoring and Evaluation Arrangements ......................................................................... 37

C. Sustainability ................................................................................................................................... 38

IV. PROJECT APPRAISAL SUMMARY ..................................................................................... 38

A. Technical, Economic, and Financial Analysis ............................................................................... 38

B. Fiduciary ...................................................................................................................................... 40

C. Safeguards ...................................................................................................................................... 43

D. Gender ............................................................................................................................................ 46

C. KEY RISKS ....................................................................................................................... 48

VI. RESULTS FRAMEWORK AND MONITORING ..................................................................... 50

ANNEX 1: Implementation Arrangements and Support Plan .................................................. 89

ANNEX 2: Disbursement Linked Indicators under the project .............................................. 111

ANNEX 3: Country Portfolio Results Chain for an Integrated Approach to Tackling Childhood Stunting ............................................................................................................................... 126

ANNEX 4: Monitoring and Evaluation Framework for the Nutrition convergence approach 134

ANNEX 5: Framework for the Design of a Common Nutrition Social Behavioral Change and Communication Strategy for the Overall World Bank‐Financed Nutrition Convergence Approach ............................................................................................................................. 144

ANNEX 6: Economic and Financial Analysis .......................................................................... 149


Page 1 of 156

DATASHEET

BASIC INFORMATION BASIC INFO TABLE

Country(ies) Project Name

Lao People's Democratic Republic

Health and Nutrition Services Access Project

Project ID Financing Instrument Environmental Assessment Category

P166165 Investment Project Financing

B‐Partial Assessment

Financing & Implementation Modalities

[ ] Multiphase Programmatic Approach (MPA) [✓] Contingent Emergency Response Component (CERC)

[ ] Series of Projects (SOP) [ ] Fragile State(s)

[✓] Disbursement‐linked Indicators (DLIs) [ ] Small State(s)

[ ] Financial Intermediaries (FI) [ ] Fragile within a non‐fragile Country

[ ] Project‐Based Guarantee [ ] Conflict

[ ] Deferred Drawdown [ ] Responding to Natural or Man‐made Disaster

[ ] Alternate Procurement Arrangements (APA)

Expected Approval Date Expected Closing Date

12‐Mar‐2020 31‐Dec‐2025

Bank/IFC Collaboration

No

Proposed Development Objective(s) To improve access to quality health and nutrition services in targeted areas of Lao PDR. Components Component Name Cost (US$, millions)

Component 1: Integrating Service Delivery Performance with National Health Insurance Payments

12.20


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Component 2: Service Delivery and Nutrition Convergence 17.80

Component 3: Adaptive Learning and Project Management 6.00

Component 4: Contingent Emergency Response 0.00

Organizations Borrower: Lao People's Democratic Republic

Implementing Agency: Ministry of Health

PROJECT FINANCING DATA (US$, Millions)

SUMMARY‐NewFin1

Total Project Cost 36.00

Total Financing 36.00

of which IBRD/IDA 23.00

Financing Gap 0.00

DETAILS‐NewFinEnh1

World Bank Group Financing

International Development Association (IDA) 23.00

IDA Credit 23.00

Non‐World Bank Group Financing

Trust Funds 3.00

Freestanding Tfs ‐ Health, Nutrition & Population GP 3.00

Other Sources 10.00

The Global Fund to Fight AIDS, Tuberculosis & Malaria 10.00

IDA Resources (in US$, Millions)

Credit Amount Grant Amount Guarantee Amount Total Amount

Lao People's Democratic Republic

23.00 0.00 0.00 23.00


Page 3 of 156

National PBA 23.00 0.00 0.00 23.00

Total 23.00 0.00 0.00 23.00

Expected Disbursements (in US$, Millions)

WB Fiscal Year 2020 2021 2022 2023 2024 2025 2026

Annual 0.00 1.20 1.61 3.56 5.30 7.13 4.20

Cumulative 0.00 1.20 2.80 6.36 11.67 18.80 23.00

INSTITUTIONAL DATA

Practice Area (Lead) Contributing Practice Areas

Health, Nutrition & Population Digital Development, Gender, Governance, Social Protection & Jobs

Climate Change and Disaster Screening

This operation has been screened for short and long‐term climate change and disaster risks

SYSTEMATIC OPERATIONS RISK‐RATING TOOL (SORT)

Risk Category Rating

1. Political and Governance Substantial

2. Macroeconomic Substantial

3. Sector Strategies and Policies Substantial

4. Technical Design of Project or Program High

5. Institutional Capacity for Implementation and Sustainability High

6. Fiduciary Substantial

7. Environment and Social Moderate

8. Stakeholders Substantial

9. Other

10. Overall Substantial


Page 4 of 156

COMPLIANCE

Policy Does the project depart from the CPF in content or in other significant respects?

[ ] Yes [✓] No

Does the project require any waivers of Bank policies?

[ ] Yes [✓] No

Safeguard Policies Triggered by the Project Yes No

Environmental Assessment OP/BP 4.01 ✔ Performance Standards for Private Sector Activities OP/BP 4.03 ✔

Natural Habitats OP/BP 4.04 ✔

Forests OP/BP 4.36 ✔

Pest Management OP 4.09 ✔

Physical Cultural Resources OP/BP 4.11 ✔

Indigenous Peoples OP/BP 4.10 ✔ Involuntary Resettlement OP/BP 4.12 ✔

Safety of Dams OP/BP 4.37 ✔

Projects on International Waterways OP/BP 7.50 ✔

Projects in Disputed Areas OP/BP 7.60 ✔

Legal Covenants

Sections and Description Institutional Arrangements Financing Agreement: Schedule 2, Section I.A Recurrent, Continuous The Recipient shall maintain, throughout the Project implementation period, the National Program Coordination Office (NPCO), Provincial Health Offices (PHO), District Health Offices (DHO), and Quality of Health Care (QHC) Committee all with composition, functions, staffing and resources satisfactory to the Association and set out in the Project Operational Manual.


Page 5 of 156

Sections and Description Project Operations Manual Financing Agreement: Schedule 2, Section I.B Recurrent, Continuous The Recipient shall ensure that the Project is carried out in accordance with the Project Operations Manual, and not amend, waive or abrogate any provisions of the manual unless the Association agrees otherwise in writing. Sections and Description Annual Work Plans and Budgets Financing Agreement: Schedule 2, Section I.C Recurrent, Annual: November 30, Annually The Recipient shall prepare and furnish to the Association for its no‐objection no later than November 30 of each fiscal year an annual work plan and budget during the implementation of the Project containing relevant Project activities and expenditures proposed to be included in the Project in the following fiscal year, including a specification of the sources of financing. Sections and Description DLI Monitoring and Reporting Financing Agreement: Schedule 2, Section I.D Recurrent, Continuous/ Due date: September 1 annually The Recipient shall: (i) maintain a DLI Verification Agency to carry out independent verification of the status of achievement of DLI Targets; and (ii) furnish reports to the Association on the status of achievement of the relevant DLI Targets no later than September 1 of each year. Sections and Description Memoranda of Understanding Financing Agreement: Schedule 2, Section I.E Recurrent, Continuous The Recipient shall make part of the proceeds of the Financing allocated to Eligible Expenditure Programs available to MOH Technical Departments, and Targeted Areas as represented by its provincial government; for the purposes of carrying out of Part 2 of the Project. Sections and Description


Page 6 of 156

Performance‐based Transfers Financing Agreement: Schedule 2, Section I.F The Recipient shall make part of the Financing proceeds available to eligible PHOs, DHOs or health centers in accordance with the guidelines, procedures and criteria set forth in the Project Operations Manual and the additional terms and conditions acceptable to the Association. Sections and Description Safeguards Financing Agreement: Schedule 2, Section I.G Recurrent, Continuous The Recipient shall ensure that the Project is carried out in accordance with the provisions of the Safeguards Instruments and the site‐specific safeguard plans, not amend, abrogate, repeal, suspend or waive any of their provisions unless the Association agrees otherwise, and report on their status of implementation as part of the project reports. Sections and Description Contingent Emergency Response Financing Agreement: Schedule 2, Section I.H In case of an Eligible Crisis or Emergency The Recipient shall adopt a satisfactory Emergency Response Manual for Part 4 of the Project and, in the event of an eligible crisis or emergency, ensure that the activities under said part are carried out in accordance with such manual and all relevant safeguard requirements. Sections and Description Mid‐term Review Financing Agreement: Schedule 2, Section II.B Once, 24 months after the Effective Date The Recipient shall prepare and furnish to the Association a mid‐term report in form and substance satisfactory to the Association. Sections and Description Co‐financing Deadline Financing Agreement – Article IV Deadline: By January 31, 2021 The Co‐financing Deadline for the effectiveness of the Co‐financing Agreement is January 31, 2021. Conditions


Page 7 of 156

Type Description

Effectiveness Financing Agreement: Article IV

(i) The Grant Agreement has been executed and delivered and all conditions precedent

to its effectiveness have been fulfilled; and

(ii) The Project Operations Manual, including the Emergency Response Manual, has been

duly adopted by the Recipient.

Type Description

Disbursement Financing Agreement: Schedule 2, Section III.B

(i) The Recipient may not withdraw the proceeds of the Financing as may be allocated to

Part 4 unless an Eligible Crisis or Emergency has occurred, all related safeguards instruments

and requirements have been completed, the emergency response implementing entities

have adequate staff and resources, and the Recipient has adopted the Emergency Response

Manual, acceptable to the Association.

(ii) The Recipient may not withdraw the proceeds of the Financing as allocated for

Eligible Expenditure Programs, unless and until the Recipient has: (i) furnished evidence

satisfactory to the Association that the Recipient has achieved the respective DLI Targets;

and (ii) complied with the Disbursement and Financial Information Letter, including furnished

to the Association the applicable interim unaudited financial reports documenting the

incurrence of Eligible Expenditure Programs during the respective DLI period up.


Page 8 of 156

I. STRATEGIC CONTEXT

A. Country Context

The Lao People’s Democratic Republic (Lao PDR) has experienced rapid economic growth over

the past decade, though this has not translated into proportional gains in poverty reduction. The growth

has not been particularly inclusive and was driven largely by megaprojects in the natural resource sector,

which has created limited employment opportunities. A landlocked country of 6.9 million, its gross

domestic product (GDP) grew over 7 percent per year over the past decade while the growth has

moderated in recent years, declining from 6.3 percent in 2018 to a historical low of 5.2 percent in 2019,

owing mainly to natural disasters (floods, droughts, a caterpillar infestation) which affected the

agricultural sector. The fiscal deficit increased to nearly 5 percent of GDP in 2019 from 4.7 percent of GDP

in 2018. Revenue mobilization remains a challenge due to partial policy implementation and weak tax

administration. The revenue to GDP ratio has declined from 16.2 percent in 2018 to 14.8 percent in 2019.

The rising fiscal deficit has resulted in growing public debt, estimated at almost 60 percent of GDP in 2019,

up from 57.2 percent of GDP in 2018. The risk of debt distress remains high.

The economic outlook is subject to downside risks. Growth is expected to rebound to 5.8 percent

on average during 2020–2021. Revenue mobilization is expected to bring down the fiscal deficit to 4.5

percent of GDP by 2021, with a debt‐to‐GDP ratio of 58.3 percent in the same year. Trade tensions could

dampen growth in Lao PDR’s major trading partners, spilling over to the domestic economy through lower

trade and investment and lower prices for export commodities. Domestic risks also include low levels of

foreign reserves and limited fiscal space – which increase the vulnerability to adverse shocks – more

frequent weather‐related shocks and limited progress on building buffers, reducing debt, and addressing

financial sector stability.

Progress towards reducing poverty has continued, albeit at a slower pace than in the past. The

pace of poverty reduction was modest compared to some of its neighbors (1.0 percent increase in GDP in

Cambodia translated to 1.2 percent poverty reduction, whereas in Lao PDR, it was only 0.4 percent).

Inequality widened over the last decade and the Gini coefficient increased from 32.4 (2002) to 38.8 in

2018‐20191. Meanwhile, the incidence of poverty (using the international poverty line) is projected to

have declined to 18.4 percent in 2019 and is expected to fall below 18 percent in 2020–2021. Poverty is

particularly entrenched among remote and highland communities that are isolated during the rainy

season, and gender disparities remain significant.

Economic growth has been heavily concentrated in urban areas2 while in rural areas, high levels of poverty and inequality prevail. Poverty incidence is estimated at 23.2 percent nationally, but it is 40 percent in rural areas without roads compared to 10 percent in urban areas. Poverty, along with lack of access to basic social services, remains entrenched in remote and highland areas in the northern part of the country even though some improvements have been observed. Infrastructure in remote areas is particularly limited, and many communities are inaccessible during the annual rainy season. These remote

1 The official estimates of poverty and inequality in 2018–2019 are expected to be available in mid‐2020. 2 World Bank. 2014. “Poverty Profile in Lao PDR: Poverty Report from the Lao Consumption and Expenditure Survey 2012‐3.”


Page 9 of 156

areas also continue to be characterized by poor access to publicly provided social services such as health and education.

Poverty and human development indicators are also worse for ethnic minorities, many of whom live in remote areas. For instance, poverty rates among the Mon‐Khmer and Hmong (at 42 percent and 40 percent, respectively) are nearly three times higher than that of the majority Lao Tai (at 15 percent). In addition, poverty reduction is continually threatened by high vulnerability to shocks and the absence of adequate support or risk mitigation measures for most of the population (World Bank 2016).3

Recent increases in public spending have improved availability of public funding in the health sector. However, fiscal pressures and larger issues around the effectiveness of public sector management have been affecting the availability and quality of health service delivery. The large fiscal deficit has limited or is expected to further constrain the ability of the public sector to allocate budget to social sectors to address the country’s development challenges. The health sector, among other critical sectors, remains largely underfunded, which can slow progress toward achieving Sustainable Development Goal (SDG) targets on some of the key health and nutrition indicators.

The limited capacity in program management, especially in public financial management (PFM), has been a major systemwide challenge which also affects the health sector. Weak planning and budgeting systems, decentralized and fragmented revenue administration, difficulty in cash forecasting and management, and continued concerns in budget execution have resulted in inadequacy of resources to the health sector. This particularly affects availability of adequate operational budgets at health facilities and hampers frontline service delivery.

B. Sectoral and Institutional Context

Over the past few decades, Lao PDR has made substantial progress regarding key public health outcomes. Life expectancy at birth increased from 49 years in 1980 to 66 years in 2014, while infant mortality decreased from 135 per 1,000 live births in 1980 to 40 per 1,000 live births in 2017. Under‐five mortality dropped from 200 per 1,000 live births to 46 per 1,000 live births in the same period. Similarly, maternal mortality ratio has significantly declined from 546 per 100,000 live births in 2000 to 206 per 100,000 live births in 2015 and total fertility rate from 4.3 in 2000 to 2.7 in 2017, respectively.

However, substantial challenges remain; maternal and child mortality rates and chronic malnutrition (stunting) levels remain among the highest in the region. For maternal and child health (MCH) outcomes, the country remains among the poorest performers globally as well as in the East Asia and Pacific region. While under‐five and infant mortality rates have shown measurable improvement, maternal mortality ratio is still significantly higher than in neighboring Cambodia which had started from a higher level in 1990. About 35 percent of Lao girls are married before their 18th birthday and 9 percent are married before the age of 15. Adolescent fertility is also a major concern with 83 births per 1,000 women ages 15–19 years in 2017—only a slight decline from 2012 at 97 births per 1,000 women. In addition, undernutrition remains a significant challenge. Corresponding to the poor MCH outcomes are

3 World Bank. 2016. Lao Economic Monitor. Challenges in Promoting More Inclusive Growth and Shared Prosperity. Thematic Section: Drivers of Poverty Reduction in Lao PDR.


Page 10 of 156

low quality of health care and low levels of coverage and utilization of key interventions, including antenatal care (ANC), skilled birth attendance, and immunization.

Challenges in improving health and nutrition outcomes adversely affect the accumulation of human capital in Lao PDR. Children born in Lao PDR today could expect to be only 45 percent as productive as they could have been if they had optimal education, good health, and a well‐nourished childhood. While the Human Capital Index in Lao PDR is above the average for low‐income countries, it is below the average for low‐ and middle‐income countries (LMICs).

Figure 1. Human Capital Index for Lao PDR

Source: Human Capital Project, World Bank, 2018 https://www.worldbank.org/en/publication/human‐capital

About 33 percent of children under five years are stunted,4 21 percent are underweight, and 9

percent are wasted. Stunting affects several groups disproportionately the poor, ethnic minorities, rural children, and upland areas of the country. Stunting and underweight rates among children in the poorest wealth quintile (which is predominantly rural) are over three times the rates for children in the richest quintile.

This persistence of high levels of childhood undernutrition presents a staggering, yet avoidable, loss of human and economic potential for Lao PDR. At the current levels of maternal and childhood malnutrition, the burden on the national economy is estimated to be at least US$200 million annually, representing about 2.4 percent of the country’s GDP.5 Although there have been marked improvements

4 Stunting is a reflection of chronic malnutrition because of failure to receive adequate nutrition over a long period and recurrent or chronic illness. It is measured by height‐for‐age. Children whose height‐for‐age is more than 2 standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height‐for‐age is more than 3 standard deviations below the median are classified as severely stunted. Lao Statistics Bureau. 2018. Lao Social Indicator Survey II 2017, Survey Findings Report. Vientiane, Lao PDR: Lao Statistics Bureau and UNICEF. 5 Bagriansky, Jack, and Saykham Voladet. 2013. “The Economic Consequences of Malnutrition in Lao PDR: A Damage Assessment Report.” NERI and UNICEF Working Paper.


Page 11 of 156

in stunting over time, Lao PDR still performs poorly compared to other countries with similar levels of income and to other Association of Southeast Asian Nations countries (figure 2). If malnutrition continues to drain the Lao economy at this magnitude, its ambitious national goal of 8 percent annual GDP growth will be difficult to sustain.

Figure 2. Stunting Prevalence by Income Levels in Select Asian countries

Source: WHO and UNICEF. 2020. WHO‐UNICEF Estimates of Immunization Coverage. https://apps.who.int/immunization_monitoring/globalsummary/timeseries/tswucoveragedtp3.html

Moreover, the national aggregates mask wide inequalities with far worse outcomes in some provinces than in others. For example, stunting rates are higher in provinces such as Huaphan (41 percent), Phongsaly (54 percent), Xiengkhuang (46 percent), and Sekong (50 percent). There are also significant variations across income levels; both stunting and underweight among children in the poorest wealth quintile (48 percent stunted) are more than three times the rates for children in the richest quintile (14 percent stunted), and the levels also vary by ethnic groups (for example, among Hmong‐Mien, reaching 50 percent) 6

Poor access to and quality of health and nutrition services are persistent problems and disproportionately affect women and the poor, leaving a large gap in essential services needed by mothers and children. For example, the recent Lao PDR Social Indicator Survey (LSIS) 2017 found that while 97.3 percent of pregnant women in richest quintile had access to ANC, only 52 percent of pregnant women from the poorest wealth quintile received ANC from a trained health professional and over 36 percent of pregnant women living in rural areas without roads had not received any ANC services. For the rural poor, many of whom live in remote areas, distance to health facilities is a major barrier to access. While only 6 percent of pregnant women living in urban area had no access to ANC, this figure was 19.5 percent for those pregnant women living in rural area with road had. Moreover, only 34 percent of

6 Lao Statistics Bureau. 2018Lao Social Indicator Survey II 2017, Survey Findings Report. Vientiane

Cambodia IndonesiaLao PDRPhilippines

Vietnam

Myanmar

Singapore

Malaysia

Timor‐Leste

Papua New Guinea

MongoliaChina

Vanuatu

Thailand

Tonga

0

10

20

30

40

50

60

70

200 600 1800 5400 16200 48600

Stunting Prevalence, p

ercent

GNI per capita, 2014, current US$


Page 12 of 156

pregnant women in rural households were assisted by a skilled birth attendant when giving birth, compared to the national average of 64 percent.

These challenges of access, service coverage, and financing have contributed to inequity in health and nutrition outcomes. Therefore, Lao PDR is grappling with some of the world’s largest equity differentials with regard to coverage and outcomes of MCH services between the rich and poor population (World Bank 2017).7 The share of women in the poorest quintile who did not receive any ANC during the last pregnancy (75.2 percent) is more than 10 times higher than the share of women in the richest quintile (6.6 percent). Regarding safe delivery, institutional births range from 87 percent in the wealthiest quintile to only 11 percent in the poorest quintile. As a result, there are high socioeconomic and geographic disparities in reproductive, maternal, neonatal, child, and adolescent health (RMNCAH) outcomes in Lao PDR, and especially inequalities related to wealth and ethnicity are pronounced. Low coverage and income disparities in the use of high‐impact RMNCAH interventions such as family planning and PNC for newborns have a negative impact on RMNCAH outcomes. In 2017, for example, infant mortality and under‐five mortality rates varied by a factor of 6 to 7 between the province with the highest rates (68/1,000 and 71/1,000, respectively, in Oudomxay) and the province with the lowest rates (9/1,000 and 11/1,000 in Xayabury).8 High levels of adolescent fertility are a real concern particularly for those who live in rural and remote areas and from low‐income groups, as early childbearing carries a higher risk of complications and limits opportunities for education and employment for young women.

Increased access to and utilization of maternal and child health (MCH) services can accelerate improvements in maternal mortality and nutrition outcomes in these vulnerable populations. To have the greatest impact on saving maternal and newborn lives, ANC must be delivered on time and include evidence‐based interventions.9 ANC provides a platform for important interventions, including health and nutrition promotion, screening for and diagnosis of pregnancy risks, and disease prevention. The platform provides the opportunity to communicate with and support women in a critical time in their own life and in the life of their fetus. Furthermore, ensuring access to skilled birth attendance, facility‐based maternity services, and essential obstetric care that is effective and of good quality can help reduce maternal and newborn mortality.10 Postnatal care (PNC) contacts with women and children provide the opportunity for early identification of postpartum issues and the provision of preventive and promotive interventions for the mother and child.

Lao PDR has a high tuberculosis (TB) disease burden with incidence of 162 per 100,000. Mortality due to TB is 30 per 100,000; TB treatment coverage in 2018 was 57 percent and Multidrug‐resistant (MDR) TB is estimated at 2.2 per 100,000. 11 TB is an important equity issue as well—with the disease’s burden being 5–10 times greater in older populations and is greater in remote and isolated areas. One of

7 World Bank. 2017. Managing Transition, Reaching the Vulnerable While Pursuing UHC ‐ Health Financing Assessment in Lao PDR. 8 Lao Statistics Bureau. 2018. Lao Social Indicator Survey II 2017, Survey Findings Report. Vientiane, Lao PDR: Lao Statistics Bureau and UNICEF. 9 WHO (World Health Organization), 2016. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. Geneva: World Health Organization. 10 World Health Organization. 2016. Standards for Improving Quality of Maternal and Newborn Care in Health facilities. Geneva: World Health Organization. 11 http://www.wpro.who.int/laos/topics/tuberculosis/en/.


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the main challenges of the program is the lack of TB services in hard‐to‐reach areas due to current limitations in access and the fact that there is limited number of primary health care network that have the capacity to offer TB services in those areas.

Lao PDR had an estimated 12,028 people living with human immunodeficiency virus (HIV) according to the United Nations Program on HIV/AIDS (UNAIDS) in 2018.12 Around 76 percent of people living with HIV/AIDS (PLHIV) in Lao PDR were aware of their status and 7,111 PLHIV started on antiretroviral therapy (ART), but only 6,085 or 64 percent of those registered for care are currently on ART treatment. Of those on treatment, 91 percent or 5,095 are virally suppressed. HIV is considered a concentrated epidemic with a rising trend among key populations, that is, men having sex with men (MSM) and female sex workers (FSW) and their clients. Prevalence among MSM has increased from 1.7 percent to 2.5 percent between 2014 and 2017 while prevalence among FSW has remained consistent at around 1 percent. However, the majority of HIV cumulative cases (83.4 percent) were identified in border provinces along the Mekong River with Vientiane Capital (40.5 percent), Vientiane Province (3 percent), Savannakhet (21.1 percent), Champasack (13 percent), Luangprabang (4.8 percent), and Khammouane (3.9 percent).13 These areas are also the most populated where large urban areas are located along the Mekong River.

There has been some improvement in immunization coverage since 2010 but it has been declining in the last years and still lies below that of countries at similar income levels. The immunization coverage data were revised downward in 2018 due to the LSIS2 survey findings. According to the latest available data14 , immunization coverage rates increased steadily for diphtheria, pertussis, and tetanus (DPT) from 74 percent in 2010 to 88 percent in 2014 but has dropped since then to 68 percent in 2018.

Efforts have been made to address the barriers to identification and treatment of HIV and TB. The barriers for key populations to access HIV services include the stigma attached to HIV which inhibits key affected populations from accessing health services. The stigma and discrimination come mainly from family, communities, and health workers. Access to health services for HIV treatment is limited as there are currently only 11 treatment sites in the country; some patients may have to travel for a day to reach the nearest treatment site, exacerbated by the cost of travel to seek treatment. These barriers constrain the progress on the three global targets for HIV treatment scale‐up. Main barriers for TB patients to reach services are out‐of‐pocket (OOP) payments, lack of knowledge, stigma, and isolation where outreach and community organizations will not extend coverage. To address these barriers, the Global Fund (GF) has been supporting the national HIV and TB programs to increase peer outreach activities through civil society organizations (CSOs) under the HIV grant and supported TB Active Case Finding through procurement of mobile GeneXperts and supporting CSOs to conduct outreach in the 22 most high burden areas in Lao PDR.

In addressing these challenges, the Government of Lao PDR (GOL) has been implementing its Health Sector Reform Strategy (HSRS) with a focus to build a people‐centered health system that provides equitable access to quality services. The strategy defines priorities for achieving universal health

12 www.aidsdatahub.org (2018). 13 Lao PDR Country Progress Report Global AIDS Response Progress 2016. 14 WHO and UNICEF, 2020. WHO‐UNICEF Estimates of Immunization Coverage. https://apps.who.int/immunization_monitoring/globalsummary/timeseries/tswucoveragedtp3.html


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coverage (UHC) by 2025, with five priority areas of reform in three phases: (a) Human Resources for Health; (b) Service Delivery; (c) Health Financing; (d) Governance, Organization, and Management; and (e) Health Information System. Phase 1 (2013–2015) of the HSRS focused on achievement of the health‐related Millennium Development Goals (MDGs) and laid out a solid foundation for universal access to quality essential services. Phase 2 (2016–2020) aims to ensure quality essential health services are accessible for the majority of the population, through development of an essential health service package (EHSP) which serves as a tool to guide the provision of a minimum set of priority public health and clinical services that must be delivered in the different types of health facilities and in the community and which aims to improve efficiency of the health system through integrated and coordinated service delivery. The 8th National Health Sector Development Plan (HSDP) 2016–2020 strives for an acceleration of the health sector reform, in particular, the development of human resources, the improvement of governance and financing, and the completion of the comprehensive health information system. Phase 3 (2021–2025) of the HSRS implementation expects to achieve UHC with an adequate benefit package and appropriate financial protection by 2025. In support of the 9th National Socio‐Economic Development Plan, the next 5‐year sector plan—the 9th HSDP 2021–2025—has been under preparation to implement Phase 3 of the HSRS which set out the attainment of UHC by 2025 as an explicit sector objective.

A recently published synthesis of data from multiple surveys15 and a previous World Bank study on health workforce found substantial gaps in the clinical abilities of frontline health workers in the management of MDG‐related clinical situations.16 These publications highlight significant gaps in the quality of health education, beginning at the preservice stage (including entry regulations or requirements for health workers) and continuing throughout the professional life of the health worker. The studies also suggest that there are opportunities to address the significant inefficiencies in health service delivery related to underutilization of frontline human resources. The publications suggest investment to reduce demand‐side barriers (such as physical access barriers and ethnolinguistic and gender barriers) to increase the utilization of essential health services. Finally, the studies also note the need for investment in improving service readiness of public health facilities to ensure the availability of essential health commodities, equipment, and infrastructure.

Shortage of qualified manpower is further compounded by an uneven distribution of health workers across provinces. The density of doctors to population in Vientiane is four times that of the rural areas. Similar but less pronounced differences exist for high‐level nurses and midwives. The same publications found maldistribution of staff (by geography, level, and type), substantial gaps in clinical knowledge, and a mismatch between the type of in‐service training provided and the knowledge needed to perform the service required.

In the last few years, great efforts have been made to improve primary health service delivery, especially MCH by increasing the number of staff uptake and deployments to health centers. Disbursement‐linked indicators (DLIs) introduced under the ongoing Lao PDR Health Governance and Nutrition Development Project (HGNDP, P151425) has achieved a redistribution of community midwives

15 Nagpal, S., E. Masaki, E. Pambudi, and B. Jacobs. 2019. " Financial Protection and Equity of Access to Health Services with the Free Maternal and Child Health Initiative in Lao PDR.” Health Policy and Planning 34 (1): i14–i25. https://doi.org/10.1093/heapol/czz077. 16 World Bank. 2016. Lao PDR Health Center Workforce Survey. Findings from a Nationally‐Representative Health Center and Health Center Worker Survey.


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to the extent that the share of health centers without a community midwife has been reduced from 56 percent in 2015 to 16 percent in 2018.

Financing for the health sector in Lao PDR has long been challenged by the low level of government investment in health and correspondingly high reliance on OOP health expenditure and external assistance for health. External financing remains high at 20 percent of the total health expenditure. Despite the significant decline of OOP expenditure by households as a share of total health expenditure from more than 60 percent in 2000 to 41 percent in 2018, OOP payments remain the largest source of financing for health in the country. However, there has been a significant increase in the government budgetary spending on health from US$11 per capita in 2011 to US$48 per capita in 2018. The country currently spends US$71 per capita or about 2.8 percent of GDP in 2018, where government health spending including external sources accounted for a combined 56.6 percent of the total health expenditure.17 While overall government spending on health has increased, further evidence is needed to understand if the increase has translated into improved availability and delivery of health services.

As Lao PDR prepares to graduate from least‐developed country (LDC) status by 2024 to become an upper‐middle‐income country by 2030, it also expects to face declining funding from external sources and the need to increase domestic financing for health. This could potentially have a destabilizing impact on key health services, such as immunization, malaria, HIV, and TB programs as the country substantially depends on external finance—in particular, in these priority health programs. Already some of the key development partners have initiated a process of transition and are reducing or even withdrawing their support to procuring commodities including family planning and vaccines and to finance the operating costs for the provision of these services. Since 2017, Lao PDR has entered the accelerated transition phase (as defined by Gavi‐ the Vaccine Alliance [Gavi]) and has begun the process of phasing out from Gavi support by the end of 2021, as the gross national income (GNI) per capita on average over the previous three years increased beyond the eligibility threshold. A plan has been prepared for moving toward full domestic financing of the immunization program. It is highly likely that both UNICEF and WHO will also substantially reduce their technical assistance (TA) to the immunization program—as an important part of their support is financed by Gavi.

The reduced availability and predictability of funding for priority health programs may potentially pose a challenge in sustaining and expanding coverage of critical services. In addition to the challenge of raising adequate domestic resources for key health priority programs, fragmentation of planning, financing flows, reporting, monitoring, management of services, and human resources are part of the transition challenge. Importantly, this transition of financing is taking place while there is still a large pending agenda on access and quality. The Gavi transition is among the earliest ones being witnessed by the country. It will also help generate lessons for similar transitions that may affect programs funded by other development partners in due course.

The recent PFM assessment in health service delivery conducted by the Ministry of Health (MOH) and World Bank Group confirmed that there are several key challenges affecting service delivery at frontline health facilities.18 Service availability and readiness of the health providers were found to be

17 Ministry of Health. 2019. 2011–2018 National Health Accounts. 18 World Bank. 2019. Public Financial Management in the Health Sector in Lao PDR ‐ Service Delivery Challenges and Opportunities.


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the major service delivery bottlenecks at all levels but more acute for the health centers. While the poor and remote population relies heavily on outreach services, lack of appropriate medical tools and equipment to carry out outreach services as well as lack of clear guidelines and supervision were found to be affecting the quality of outreach services. Frontline health workers lack relevant skills and training. A long budget preparation cycle reduces the time available for budget implementation coupled with delays in the budget approval limiting availability of cash to carry out outreach services and delivery of essential services.

Limited number of qualified personnel for accounting and financial reporting tasks has contributed to a weak control environment at all levels and in particular at the health facility level. A substantial quantum of funds from government budgetary sources and user fees are managed at the health facility level, but there is no systematic financial management (FM) system to document how funds are utilized and accounted for. The Government’s FM system does not track all budget sources going to a specific health facility. Further, health facilities do not always systematically document the collection of user fees and their use by the facility. All these inadequacies can lead to high risks of noncompliance with fiduciary requirements, unsatisfactory accounting records, and misuse of funds. With the expansion of the National Health Insurance (NHI), increasingly more and more funds are and will be channeled through the NHI funds. This will increase the need to strengthen the PFM capacity at all levels to ensure that minimum standards will be in place for sufficient accountability and transparency of funding and utilization of funds to improve quality of spending and efficiency of health service delivery in Lao PDR.

The assessment also underscored weaknesses in planning and budgeting systems in the health sector that reflect the broader macro‐level planning and budgeting systems weaknesses but are also derived from structural health‐specific disease programing constraints, weak coordination of decentralized provincial planning, and non‐existent facility planning and budgeting. Addressing inefficiencies in the allocation of resources at both central and decentralized levels of the health system against increasing health care demands of Lao PDR is urgent, because the sector will have to do more with less resources given current macro‐fiscal conditions. Furthermore, scaling up and sustaining the national Insurance scheme will in large part depend on the adequacy and reliability of planning and budgeting systems that can pool resources and share risks. Improved planning and budgeting efficiency can save resources to address inadequate equipment and drugs and skilled health workforce shortages at facilities.

Under the second phase of the HSRS implementation, the Government has made a major policy decision to establish the NHI scheme and to progressively expand social health projection to the whole population through a unified scheme by integrating the free health services for the poor (Health Equity Fund ), policy for free services for mothers and children under 5 years of age (free MCH, and community‐based voluntary health insurance—thereby reducing fragmentation in the system. In 2016, the MOH officially launched a tax‐based scheme to expand the coverage for the informal sector. Since its launch in 2016, the NHI scheme has been quickly rolled out to all provinces except Vientiane Capital,19 where it will be covered in the near future. As stipulated in the National Health Insurance Law approved in December

19 The NHI scheme has expanded in a few provinces at a time, starting with the smallest and poorest provinces. In 2016, it was implemented in four provinces: Attapeu, Xaysomboun, Luang Namtha, and Sekong. In January 2017, it was expanded to six additional provinces: Bolikhamxay, Saravan, Phongsaly, Huaphan, Oudomxay, and Xiengkhuang. The NHI was further expended to six additional provinces: Savannakhet, Vientiane, Bokeo, Sayaboury, Khamouane, and Champassak by the end of 2017. Luang Prabang Province was covered by the NHI in 2018 and Vientiane Capital is expected to be covered in the near future.


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2018, NHI has initiated a merger of the formal sector schemes covering private employees and civil servants under the National Social Security Fund in 2019.

Currently, the NHI scheme covers about 5 million people or about 74 percent of the total population. If we include other insurance schemes (such as for civil servants and private employees), the total social health protection coverage in Lao PDR is about 94 percent of the population. Under the NHI scheme, members are required to pay a small co‐payment at the time of receiving health services at the public health facilities. NHI uses capitation payment for outpatient services at all levels of health facilities and for both outpatient and any inpatient services rendered at health centers. The capitation rate is calculated from catchment population and utilization rate. Inpatient services are reimbursed on a case‐based payment at hospitals (including district, provincial, regional, and central hospitals, as well as at specialized centers). Contracted referral hospitals or specialized hospitals at the central level are reimbursed for both outpatient and inpatient services through case‐based payment. Co‐payment applicable at the health center level for both the Out‐Patient Department (OPD) and Inpatient Department (IPD) is LAK 5,000 per visit, OPD at district hospital is LAK 10,000, while OPD at provincial hospital requires LAK 15,000 and co‐payment is LAK 30,000 for IPD visits at both district and provincial hospitals. Co‐payment is exempted for patients who are on the list of poor households, for pregnant women, and for children under five years of age.

However, effective coverage and financial protection requires a fully operational and sustainable NHI system and managing smooth integration of multiple schemes still operating in many provinces during this transition period. The National Health Insurance Strategy 2017–2020 provides a vision and clear directions for the successful rollout of an integrated NHI system, which requires strengthening of its legal status and organizing the institutional structure of the NHI Fund. The National Health Insurance Bureau (NHIB) has to fulfill key operational functions to provide effective coverage including stewardship, revenue collection and pooling, FM, administration, strategic purchasing, technical support to facilities, interface with the public, verification, and monitoring and evaluation (M&E), and its progress to take on these roles will require considerable support. In addition, the NHIB does not reimburse the health facilities for services provided through integrated outreach, which reduces the incentives for health facilities to undertake such outreach, thereby reducing the potential of contributing to the government agenda of achieving universal access to health services.

The challenge that Lao PDR faces on quality of health and nutrition services is now increasingly at the center stage of policy attention. As a key part of the health sector reform, the MOH has adopted the policy on health care service quality assurance of ‘Five Good, One Satisfaction’ at all levels of the health system since 2016. To operationalize this policy, the Department of Health Care and Rehabilitation (DHR) plans to develop quality measures for each level of the public health system, corresponding to the delivery of the country’s EHSP. The ‘Five Good, One Satisfaction’ policy calls for the attainment of indicators in the domains of warm welcome, cleanliness, convenience, accurate diagnosis, and good and quick treatment as the five ‘goods’ and on patient satisfaction. This is intended to be achieved as a consultative process involving key MOH departments and external stakeholders through a revision of the content of the supervisory checklist currently used for provincial DLI 6 under the HGNDP. This changing configuration of the health system in Lao PDR is occurring amid multiple transitions in the way health care is financed in the country and necessitates alignment of financial and technical support from development partners and close coordination among different stakeholders in the health sector.


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The World Bank, through its Lao PDR Health Sector Programmatic Advisory Services and Analytics (P164585), has also been generating evidence and providing technical assistance (TA) and capacity‐building support for health financing reforms to ensure sustainable financing for UHC in Lao PDR. This includes the Health Financing Systems Assessment which identified key constraints and opportunities of Lao PDR’s health care system in its acceleration toward UHC supported by the Integrating Donor‐financed Health Programs Multi‐Donor Trust Fund (IDFHP). The IDFHP, supported by the Government of Australia through the Department of Foreign Affairs and Trade (DFAT), as well as other MDTF donors including Bill and Melinda Gates Foundation, Gavi Alliance and Global Fund, aims to support countries in strengthening their health systems toward achieving UHC, and it has been and continues to be a major contributor to World Bank work in this area.

To improve sustainability and further use mainstream government structures for program implementation, the GF will be jointly co‐financing the Health and Nutrition Services Access Project (HANSA) in an amount of US$10 million from its allocation for Lao PDR in the next funding round. This will contribute to strengthening of the government capacity across ministries (Ministry of Finance [MOF], Ministry of Planning and Investment [MPI], and MOH) to lead the transition planning and effectively manage the transition of various externally financed programs. In a regional partnership with DFAT, work is currently ongoing in Lao PDR to support sustainable financing for priority public health programs, with a focus on immunization, TB, HIV, and malaria programs. This partnership will also provide TA to HANSA‐supported activities for the sustainability of these programs, in close partnership with the GF. In addition, complimentary TA activities will be funded by Gavi and implemented during the first two years of HANSA implementation. The Gavi‐funded activities will focus on building capacity for FM at all levels in the health sector, helping achieve DLI E, and ensuring that minimum standards will be in place for sufficient accountability and transparency of funding and utilization of funds and to improve quality of spending and efficiency of health service delivery at frontline facilities in Lao PDR.

Further, to inform policy discussions on the need for adequate financing of NHI, especially domestic resources for health and to project future financing needs for UHC, a costed EHSP is crucial. This EHSP should also consider costs for mainstream delivery of hitherto vertically delivered priority public health programs, such as HIV, TB, malaria, and immunization services is crucial. In this respect, a joint effort for costing the EHSP is being undertaken by various MOH technical departments and development partners including the WHO, Swiss Red Cross, United Nations Population Fund [UNFPA], and the World Bank. Data generated from this exercise will be used to identify resource needs, advocate for funding, improve planning and budgeting, and ensure equitable and efficient resource allocation. Appropriate costing of ESHP and the interventions being financed by the NHIB on a case‐based payment structure would also help ensure sustainability of the NHI design and implementation.

Development partners such as the WHO, Japan International Cooperation Agency (JICA), and the Asian Development Bank (ADB) are active in the quality agenda in Lao PDR, and the World Bank, GF, and DFAT will closely coordinate with their activities through their investments in HANSA. JICA is financing a hospital quality improvement project supporting two provinces in southern Lao PDR. ADB is preparing a new project on quality enhancement to be implemented from 2021, with a focus on key inputs such as health worker training, equipment availability, and supply‐side readiness. The WHO has been providing technical support to the DHR in conceptualizing and developing the quality standards agenda and is also active in the quality aspects of key public health care programs. HANSA has been designed to complement (and not duplicate) any of these efforts.


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Climate change can have important consequences for Lao PDR. It has been predicted that nationally, average daily temperatures will rise, precipitation will increase, and the frequency of droughts might increase, though but only marginally so. Consequently, heavy precipitation may limit both the ability of patients to access health facilities to receive essential nutrition and health service as well as the ability of health workers to travel to remote areas to provide these services. Climate change is also expected to increase the risks of waterborne and vector borne diseases.

Gender gaps in women’s endowments in health, education, and voice/agency are persistent, mutually reinforcing, and often transmitted across generations. There is extremely poor access to quality health care, low literacy among women, unequal opportunities for women and men to participate in livelihood activities and wage jobs, and low participation of women in planning and decision making in family and community level. There are persistent challenges to women’s autonomy, including control over their own health care and self‐esteem. Diverse literature on the causes of stunting in Lao PDR points to elements such as women’s and mothers’ socioeconomic status, level of education, early marriage, and age of pregnancy, among others, as determinants of stunting. Mothers’ level of education, for example, is significantly correlated with stunting, and about 45 percent of stunted children’s mothers received no education or only early childhood education (LSIS 2017). Less than 60 percent of women in poor households can read and write, compared to over 80 percent of men. Two separate studies found that higher self‐esteem for women, defined as their intolerance for domestic violence, is associated with lower levels of childhood stunting in Lao PDR20 21.

High maternal mortality and childhood stunting (described above) are rooted in poor access, quality, and cultural accessibility of health and nutrition services for women and children. While both men and women in rural Lao PDR have limited access to health services, the impacts are exacerbated for women due to the health and mortality risks of childbearing. Lao PDR’s maternal mortality rate remains one of the highest in the East Asia and Pacific region (197 per 100,000 live births compared to a regional average of 62 per 100,000)22 and is associated with factors such as the low utilization and quality of ANC, low‐skilled birth attendance and improper infection prevention and control, and poor health and nutrition behaviors during pregnancy. As noted, the country faces challenges in the knowledge and competencies of health workers providing these MCH services. Moreover, although more than half of health center staff were female, the majority of births were assisted by male staff according to the client perspective of gender dimensions in Lao PDR health center workforce survey 2016. This lack of gender sensitive health care could be a barrier for ethnic women to access the health care that they needed.

Lao PDR’s high rates of teenage pregnancy contribute to the burden of maternal mortality and stunting. Lao PDR’s adolescent birthrate was the highest in the region—about 94 out of 1,000 births correspond to girls ages 15 to 19 (UNFPA 2016) compared to East Asia’s regional average of 47 out of 1,000 births. Early marriage was at 33 percent in 2017 and is particularly pervasive in rural areas and among women with lower educational attainment; it overwhelmingly (83 percent) results in childbearing

20 Kamiya Y. (2011). Socioeconomic determinants of nutritional status of children in Lao PDR: effects of household and community factors. Journal of health, population, and nutrition, 29(4), 339–348. doi:10.3329/jhpn.v29i4.8449 21 Kamiya, Y., Nomura, M., Ogino, H., Yoshikawa, K., Siengsounthone, L., & Xangsayarath, P. (2018). Mothers' autonomy and childhood stunting: evidence from semi‐urban communities in Lao PDR. BMC women's health, 18(1), 70. doi:10.1186/s12905‐018‐0567‐3 22 World Bank. 2019. World Bank Open Data. https://data.worldbank.org/.


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within the first year of marriage. Early childbirth carries high risk of complications and mortality during delivery, low birth weight births, undernourished children, and limits opportunities for continued education and employment for young women. It remains widely accepted as a leading cause of stunting in Lao PDR: children born to mothers ages 18 and below are 10 percentage points more likely to be stunted23.

Critical gaps in preventive and basic curative outreach services have a disproportionate impact on the women and children in the poorest population groups, ethnic minorities, and those who live in the difficult‐to‐reach areas and depend on these services for immunization, ANC, PNC, and growth monitoring and promotion. A number of studies, including the rapid field assessment carried out by the World Bank in 2016, found that there were great variations in the services offered during such outreach between and within the two provinces surveyed and that only a few health centers could provide the prescribed integrated outreach services on a regular basis. Lack of appropriate medical tools and equipment to carry out outreach services as well as lack of clear guidelines and supervision were found to be affecting the quality of outreach services. It was also found that the areas with most effective outreach were those in which regular supportive supervision and monitoring were provided. Such findings indicate that a share of the population, particularly the most disadvantaged, in fact do not have access to even basic services and that in addition to provision of financial protection for the poor, the delivery of basic preventive and curative services, especially essential services for women and children, needs to be streamlined and strengthened.

The growing epidemic of HIV among key populations (transgender, MSM, and FSW) highlights gaps in the inclusiveness and responsiveness of the Lao PDR health system to issues related to sexual orientation and gender identity. This requires focused efforts at the health worker level while also exploring innovative solutions to ensure that health services remain accessible for these disadvantaged groups.

C. Relevance to Higher Level Objectives

The project is fully aligned with the country’s 9th HSDP 2021–2025, the World Bank Group’s twin goals of eradicating poverty and promoting shared prosperity, the World Bank Group’s 2012–2022 Social Protection and Labor Strategy, and the World Bank Group’s 2017–2021 Country Partnership Framework (CPF) (Report No. 110813‐LA) for Lao PDR. The CPF Focus Area 2 ‘Investing in People’ includes, as key objectives, reducing the prevalence of malnutrition as well as improving access to and quality of health services. Similarly, the proposed financing remains highly relevant to the World Bank Group’s twin goals to reduce poverty and promote shared prosperity as it continues to focus on service delivery at frontline levels and by incentivizing integrated outreach services in reproductive, MCH, and nutrition services. Achieving UHC by 2025 is an explicit sector development goal, and the 9th HSDP focuses on expanding coverage of quality health services and improving public financing for health to ensure sustainable financing for UHC. HANSA will contribute to attain the National TB Strategic Plan 2021–2025 targets to decrease the incidence of TB and the mortality due to TB and to achieve zero catastrophic costs for TB patients, which in turn is in line with the WHO’s Global End TB strategy.24 HANSA will also contribute

23 Osornprasop, Sutayut and Obert Pimhidzai. 2016. Nutrition in Lao PDR – Causes, Determinants, And Bottlenecks. Vientiane and Washington DC: World Bank 24 http://www.who.int/tb/strategy/en/.


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to the National HIV Strategic Plan 2021–2025 to decrease HIV prevalence. Through efforts at improving health and nutrition outcomes in Lao PDR, the project also contributes to Lao PDR’s investments in human capital and at improving the human capital index of the country.

Since approval of the CPF, and in response to the multidimensional causes of malnutrition in Lao PDR, the World Bank has made a commitment to a multisectoral action plan to support the GOL’s efforts to tackle childhood stunting. The long‐term vision for the World Bank’s nutrition agenda is aligned with the GOL’s objective to reduce stunting prevalence at the national level by 40 percent (to 25 percent) by 2025. As such, the goal is to redefine the World Bank’s approach to tackling undernutrition in Lao PDR to optimize existing and future operational and TA commitments (active and pipeline), as well as the policy dialogue on nutrition, anchored in concrete operational commitments and a defined mechanism to lead a multisector policy dialogue.

Progress toward reducing stunting can be enhanced through coordinated multisectoral approaches that effectively address the underlying determinants of nutritional status—food security, access to health care, child care practices, and access to water and sanitation. Reductions in stunting are more likely to materialize when the multiple contributing factors are adequately addressed for a child. Recognizing the multifactorial character of malnutrition, the Plan of Action 2016–2020 advocates a convergence of 22 key interventions that combine nutrition‐specific interventions (those which address undernutrition directly) with nutrition‐sensitive interventions (which operate primarily outside of the health sector, including water, sanitation, and hygiene [WASH]). The World Bank’s multisector convergence approach is detailed further in the proceeding paragraphs and in annex 3, including the Country Portfolio Results Chain for an Integrated Approach to Tackling Childhood Stunting in Lao PDR.

The current World Bank portfolio supports the multisector convergence through the HGNDP, the Reducing Rural Poverty and Malnutrition Project (P162565), the Scaling‐Up Water Supply, Sanitation and Hygiene Project (P164901), the Poverty Reduction Fund III Project (P157963), and the Early Childhood Education Project (P145544). An overarching framework to address childhood stunting in a coordinated and impactful manner over the next decade has been developed and is summarized in figure 3. Presently, a geographic and programmatic convergence is planned across all these projects, namely in the 12 priority districts in the four northern provinces of Oudomxay, Phongsaly, Huaphan, and Xiengkhuang (nutrition convergence provinces)

Agreement was reached that nutrition‐sensitive and nutrition‐specific interventions in Lao PDR will be coordinated to the extent feasible in four key areas: (a) geographic convergence of nutrition‐specific and nutrition‐sensitive interventions in the same communities and households in the 12 priority districts in the four northern provinces,; (b) use of a common Social Behavior Change Communication (SBCC) strategy, action plan, and tools for consistent messaging; (c) leveraging of each other’s delivery platforms, for example, pre‐established community structures; and (d) exploring of possibilities for common monitoring and evaluation frameworks. This project forms an integral part of this convergence approach and complies with these agreed areas for coordination across the converged projects.


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Figure 3. World Bank‐Lao PDR Phased Multisectoral Approach to Reduce Stunting, 2018–2028a

Note: a. The national target of reduction of stunting to 25 percent pertains to the national level. The World Bank convergence approach will be centered on a subset of four provinces. Given that the operations will converge in areas with a higher stunting prevalence (including some provinces with over 60 percent stunting), the approach will significantly contribute to the national goal of stunting reduction.

In Phase 1, the overall objective is to lay the institutional and operational foundations for the multisector convergence approach before possible scale‐up in subsequent phases. Five active operations and one pipeline operation (HANSA) have been identified as nutrition‐sensitive and through simultaneous implementation in the same geographic areas, and reaching the same households, will help maximize the reduction in stunting prevalence. Each of these interventions will address a key cause of undernutrition in Lao PDR: poverty and vulnerability, limited access to quality health and nutrition services, limited access to water and sanitation, and limited knowledge of adequate MCH and nutrition practices and early childhood development at the household level. In addition, these projects will help address underlying issues that cut across sectors, particularly gender inequality and gender norms that underpin women’s lack of decision‐making authority in the family and community, low social value, and high burden of work that contribute to high levels of stunting.

HANSA is a critical piece at the center of this convergence approach, making a concentrated effort on improving the supply of health and nutrition services in the convergence provinces, as well as sustaining the SBCC village‐level platform which has been developed under the HGNDP in the same geographical area. Specifically, HANSA will enable increased access and utilization of both nutrition‐specific and (health‐related) nutrition‐sensitive interventions which are essential for improved maternal and child nutritional outcomes. The project will achieve this by strengthening as well as improving the quality of service delivery for UHC, with a special focus on MCH and nutrition services. This will be achieved through its support to community‐based SBCC activities (in 12 convergence districts) aimed at contributing to improvements in maternal nutrition and related caring practices, infant and young child feeding and caring practices, sanitation and personal as well as environment‐related hygiene behaviors, dietary diversification, and other determinants of nutrition at the village level. HANSA will support and


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ensure a continuum of nutrition service delivery that includes the frontline levels of the health system and through to the community.

HANSA also represents a platform for alignment of development partners toward sustainable financing of the health system in a way that sustains and enhances the performance of priority public health programs. The GF and Integrating Donor‐Financed Health Programs (IDFHP) are co‐financing partners for HANSA, closely supporting the analytical work and design effort for HANSA. The GF investment is based on the recently signed World Bank‐Global Fund Co‐Financing Framework agreement. The funds would be pooled at the country level and will jointly finance agreed project expenditures and cross‐referenced in the respective IDA Financing and GF grant agreements with the Government. DFAT, through the IDFHP, is continuing its investments in HANSA from its regional partnership with the World Bank, building upon the investments made in the HGNDP. Gavi is supporting the much‐needed TA for capacity building in PFM at the decentralized level, which is critical to the design of HANSA. Lao PDR is thus emerging as a frontrunner example of the Sustainable Financing ‘Accelerator’, one among the seven “Accelerators” under the Global Action Plan for Healthy Lives and Well‐Being for All. It is expected that other financing partners may also be involved with HANSA in the future, as a results‐based mechanism that focuses on aligning the different departments and programs in the country’s health sector and increasing the financing and performance of the frontlines. It also provides an opportunity to coordinate technical inputs from UN agencies such as the WHO, UNICEF, and UNFPA, as well as the participation of CSOs, to focus joint efforts on achieving the health systems results that HANSA is trying to promote.

II. PROJECT DESCRIPTION

A. Project Development Objective

PDO Statement

To improve access to quality health and nutrition services in targeted areas of Lao PDR.

HANSA has a particular focus on the four northern provinces in Lao PDR, which have been chosen for multiple, simultaneous, and mutually reinforcing investments by the GOL and the World Bank, as these provinces represent the most ethnically diverse, remote, and disadvantaged geographical locations in Lao PDR, with several service access challenges—particularly for women and children. Several nutrition‐centric interventions under HANSA, such as DLIs for SBCC, integrated outreach, and for growth monitoring promotion, are concentrated in the 12 nutrition convergence districts in these four provinces. Other interventions, which will eventually roll out nationwide over the lifetime of HANSA, such as the Quality and Performance Scorecard (QPS), PFM capacity building at health center levels, and the direct data entry under District Health Information System version 2 (DHIS2), also commence in these four provinces first and therefore will see the longest duration of investment efforts in these provinces. The interventions for TB and HIV are targeted differently, on provinces according to the respective program priorities.


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PDO Level Indicators

The following indicators reflect the key result areas at the PDO level. For all the indicators, gender‐disaggregated data will be collected and reported wherever possible, and where available, disaggregated analysis will also be undertaken along other dimensions of vulnerability such as socioeconomic status, ethnicity, and geographical location. The Results Framework will rely on administrative sources to the extent possible.

Improved access to quality healthcare services

Number of deliveries attended by a skilled birth attendant (this has been chosen as an access indicator from the list of indicators monitored by the National Assembly; it can be tracked from DHIS2; it is also an important measure of access and equity for pregnant women).

Number of health centers scoring above 60 percent on a standard quality assessment system with third‐party verification (it is a measure of quality and will be based on administrative data from QPS; can be tracked from DHIS2).

Improved Access to quality nutrition services

Percentage of children under 2 years of age whose growth is adequately monitored as per national guidelines in the twelve nutrition convergence districts (this is a nutrition convergence indicator; can be tracked from DHIS2, though the PDO indicator will be monitored using household survey data).

Percentage of pregnant women who receive 4 antenatal care contacts in the twelve nutrition convergence districts (measure of maternal health, nutrition specific indicator, and will be monitored using household survey data).

Increasing the utilization of primary care and improving efficiency of public spending

Share of outpatient cases delivered at the primary healthcare facilities among the total outpatient services delivered in the country (including hospitals) (percentage) (indicator of efficiency and indicator of primary care performance)

B. Project Components

Component 1: Integrating Service Delivery Performance with National Health Insurance Payments (US$12.2 million)

An important element of HANSA is the evolution of the HGNDP’s supervisory checklist based on experiences from other countries into a QPS. This component will support performance‐based fund transfers to the health center level which are directly proportionate to their QPS score and thereby providing them flexible resources to spend on a specified set of operational expenses that will be specified in the project operations manual. The QPS system will enable more systematic assessment of the quality, and performance of the health centers, in line with the MOH Quality of Health Care (QHC) strategy, and to verify and validate these scores through both internal and external processes. This QPS will provide a composite score based on which payments are released directly to health centers under Component 1 of HANSA. The scorecard will focus on tracer indicators for priority public health programs including MCH,


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communicable disease, immunization, TB, HIV, and nutrition services that will enhance measurement, accountability, and motivation to deliver these services, support integration and improvement of clinical quality, and therefore patient utilization and outcomes. These payments will be channeled through the NHIB and form an added performance layer to the capitation payment already earmarked for individual health centers. The funds will be accounted for through the accounting systems rolled out to the health center level by the Department of Finance (DOF). The DOF, NHIB, DHR, Department of Health Professional Education (DHPE), and Department of Planning and Corporation (DPC) will therefore have to plan and roll out these interventions in close coordination, which will be enabled through the DLIs under Component 2. Efforts will be needed to improve autonomy to use these resources based on the priorities at the local facility level. Rollout will be undertaken in a phased manner to allow the system to evolve and to ensure adequate supervision and capacity‐building effort, especially in the early, adaptive learning stages of the system.

The initial rollout of this performance‐based payment to health centers will take place in the four nutrition convergence provinces in view of the project’s strong focus in these areas. After that, the mechanism will be rolled out in two to four additional provinces in each six‐monthly cycle, to allow time for assessor training and PFM capacity building in a phased and sustained manner. An operational manual of this performance‐based mechanism will be developed within one month after project effectiveness and will include details on the assessment cycle, verification sampling, resolution of variation of scores between assessment and verification, and calculation of the payment based on facility scores and fund flow mechanisms. It is expected that the first pilot will be undertaken in the four northern provinces in January–June 2020, with a perspective to formally roll out the system in these four provinces by the end of 2020 and eventually achieve nationwide rollout in 2–3 years.

A comprehensive QPS will be developed for this purpose under the leadership of the DHR in close coordination with all the technical departments involved. The scorecard will cover multiple dimensions to assess the performance of service delivery and quality, including infection prevention and control (IPC), staff knowledge and skills, availability of key supplies and commodities, delivery of integrated outreach services to Zone 2 and Zone 3 villages, and performance on priority public health programs with a high weightage for indicators on MCH, nutrition, and TB. Scorecard elements related to service availability and readiness for IPC and specific MCH services with a relatively high weightage are aimed at improving the clinical quality and thereby the outcomes of health services rendered at primary care level. Upon development of the scorecard including the clinical vignettes forming part of the same, it will be field tested in selected sites in two different provinces before further adaptations are made. Further, training manuals will be developed based on the existing examples from other countries. It is expected that for the first rollout of the QPS, around 220 health centers in these four nutrition convergence provinces will be assessed. To meet this target, one assessor pool of four medical, nursing, or midwifery professionals will need to be formed and trained in each district, with one team derived from this pool (two assessors per team) expected to assess 10–12 health centers twice a year. To form this pool of certified assessors, the DHR and DHPE will identify the master trainers based on qualification and competence required, who will subsequently train the subnational levels through a cascaded training of the assessors. The assessors are to be selected among the District Health Office (DHO) staff based on their commitment, soft skills, knowledge, rigor, and ability to prioritize sufficient time for this task. Given the importance of culturally and gender‐sensitive skill, assessment and coaching, the assessor pool will include no fewer than one (of four) female assessors; the project will monitor progress toward an average target of two female assessors per team. Provisions such as a ‘bonus score’ in the QPS for health centers


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that have staff who can speak the dialects spoken by the dominant ethnic minorities in the locality of the health center will aim at addressing a key bottleneck to access health services.

As a constituent of the QPS system, the required tools such as clinical cases or vignettes (for commonly encountered clinical conditions) will be developed by the DHPE to measure the quality of services provided at primary care level, with an additional tool to record phone interviews to measure satisfaction levels of patients. The vignette tools will also be included in the QPS. A vignette is a tool to assess the clinical management of a particular case. This will help address issues on quality of care in the short and medium term. The DHR and DHPE will work with other technical departments to develop these tools building on the existing examples of other countries (the most recent being Cambodia) adapting them to the Lao PDR context in accordance with the national guidelines. Further, the tools need to be field tested (in two provinces, as mentioned above) and adjusted based on the experience for the first phase rollout in the four target provinces. Vignettes will be developed for, at minimum, MCH services such as quality ANC and PNC visits, immunization and growth monitoring and promotion visits, and family planning to ensure a focus on closing key gender gaps.

Performance assessment of health centers will take place every six months by certified assessors from the DHO using a structured assessment mechanism. To ensure continued reliability and rigor of the system, a random sample of health centers will be re‐assessed by an external verification agency that will be competitively recruited by the NHIB for this purpose. The first formal assessment is expected to be rolled out over January–February 2021, and over the next two months (March–April 2021), external verification will help compare the results based on a sample. Reconciliation of the results and payment will be in the following two months (May–June 2021). During the same period of May–June 2021, the DHR and DHPE will undertake training for the next set of district assessors for rolling out the system in 2–4 additional provinces. This cycle will then continue every six‐monthly period, increasing the number of health centers assessed in each round, until national rollout is achieved.

To ensure adequate level of effort and competency is maintained to conduct the assessment and also provide coaching to health centers, the assessors’ performance itself will also be assessed by the DHR and Provincial Health Offices (PHOs), as well as technical departments and centers. As such, capacity building of these district‐level assessors and their certification becomes critical to the success of this mechanism. The DHR has therefore proposed that timely training of these assessors throughout the rollout period be included as one of the DLI conditions, which can then also be used to meet the costs of the future rounds of assessments.

The DHR will assume the overall coordination role and technical leadership for Component 1 and will work in close coordination with other technical departments. A QHC technical oversight committee (“QHC committee”) comprising key technical departments as well as the Laos Women’s Union has been established for this component under the leadership of the Director General of DHR, and an operational subcommittee of the QHC committee will be involved in day‐to‐day implementation and decision making, including in finalization of assessment scores. A verification agency will use the same assessments on a random sample basis as well as risk basis, and these scores will be compiled by the NHIB and shared with the QHC committee. Based on these inputs, the DHR will calculate the total performance payment to be added to the capitation payment of the respective health centers and organizing the payment for the same through the DOF and NHIB. The design of the QPS system will be in accordance with the ‘Five Goods, One Satisfaction’ framework used by the MOH, and the expectations on which


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health centers will be monitored will be based on the ESHP and the programmatic roles of health centers in the implementation of public health programs. The component will build upon and learn from earlier and ongoing efforts to improve the quality of health care, such as a hospital quality pilot by JICA in southern provinces and the ongoing TA by the WHO. It will be closely coordinated with a new project being prepared by ADB that will focus on strengthening equipment availability and health worker skills, as important inputs to improve the quality of health services.

Component 2: Service Delivery and Nutrition Convergence (US$17.8 million)

This component will use DLIs. In total there will be 12 DLIs. Several of these DLIs are prioritized toward the four multisectoral nutrition convergence provinces in northern Lao PDR, focusing on the 12 nutrition convergence districts, and the other DLIs have a nationwide footprint. It will continue the legacy of results‐based instruments focused on service delivery improvements from the predecessor HGNDP, adapted to the nutrition convergence approach and to the changing health system configuration in Lao PDR. DLIs will be instrumental in the delivery of HANSA, to organize and implement the quality assessment system, for PFM improvements directed at the health facility level, and to strengthen the integration and sustainability of vertical programs, particularly for TB and HIV.

Table 1. Summary of DLIs

Improved quality of health services at health center level

DLI A Quality performance and service readiness measurement conducted regularly at health center level

DLI B Number of patients who pay out of pocket payment for “Free” Maternal and Child Services reduced

DLI C Availability of essential drugs and supplies at health center level improved

DLI D Number of provinces in which the number of health centers without a clinical health worker, as reported in the DHIS2, has been reduced.

DLI E Improvement of financial management capacity at health center level

DLI F Increase coverage and correctness of event capture reports for selected services

Addressing Malnutrition (focus on 12 nutrition convergence districts in the 4 northern provinces of Oudomxay, Xiengkhuang, Phongsaly, and Huaphan)

DLI G Implementation of Social and Behavioral Change Communication and Growth Monitoring and Promotion activities at village‐level

DLI H Number of villages in Zones 2 and 3 in nutrition convergence provinces in which integrated outreach sessions are conducted

Service Delivery and Priority Public Health Programs

DLI I Number of Immunization Target Districts which have increased the Pentavalent 3 and deliveries with Skilled Birth Attendant

DLI J Number of notified TB cases of all forms (that is, bacteriologically confirmed and clinically diagnosed new and relapse cases).

DLI K Increased coverage of (a) HIV testing among key populations (female service women [FSW]) and men having sex with men [MSM]); (b) and HIV treatment among people living with HIV.

DLI L Increase in national readiness for health security in responding to pandemics and health emergency at international boundaries (airports and ground crossings)

The proposed DLIs will focus on the following:

(a) Improved quality of health services at the health center level. The DLIs will support the monitoring of service readiness and quality at the health center level as well as quality


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performance and service readiness measurements conducted regularly at health center level. Standards for both clinical quality performance and FM, tools for their assessment, and training manuals will be developed. These quality enhancements, trainings, and assessments will initially be rolled out in the four priority nutrition provinces and subsequently to all provinces in a phased manner. Timeliness of these payments as well as reduction of OOP payments for free MCH services will also be supported through these DLIs.

(b) The DLIs will also support supply‐side readiness, including continued availability of essential drugs and supplies at the health center level, placement of additional clinical staff at the health center, and the preparation of a health service decree which will facilitate the local contracting of additional staff and payment of staff incentives when required. Another DLI focusing on enhancement of FM capacity at the health center level is also included. Improved data for and monitoring of individual patients through an MCH tracker system (for instance, to monitor receipt of full ANC/PNC) or through event capture and collection of household data at village level, as well as the information technology to support the QPS system, will be supported through DLIs, improving the availability of sex‐, location‐, and ethnicity‐disaggregated data to inform sectoral policy.

(c) Addressing malnutrition. For nutrition‐specific services, DLIs will focus on the four nutrition convergence provinces to ensure that the basic service improvements at the health center level and the SBCC improvements at the village level are available in support of the multisectoral nutrition convergence agenda. It will support the SBCC and growth monitoring and promotion activities at the village level in the four priority provinces, as well as integrated outreach of five services for villages in Zones 2 and 3 in these four northern provinces. Further, the focus of all the interventions targeted at the four nutrition convergence provinces is particularly on the 12 specified districts where multiple investments are converging. Thus, even though the units of rollout are the entire provinces, the DLI verification protocols for DLI A, DLI C, DLI E, and DLI F will require that targets for each year from year 1 to year 4 will also need the specified achievement in at least 90 health centers in the 12 nutrition convergence districts to be part of the overall targets specified in the DLI. Similarly, for DLI D, a predominant part (greater than 75 percent) of the overall provincial targets specified in year 1 for this DLI needs to be from the 12 convergence districts. The provision of partial achievement for these five DLIs is not applicable if this minimum requirement is not met. Similarly, DLI H will focus on integrated outreach in the 12 convergence districts, though a limited number of villages can be achieved from other districts in the four nutrition convergence provinces, as detailed in the verification protocol. These interventions are at the core of the support HANSA provides to the nutrition convergence agenda and will focus on two key areas:

(i) Improved access to and quality of nutrition services. This will be achieved through better and more quality nutrition services at the facility level (that is, Component 1 and DLI A working together will measure performance on several key indicators on nutrition services, while DLI C will ensure availability of essential nutrition supplements such as Iron‐Folate, Zinc, Vitamin A, and other supplies). Improved access will also be achieved through the continued focus on integrated outreach which will include the provision of


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ANC, immunization, growth monitoring and promotion, family planning, and health education services that all contribute to improved nutrition outcomes.

(ii) Strengthening village‐level SBCC. This component continues the emphasis on a functional platform at the village level which will also provide an opportunity for other convergence projects to leverage for their engagement with pregnant women and mothers/caregivers of children under five. Through improved links with the health system, this also ensures effective and consistent delivery of messages and other services, including growth monitoring and promotion. The SBCC will also target key behavioral drivers of undernutrition and contribute to increasing women’s empowerment along with other convergence projects such as improving women’s diet and rest during pregnancy, delayed marriage, and addressing harmful behaviors and food taboos among ethnic populations. The DLI will require the adaptation of Lao language content into appropriate materials and modalities for ethnic populations. The work plans to achieve this DLI will also need to support activities such as training and materials development on these dimensions. The data reporting period for this DLI will be further specified in the POM so that there is a full 12‐month period during which SBCC performance is measured each year, without any overlaps from year to year.

(d) Strengthening priority public health programs. There will be a special focus on improving the immunization coverage and delivery by skilled birth attendants in 50 districts which are identified as the lowest performing districts on immunization and skilled birth attendance. Support will also be provided to improve case finding and treatment for TB as well as to increase coverage of HIV testing of key populations (FSW and MSM) and increase the number of people living with HIV being enrolled on treatment. Further, the project will support strengthening of health security and preparedness, especially at ports of entry. Through strengthening PFM, improved fund flow and availability, reliability in availability of human resources and supplies, integrated outreach, and strengthening frontline platforms, HANSA enables sustainability and efficiency to deliver these priority public health services. Finally, these DLIs reinforce each other as well as Components 1 and 3. The platforms supported by HANSA for ANC, immunization, and institutional deliveries are also critical platforms to deliver nutrition services and messages, delivering impact of these interventions for multiple priority public health programs, thereby contributing to the achievement of the National Assembly health sector targets. The full DLI matrix and verification protocols are included in annex 1.

Component 3: Adaptive Learning and Project Management (US$6.0 million)

This component will finance project coordination and management costs as well as some critical activities that will support the implementation of the project. These will include investments in health information systems, enhancing the project’s focus on gender and equity dimensions, external verification of results for Components 1 and 2, institutional capacity building for environmental health and safety, regulatory strengthening, M&E, and project coordination and management. The component’s focus on M&E is intertwined with incorporating the lessons learned from implementation to update the design on an ongoing basis, ensuring adaptive learning. Annual review workshops on the QPS system, for example,


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will update the tools and documentation for future rounds of rollout and implementation, based on the feedback received.

Strengthening health information systems. Under the HGNDP, DHIS2 has been instrumental in providing a reliable data source through a web‐based open‐source system. The combination of strengthening and expanding DHIS2 and using the data generated to monitor and disburse against the agreed DLIs is instrumental in supporting the internal verification of the project’s DLIs, with improved timeliness, completeness, and accuracy of data used to assess the achievement of DLI targets. The MOH is now also expanding their innovative approaches of direct data entry in more provinces and pioneering the creation of an offline data entry tool in DHIS2. HANSA will continue to support these efforts toward further integration, expansion, and maintenance of DHIS2. The component will finance any specific expansions required to improve the availability and quality of the project’s gender and equity focus, such as gender and/or wealth stratified data, service continuity (for example, full ANC or complete course of HIV treatment), and so on. The component will provide continued support to identify the gaps in operational cost to implement these DHIS2‐related activities.

Gender and equity focus. HANSA will support an additional consultant at the DPC for the entire project period to support the progress of project implementing entities in gender equality and equity in implementation of the project. This will include mainstreaming gender and equity into Components 1 and 2. The project will also fund gender and equity innovations identified at provincial and service delivery levels to address locally specific bottlenecks. This process will be supported by the gender and equity consultant. The consultant will support the use of gender and ethnicity disaggregated data (being supported under HANSA) and by monitoring the gender responsiveness of project activities, inform policy, and bring challenges to the attention of project management. Key issues will include improving the availability of male and female health workers in remote areas and deepening the outreach and immunization coverage to more villages. The project will support the MOH in building the gender and equity capacity of management and staff in line with the Government’s gender equality and women’s empowerment laws and policies and the ministry’s health sector Gender Strategy as it supports the objectives of HANSA. This will include analysis of key gender gaps, such as the relationship between high adolescent pregnancy and health and nutrition outcomes, and the gender and social vulnerability of key populations (MSM, FSW, and transgender) and PLHIV. A joint gender assessment for HANSA is planned to be undertaken during the first half of 2020. Its findings will inform the development of a Gender Action Plan and terms of reference (TORs) for the gender and equity consultant and focus attention on key areas where the project can directly contribute in this important agenda for the country.

Independent academic institution (IAI) for DLIs and verification agency for QPS scores. HANSA envisages to continue engaging an IAI (as has also been done under the HGNDP) to conduct external verification of DLIs, to be funded by the project on an annual basis. The IAI will be contracted by the National Project Coordination Office (NPCO) through a competitive process. The task of the IAI is to independently verify data on DLIs performed by central and provincial implementing agencies using sample survey methodology agreed in advance with the NPCO (in consultation with the funding partners). Further, under HANSA, another verification agency will be contracted by the NHIB (with the procurement process to be supported by the DPC) to undertake sample and risk‐based verification of the QPS being introduced under Component 1.


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Preparatory cost for rolling out component 1 in the first four nutrition convergence provinces before funding from the first round of DLIs becomes available to the implementing entities will also be funded under this component. For example, the DHR, DOF, and DPC may need to carry out their readiness and capacity building activities in May–June 2020 using these funds through the IDA retroactive financing facility, as well as financing for training and initial assessments for the first round after project effectiveness. This will be in addition to some bridge financing being provided through the HGNDP.

End line nutrition Knowledge, Attitude, and Practices (KAP) survey in convergence provinces, if not funded from any other source, will also need a provision to be funded from HANSA to complete the activity initiated under the HGNDP and to inform future investments in nutrition convergence. This will be particularly important to capture evidence of changes in gender norms and gender division of labor that contribute to improved health and nutrition behaviors and risk reduction including family violence.

Regulatory system enhancements. HANSA will also have a provision to support any seed funding required to improve the regulatory role of the MOH, in relation to service quality (especially in the private sector); regulation of food and drugs (including supplies and equipment); and health professional licensing and health security. However, the nature of this funding will be catalytic and full‐fledged implementation of these activities will need to secure alternative resources. The role of the NHIB as the regulator for the NHI system will also need significant capacity building which will also be funded from Component 3.

Overall project coordination and management. The project will continue to support provision of technical and operational assistance for the day‐to‐day coordination, administration, procurement, FM, environmental and social safeguards, M&E, and financial audit. A technical staff for supporting the QPS will be supported as well. The component will also support provision of capacity building and supervision of MOH staff at all levels—central, provincial, and district—for health program planning and implementation and carrying out of studies and surveys necessary to inform the implementation of activities and of social and environmental safeguards.

Component 4: Contingent Emergency Response (US$0)

The objective of the Contingent Emergency Response Component, with a provisional zero allocation, is to allow for rapid reallocation of credit proceeds during an eligible emergency, disaster, or catastrophic event, with implementation guided by the Emergency Response Manual. It will augment the country’s response capacity in the event of an emergency, following the procedures governed by OP 8.00 (Rapid Response to Crises and Emergencies). The component would finance activities to be implemented only by the MOH as the implementing agency of HANSA, to address health‐related consequences of an eligible natural disaster (such as flooding, landslide, or earthquake) and to respond to health emergencies such as disease outbreaks. In the event of an emergency, financial support could be mobilized by reallocation of funds from other components and/or Additional Financing (AF) to support expenditures on a positive list of goods and/or specific works and services required for emergency recovery. The Emergency Response Manual, governing implementation arrangements for this component, will be prepared by the Government as a condition of effectiveness.


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C. Project Beneficiaries

The project’s target groups include the population of the four nutrition convergence provinces of Lao PDR, especially women and adolescent girls, infants, and young children in the twelve convergence districts in these provinces, who will benefit from the full range of interventions under the project. For several interventions under the project, including QPS at primary care level, as well as several DLIs that have a larger footprint, the project’s coverage will eventually be all users of these services nationwide. In terms of TB and HIV programs, a special focus is on vulnerable populations—such as MSM and FSW in selected high prevalence provinces. A secondary target group for the project are the health workers serving the beneficiaries in the covered provinces, as well as the MOH national and provincial staff who form the supervisory levels for the system, who will benefit from the structured supervision opportunities and the focus on improved skills and knowledge among health providers.

D. Results Chain

E. Rationale for Bank Involvement and Role of Partners

The rationale for World Bank support on primary care, particularly on MCH and nutrition, is strong. Reducing the drivers and intergenerational consequences of undernutrition will be central to


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increasing human capital formation, accelerating poverty reduction, improving gender equity, and achieving sustainable development. HANSA builds upon and aims to sustain the gains achieved under the HGNDP, which supported access to and utilization of key MCH and nutrition services in target areas in Lao PDR. HANSA is expected to commence its disbursements from January 2021, aligned with the beginning of the new HSDP. At the same time, the HGNDP is closing in December 2020, and so there is neither any overlap nor any gap between the two projects. Also, as part of its ongoing restructuring, the HGNDP will likely be positioned to finance several preparatory activities of HANSA which will also help sustain HGNDP investments. By continuing to strengthen underlying government systems in health and subnational administration—such as service delivery, health information management systems, PFM, and governance—the project will further enhance the efficiency of the use of existing public sector resources.

World Bank support through HANSA will be complemented by other TA and knowledge products through the expected programmatic advisory services and analytics that will accompany investment funding. Furthermore, collaboration with sectors beyond health which have impacts on health and nutrition outcomes, such as in social protection, water, agriculture, and infrastructure (for example, Poverty Reduction Fund II), will be done mainly through the multisectoral nutrition convergence approach to reduce stunting, allowing for greater cross‐sectoral links and synergies. The World Bank is also well positioned to leverage expertise from across the World Bank Group to support the project in these areas, as well as in health financing, governance, and PFM, all of which are critical elements to strengthen government systems and support capacity building, which are critical elements of HANSA.

This project will receive co‐financing from the GF25 as well as the IDFHP. The GF aims to support the Government health’s sector reform to reach UHC by 2025 and, through this, enhance sustainability of GF investments. This joint investment is expected to strengthen health systems, increase the GF’s participation in the UHC policy dialogue, enhance programmatic performance for the TB and HIV programs, reduce inefficiencies, and increase financial absorption of GF funding. For both GF and IDFHP, the modalities of results‐based financing are attractive, as it strengthens country ownership of priority public health programs and provides flexibility and autonomy to the country for better planning and helping support the country to prioritize and make decisions based on the actual need at different levels of the health system. In addition, a particular focus of DFAT is to support gender equality and social inclusion as fundamental to equitably advancing UHC. In the highly unlikely event that the co‐financing from GF or IDFHP does not materialize, this will be addressed by an appropriate scaling down of the project, and results framework will be modified to reflect a lower level of achievements through restructuring; this could also be addressed through additional financing from IDA if such resources may be available. Gavi has also supported HANSA interventions through its support to TA for PFM at the decentralized level and to DHIS2. These priorities of the partners closely resonate with World Bank priorities and make for high synergies emanating from the partnership.

From the outset during project preparation, collaboration and coordination with other major development partners and donors (including the GF, Gavi, WHO, ADB, JICA, and others) have also been taking place to seek possibilities of co‐financing and to ensure synergies across interventions in support of the GOL’s efforts. Through the use of results‐based modalities and thereby moving input financing and detailed planning and design to government teams, the project prepares the ground for reduced external financing for these programs in the coming years. It also brings these programs directly on the radar of

25 It is expected that the Co‐financing Agreement between the Lao PDR and the GF will be delivered by August 31, 2020.


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the Government’s budgetary financing mechanisms, as the DLIs would flow to them through the MOF and MOH channel, creating greater recognition of the need for continued investments in these programs while also driving efficiency improvements. Finally, because the payments are based on the desired results and outcomes being achieved, it also keeps the focus on program effectiveness and implementation quality at a high‐performance level.

F. Lessons Learned and Reflected in the Project Design

The project aims to provide technical and financial support to the changing health system configuration in Lao PDR and bringing all key players in closer coordination. Financing through HANSA will complement and leverage both national and development partner financing for health. By encouraging joint and coordinated financing and TA by development partners, it will aim to achieve higher synergies and reduced fragmentation and duplication created by parallel financing from different development partners. The GF is providing approximately 65 percent of its 2021–2023 allocation for TB and HIV programs directly through HANSA, in an innovative co‐financing partnership aimed at the sustainable financing of TB and HIV programs. The activities to be supported directly link to the GF priorities, including DLIs that will help strengthen TB and HIV services such as supply chain, availability and quality of clinical staff at health centers, integration of services at health center level and continuation of support to the rollout of DHIS2, integrated outreach, and so on, as well as multiple focus areas within the health center performance scorecards and project management costs. Beyond its financing for HANSA, the GF will directly finance procurement of drugs and supplies for the TB and HIV programs.

HANSA builds on and sustains successful activities on mainstreaming information systems for health and nutrition services, building on investments from the ongoing HGNDP and its predecessors as well as the past investments made by the GF, including in sourcing TA through the WHO. In December 2017, DHIS2 was adopted through a Ministerial Decree as a national platform for the health information system to collect, consolidate, and report health‐related data and to monitor progress of government indicators.26. This web‐based system has been steadily mainstreamed integrating various vertical program data and Lao PDR remains a leading example of an LMIC which has been able to achieve such integration. The HGNDP has been supporting this process through extensive development, use, and expansion of DHIS2 as a tool to effectively manage and monitor delivery of services through an integrated central platform. With the further shift toward results‐based financing under HANSA, it is expected that DHIS2 will further evolve to provide real‐time health service information, track expenditures and manage basic financial accounting, manage adequate availability of drugs and supplies, and adequately distribute and manage human resources. In the first year of HANSA, event capture at health facilities is expected to expand to the four northern priority provinces, in addition to Luang Prabang and Saravan where these are already rolled out, thus enabling data monitoring and reporting for many of the new features to be introduced under HANSA at the health center level. Prior investments and experience with the HGNDP, as well as ongoing synergies through ‘bridge financing’ expected from the HGNDP, are enabling HANSA to build upon the past lessons. HANSA design is also informed by the analytical work undertaken by the World Bank and its partners, including on the health financing transition, access and equity challenges with MCH services, PFM bottlenecks, teenage pregnancies, community‐level nutrition interventions, and on costing of health services.

26 This includes including 10 national indicators for health, SDGs, UHC, and LDC as well as project DLIs.


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By continuing the use of results‐based instruments that incentivize performance, HANSA aims to achieve greater results from the underlying health sector investments, thereby addressing the constraints of limited fiscal space to increase public spending on health while augmenting performance and results. The project builds on the gains achieved through the ongoing HGNDP, which channeled approximately 80 percent of its current total financing through DLIs. In addition, the DLIs will be continued as the main mechanism to channel funds to central and subnational levels to strengthen the health systems and deliver services more effectively.

HANSA will ensure an enhanced focus on primary care and decentralization. HANSA aims to provide additional resources to the decentralized levels, specifically the health center level, through their performance measured by a structured scorecard, administered twice a year by their supervisory authorities, who will be specially trained and certified for this purpose. The additional resources, directed to key quality and performance priorities, will help create a virtuous circle, incentivizing health centers to invest resources and energy in improving their service quality and performance regarding key public health priorities. It will also make available an increasing quantum of flexible resources they can use for this purpose. It will create structured and uniform supervisory inputs and attention to their performance and thereby help them address challenges in their performance on time. Last but not the least, the health center staff will receive capacity‐building support in FM, creating an environment of improved accountability and increasing autonomy in the use of these flexible resources.

To ensure stronger ownership and sustainability, the project aims to gradually mainstream fiduciary responsibilities into government structures through capacity strengthening at both central and subnational levels. During the project, it is expected that the DOF of the MOH will assume increasing responsibilities in FM and procurement of the project through gradual transfer of capacity from the current Project Coordination Unit setup, with an eventual perspective to mainstream these functions within the ministry structures. Introduction of performance‐based payment at health center levels will also help increase autonomy at the frontline services delivery level and build basic FM capacity at this level to manage their own resources.

HANSA will continue interventions in line with the Country Gender Action Plan for FY2017–21. The HGNDP has been supporting the GOL in addressing some of the major health‐related gender issues, for example, adolescent pregnancy and maternal mortality. Women, in general, still have lower literacy rates than men; their knowledge of how the HIV and sexually transmitted infections (STIs) are transmitted is very low at 19 percent, and this is especially challenging among poor women and in rural areas. Girls constitute the majority of those who have never been to school, and therefore, they face a high risk of teenage pregnancy including the risk of dying due to childbirth, as well as persistent nutrition challenges for themselves and their children. As the project moves forward, gender barriers in accessing key MCH, HIV/AIDS, and TB preventive services and treatment will also be integrated into the systemic health sector interventions to be taken up by HANSA. The Gender Action Plan is of relevance to the health sector. The gender‐specific features of the project are further described in section IV.D.

III. IMPLEMENTATION ARRANGEMENTS

A. Institutional and Implementation Arrangements


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The project will be an Investment Project Financing (IPF) using a mix of input and Results‐based Financing, including the DLI mechanism to reinforce key health system results and a performance‐based payment mechanism at the health center level. In consideration of the current IDA cycle, the project will be front‐loaded with the available resources in IDA18, including retroactive financing, and an AF will need to be undertaken based on disbursement pattern and needs assessment as the project implements.

The institutional arrangement of the project will follow a similar mechanism as that of the HGNDP. At the national level, the existing NPCO in the DPC and the current Program Management Unit (PMU), as the principal recipient of GF financing, will be merged into one consolidated unit to be responsible for overall project management and administration, fiduciary aspects, implementation of project activities, and achievement of DLIs in close coordination with the MOH technical departments and those PHOs and DHOs participating in the project implementation and for M&E.

The NHIB and DHR, the latter working closely with the DHPE, will play a central role in the design and implementation of Component 1, in close coordination with other technical departments including the Food and Drug Department (FDD), Department of Communicable Disease Control (DCDC), DPC, Department of Hygiene and Health Promotion , and DOF. Likewise, centers under these departments will play a critical role in the implementation of activities in their respective key areas.

The DOF will play an increasingly larger role in taking on more fiduciary management responsibilities and in coordinating and taking on the oversight role for building FM capacity at subnational levels, including at the health center level. In addition, the DOF will monitor the Eligible Expenditure Program (EEP) for DLIs under the project and ensure that these are reported to the World Bank at the time of submitting the DLI payment request and for the audit thereof.

At the subnational level, the PHOs and DHOs will continue to assume the roles for monitoring and supervision, especially in the implementation of DLIs and the QPS. Enhanced coordination between provincial levels and district levels is critical. PHOs will be responsible for (a) the implementation of project activities and achievement of DLIs in the province; (b) the monitoring and reporting to the MOH of project activities and achievement of DLIs; and (c) the provision of technical support to DHOs in the implementation of project activities at the district and village levels, including the monitoring of quality performance through the QPS. The DHOs will be responsible for (a) the implementation of project activities, including the six‐monthly quality assessments at the district and health center level, and (b) the supervision and provision of technical support to health facilities in their delivery of health and nutrition services.

In view of the co‐financing from the GF and the use of HANSA as a mechanism for sustainable financing of priority public health programs, the implementation modalities for HANSA will include the Country Coordination Mechanism (CCM) used for HIV, TB, and malaria as a key stakeholder. The interaction with the CCM is expected to be a regular mechanism during implementation support missions for information sharing and seeking feedback from the project stakeholders. In line with the GF processes, the CCM will also play a role in the funding request submission of the co‐financing share of the GF.


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Climate Change

Though climate change is a likely threat to food security and ability to access and provide outreach for health and nutrition services in Lao PDR, it is expected to have a low impact on stunting. Climate change is expected to make extreme weather events and natural disasters such as droughts and floods more severe. Notably, many of the country’s costliest natural disasters have taken place in the past few years, including the 2015–2016 El Niño, and flooding in 2018.27 Climate change is also expected to increase the risks of waterborne and vector borne diseases. The community‐based platforms that the GOL has established to facilitate coordinated multisector inputs to reduce stunting, and will be co‐financed through HANSA DLI financing, are also likely to reduce the adverse impacts of these consequences.

Component 1, through the QPS implemented across all health centers in the country, will also help reduce climate vulnerabilities and improve climate adaptation. The QPS will (i) promote health center readiness to provide services during natural disasters or protracted crises associated with the impact of climate change, and (ii) strengthen health security through surveillance, monitoring, and/or awareness‐raising of climate‐sensitive diseases.

B. Results Monitoring and Evaluation Arrangements

The DPC, through the NPCO, will continue to be responsible for overall M&E of the project. The project will continue tracking the results of DLIs through DHIS2, with further expansion of the system to accommodate other results captured at different levels of the health system, including reporting on financial accounting and village SBCC sessions. Event capture and/or MCH tracker, as feasible, will be rolled out to all the four priority provinces in a phased manner, with scope for further expansion in the country.

A midterm review will be undertaken in CY2022, to assess progress and inform future investments. The timing of the midterm review will thus also be aligned to inform the next cycle of GF financing.

A comprehensive ‘nutrition convergence’ M&E framework (see Annex 4) has been established specifically to (a) track the convergence of the GOL‐World Bank nutrition convergence at the village level; (b) report on process as well as outcome nutrition indicators; and (c) quantify the impact of the convergence approach, its cost‐effectiveness, and effectiveness of individual interventions that are associated with individual projects. This will be achieved by tracking the delivery of interventions at the village level, monitoring the process, measuring household‐ and individual‐level outcomes, and imbedding impact evaluations in the projects to measure attributable impacts of the portfolio interventions.

The evidence base for the proposed project and overall convergence approach will build on the results of the KAP survey under the HGNDP; the first KAP survey was conducted in the 12 priority districts in July–August 2017. The information gathered from this survey is informing the design of the SBCC and overall program design. A follow‐up KAP survey is scheduled for 2020 (last year of HGNDP implementation). These studies will enable a deeper understanding of the sociocultural norms, behaviors,

27 https://www.gfdrr.org/en/lao‐peoples‐democratic‐republic; https://www.worldbank.org/en/news/feature/2019/04/09/recovery‐and‐resilience‐in‐lao‐pdr.


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enabling environments, and obstacles to improved health and nutrition‐related practices. The follow‐on survey will serve as the baseline for the proposed nutrition multisectoral programmatic approach, and resources would be provided under this project to finance one more round of the KAP as the end line for Phase 1 of nutrition convergence. This subcomponent will also finance qualitative studies in the 12 selected districts, which will be designed to complement parallel quantitative data gathering efforts.

C. Sustainability

The project was designed in response to the changing health financing context in Lao PDR, with the imminent reduction in external financing and growing importance of the NHI. As such, sustainability is one of the foremost design considerations for HANSA. One key focus is on strengthening primary health care performance, which is known to be cost‐effective, equitable, and at the heart of UHC. With a view to ensuring sustainability of activities, the project intends to increasingly use government structures, and with a focus on results, it inspires autonomy and the use of national planning and implementation modalities.

IV. PROJECT APPRAISAL SUMMARY

A. Technical, Economic, and Financial Analysis

Economic Analysis

Rationale for Public Intervention

Public financing and provision of health and nutrition services focusing on women, children, and vulnerable populations are justifiable due to market failures, externalities, and equity grounds. Well‐targeted investments can yield broad and long‐standing benefits beyond immediate health outcomes and improvement in nutrition status, such as better protection against catastrophic health spending, reduction of inequality through more equal access to RMNCAH and nutrition services and strengthening of the health system generally (for example, through service integration) help in paving the way toward UHC.

There is strong commitment from the GOL and the World Bank to address financing and delivery bottlenecks for nutrition and health services in Lao PDR under the nutrition convergence agenda. The growing understanding of the links between ill health and high stunting rates at young ages and the lifelong negative consequences and costs to society of these conditions has cemented the political commitment. The design leverages and builds on existing institutional structures and service delivery mechanism both at facility and community level. While the proposed expansion of health and nutrition services can be ambitious, the focus on decentralizing financing to the frontlines increases the capacity of frontline service providers and improves overall quality and performance of health service delivery.

Description of Development Impact of the Project

The project aims to increase access and utilization of quality MCH and nutrition services which are essential for improved maternal and child nutritional outcomes. Access to quality health care has been recognized as an important health system priority. Mortality in LMICs due to poor care surpasses


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mortality attributable to lack of access to care. According to the recent study by Kruk et al. (2018),28 8.6 million people die from treatable conditions in LMICs annually, 3.6 million from lack of access, and the remaining 5 million from insufficient care. The loss of productivity alone in LMICs due to low quality care is estimated at between US$1.4 trillion and US$1.6 trillion annually. Ineffective care also contributes to additional direct treatment costs to the health system.

Interventions aimed at improved MCH have been identified as some of the most cost‐effective interventions. The global investment framework for RMNCAH finds that US$1 invested in the essential package of MCH and nutrition interventions is estimated to yield about US$9 in economic benefits. At the macro level, investments in MCH and nutrition interventions reduce national economic losses attributed to increased mortality morbidity and decreased cognitive ability which directly reduces educational attainment and labor productivity in adults. In Lao PDR, a recent study estimated economic losses associated with undernutrition of at least US$200 million annually, representing about 2.4 percent of the country’s GDP.29

Increased investment in public health programs has largely been associated with lower health care costs, improved population health outcomes as well as improved efficiency and productivity of the health system. The project will contribute to saving health care costs related to treating TB and HIV by supporting improved case finding and treatment for TB, increased coverage of HIV testing among high‐risk populations, and treatment for persons living with HIV. The geographic convergence under this project will not only contribute to improved allocative efficiency but also to health equity by targeting resources where they are most needed.

Economic Benefits of Investing in Health and Nutrition

An evaluation of the impact of the interventions financed through this project on health and nutrition outcomes was conducted, and the net present value of the project, the internal rate of return, and the benefit‐cost ratio were calculated. Specifically, the analysis employs the Lives Saved Tool (LiST) to estimate the impact of the project in terms of the number of deaths averted by the different health interventions. LiST was used to model the impact of expanding the coverage of the following MCH and nutrition‐specific interventions: iron supplementation in pregnancy, skilled birth attendance, health facility delivery, exclusive breastfeeding of children less than one month, injectable antibiotics for neonatal sepsis/pneumonia, and oral rehydration solution for the treatment of diarrhea.

The impact modelling using LiST showed that the project would result in 2,226 child deaths averted (904 of whom were less than one month) and 28 maternal deaths averted over 2020–2024. The impact of the project on health and nutrition status of women and children would translate into substantial economic benefits. Table 2 summarizes the expected net benefits and benefit‐cost ratios with discount rates of 0 percent, 3 percent, and 10 percent.

28 Kruk, Margaret E., Anna D. Gage, Naima T. Joseph, Goodarz Danaei, Sebastián García‐Saisó, and Joshua A. Salomon. 2018. “Mortality Due to Low‐quality Health Systems in the Universal Health Coverage Era: a Systematic Analysis of Amenable Deaths in 137 Countries.” The Lancet 392.10160: 2203–2212. 29 Bagriansky, Jack, and Saykham Voladet. 2013. “The Economic Consequences of Malnutrition in Lao PDR: A Damage Assessment Report.” NERI and UNICEF Working Paper.


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Table 2. Expected Net Benefits and Benefit‐Cost Ratios

Project Cost: US$36 million

Discount Rate Net Benefit (US$, millions) Benefit‐Cost Ratio

0 percent 59.6 1.66

3 percent 51.4 1.43

10 percent 37.0 1.03

The results of a cost‐benefit analysis show that each US$1 invested by the project would generate at least US$1.03 in benefits and could generate up to US$1.66 (see annex 6 for assumptions, methods, data, and results). Conservative assumptions have been used for the expected impact of this project and therefore it is likely that the real benefits have been underestimated. If only the impact of the program on child mortality is considered, one under‐five death would be averted at US$16,200 and a disability‐adjusted life year (DALY) would be saved at the cost of US$990. According to the WHO criteria,30an intervention that averts one additional DALY at a cost of less than GDP per capita is considered as ‘very cost‐effective’ and an intervention that averts one additional DALY at a cost of between one‐ and three‐times GDP per capita is deemed ‘cost‐effective’ and representing ‘good value for money’. According to this benchmark, the project could be considered as ‘very cost‐effective’ from its impact on child mortality alone.

Financial Sustainability

The financial implications of the proposed project investment over 2020–2024 was assessed using three scenarios: (1) general government health expenditure (GGHE) remains at the current level of 7.9 percent of general government expenditure (GGE), (2) GGHE reaches 9 percent of GGE as per commitment by the GOL, and (3) GGHE is as per the 9th HSDP. The proposed project financing accounts for about 1.8 percent of the government expenditure on health over 2020–2024 if GGHE remains at the current level (Scenario 1), 1.6 percent if GGHE reaches 9 percent of GGE as per commitment by the GOL (Scenario 2), and 1.2 percent if GGHE is set according to the 9th HSDP (Scenario 3).

If the project investment is spread evenly across the project period, it would increase government per capita spending in 2024 by US$0.94, from US$60.02 to US$60.96 in Scenario 1, from US$70.72 to US$71.66 in Scenario 2, and from US$92.33 to US$93.26 in Scenario 3. The increase in per capita spending is relatively small and it is, therefore, expected that this project will be financially sustainable. Further, the project contributes to financial sustainability of priority public health programs by mainstreaming investments of TB and HIV programs through government systems and giving greater autonomy in programming of these funds using government systems.

B. Fiduciary

(i) Financial Management

In view of the MOH’s experience with DLIs and the risk mitigation strategies to be pursued at implementation, the overall FM risk is considered Substantial. The main FM risks identified are weak

30 WHO (World Health Organization). 2002. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva: WHO


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capacity and lack of experience at all levels, from the central level to the district level. In addition, the FM assessment identified weak segregation of duties among the staff members performing financial accounting and reporting roles at all levels. The weak capacity results from limited number of qualified personnel for accounting and financial reporting tasks. The limited staff has also contributed to lack of segregation as the same staff members perform incompatible duties. Limited staffing strength and capacity together with weak internal controls have contributed to a weak control environment at all levels assessed. All these inadequacies can lead to noncompliance risk to fiduciary requirements, unsatisfactory accounting records, and misuse of funds.

Budgeting and planning. A budget shall be prepared for each component annually and cover the period of the GOL fiscal year (January to December) and in accordance with the approved annual work plan. The quality of budgeting and forecasting will be strengthened as part of support provided by the NPCO. The NPCO will elaborate the process and timing for the preparation and approval of the annual budget following similar process stated in the State Budget Law. Project annual budget will be reviewed and approved by the task team.

Accounting policies and procedures. The existing Financial Management Manual (FMM) for the HGNDP is acceptable for use in HANSA. A cash basis of accounting will be used by the project to prepare financial statements. ACCPAC accounting software, currently used in other World Bank‐financed projects, will be used to record transactions and produce project financial reports. Field offices will also use the same software to record transactions and enable automatic download of financial data, where applicable. Separate books of accounts will be maintained for the project.

Financial reporting. The project will follow the GOL fiscal year (January to December). Interim Unaudited interim financial reports (IUFRs) will be prepared by the NPCO and will cover the period of six months (semester) and will be due for submission within 45 days of the end of each semester. The IUFR will follow a format agreed with the World Bank and report on sources and uses of funds by project components/activities including fund balances. Variance analysis between actual and budgeted expenditure will be performed and reported as part of the IUFR. The NPCO will also prepare the project annual financial report for audit.

Audit arrangements. The project will be subject to an annual audit by qualified auditors to be recruited on behalf of the project by the MOH, with TORs acceptable to the World Bank and GF. The audit will cover expenditure incurred at all levels; the audit report together with a Management Letter will be submitted to the World Bank no later than six months of each fiscal year end. Audited financial statement and audit opinion will also be subject to disclosure in accordance with the World Bank Policy on Access to Information. Mechanism for disclosure will be agreed.

Funding for Component 2 will be channeled through a government system and will finance specific budget line items constituting the ‘Eligible Expenditure Program’. There is a risk that the departments in the MOH which were not included in the DLI modality under the HGNDP and the provinces/districts which were not involved directly may take time to understand this new combined programmatic and results‐based mechanism and may not use the additional funding optimally for achieving the agreed objectives. Building on lessons learned from the HGNDP, the project will provide capacity building on the new funding mechanism at the central and provincial levels. Verification of


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achievement of the DLIs by an independent agent is crucial, and funds are expected to be allocated to contract an independent institution to fulfill this requirement.

For Components 1, 3, and 4, a Designated Account (DA) will be set up at the Bank of the Lao PDR to channel project funds to the DOF in the MOH to be used for making payments for project activities. The IDA and MTDF funds will be pooled in one DA. The GF may set up and pool its DA with IDA or keep it separately. All draw‐downs would have two signatories: Panel A: project manager, assistant project manager, or a designated MOH officer for the project; Panel B: Deputy Director General of the DOF or FM specialist. Such arrangements should be mirrored at the targeted provincial level and at district levels of the NHIB where DAs shall also be set up as a transitional measure until direct electronic transfers to health centers are made functional.

Disbursement under Component 2 relating to the EEP will be based on the MOH fulfilling the following requirements: (a) adopting the Project Operations Manual, in form and substance satisfactory to the World Bank; (b) furnishing evidence satisfactory to IDA that it has achieved the respective DLIs targets, including a memorandum of understanding, in form and substance satisfactory to the World Bank, which has been duly executed between the MOH, the target province, and health facilities; and (c) furnishing to the World Bank the IUFRs documenting the incurrence of EEPs against which withdrawal is requested. If the EEP is lower than the DLI values, the disbursement of IDA will be adjusted accordingly—a situation which is not expected to occur. The proposed EEP, which will be set forth in the Project Operations Manual, would consist of the GOL’s expenditure line Chapter 60 (wages, salaries for government health staff). The budget figure for Chapter 60 is adequate for the EEPs. The IUFR will also include evidence of the additionality that IDA funds bring to the central and the provincial level allocation of the GOL and provincial budget (not applicable in the first year).

(ii) Procurement

Out of the total project financing of US$36 million, US$17.8 million would finance service delivery and nutrition convergence through DLIs under Component 2. US$12.2 million is allocated for integrating service delivery performance with NHI payments under Component 1. The rest of the funds will finance TA and capacity building at the central and subnational levels. Procurement under Component 3 of the project will be carried out in accordance with Procurement Regulations for IPF borrowers dated July 1, 2016, revised November 2017 and August 2018, and provisions stipulated in the Financing Agreement. Procurement under Component 4 will be carried out based on provisions on an Emergency Response Manual to be agreed between the GOL and the World Bank. The World Bank’s Systematic Tracking of Exchanges in Procurement (STEP) will be used for all procurement transactions, that is, preparing and updating of Procurement Plans and processing, clearing, communicating, and tracking of procurement activities.

According to the institutional arrangements, the DPC, which is responsible for procurement under the previous World Bank‐financed projects will be responsible for the procurement, overall coordination, supervision, and management of the proposed project with assistance of a national procurement consultant as under the previous World Bank‐funded project. Based on the procurement performance of the DPC under the previous project, the capacity of the DPC to manage procurement activities was found adequate with further strengthening. The procurement risk is rated Moderate based


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on the capacity and risk assessment. The key risks and the corresponding mitigation measures are discussed in annex 1.

C. Safeguards

Environmental Safeguards

OP/BP 4.01 ‐ Environmental Assessment will be triggered under the project. However, potential environmental impacts are assessed to be minor and site specific and for which mitigation measures can be readily designed. The minor renovation and refurbishing activities may generate limited adverse environmental impacts such as dust, noise, vibration, waste, solid waste, safety issues, and health risks associated with exposure to asbestos‐containing materials. The project support in service delivery at health centers will result in increased generation of health care waste including sharps, infectious waste and anatomical waste (placenta), which is expected to be a small amount. To avoid any possible impacts during renovation works, specific Environmental Code of Practices (ECOPs) will be implemented by contractors (or those responsible) for health care facilities’ renovation/refurbishment activities. Health centers in HANSA will follow sharp waste management guidelines, which have been recently developed under the HGNDP and are in line with the MOH’s regulations and international guidelines.

An Environmental l Management Framework (EMF) has been prepared and publicly disclosed on the MOH’s website and on the World Bank website on January 3, 2020. The ESMF will provide (a) guidance for screening and managing potential environmental impacts; (b) ECOPs to be implemented by contractors (or those responsible) for health facilities’ renovation/refurbishment activities; (c) a guideline for safe management of health care waste with a focus on sharps waste to be followed by health centers; and (d) capacity building and M&E to be carried by project implementing agencies. The EMF, including ECOPs and health care waste management (HCWM) plan, will be part of the Project Operations Manual.

The project monitoring and reporting system will cover environmental safeguard aspects. It is expected that some indicators on HCWM and IPC will be part of the QPS under Component 1, with regular assessments and verification every six months, enabling the MOH to monitor actual practices at the health center level.

Institutional capacity for environmental, health, and safety. A training program on HCWM and IPC will be developed and provided to health care professionals. Training curriculum will cover (a) segregation, containment, handling and storage, transport, treatment, and disposal of health care waste, especially sharps; (b) handwashing, disinfection, and sterilization; use of personal protective equipment; and prophylaxis treatment of exposures; and (c) ECOPs in renovation or repairs of any health facilities as needed. The NPCO will hire a consultant with HCWM and IPC skills who will provide guidance and training of trainers at the provincial and district levels, who are responsible for training all primary stakeholders involved in health care facilities. In addition, information, education, and communication (IEC) materials on the correct management of health care wastes will be developed to build awareness among health care workers.


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Social Safeguards

The implementation of the project, particularly Component 1 and several DLIs under Component 2, will start with four nutrition convergence provinces in northern Lao PDR where the majority ethnic groups reside. The project would then be rolled out to cover all provinces. It is expected that the project will expand these activities to an additional two to four provinces in each six‐monthly cycle. Final areas and timing for the expansion will be included in the Operations Manual and monitored by the Steering Committee in charge of the project. For the DLIs addressing TB and HIV, the provinces will be selected based on their TB and HIV prevalence—specifically in high‐risk groups such as FSW, MSM, and transgender.

As the project is national in scale, it will have to consider the needs of all ethnic minority groups of Lao PDR in its design. The ethnolinguistic classification of ethnic groups in Lao PDR identifies 49 categories of ethnic groups and over 160 subgroups. The four main categories are the Lao‐Tai, Mon‐Khmer, Hmong‐Mien, and Sino‐Tibetan. The project is expected to help strengthen inclusion and accessibility to health services of the poor and vulnerable groups as well as ethnic groups especially those in remote rural areas. While adverse impacts on indigenous peoples or vulnerable groups are not expected, the project will benefit these groups, and as such, the World Bank OP 4.10 on Indigenous Peoples is triggered. To both understand risks and impact and inform the project design, an Ethnic Group Development Framework (EGDF) and a social assessment was undertaken.

The project will trigger OP/BP 4.10 ‐ Indigenous Peoples, given the intervention in geographic areas where many ethnic groups reside. The social assessment of the risks and social impact was conducted and disclosed in‐country on December 25, 2019, and on the World Bank website on January 3, 2020, with a focus on two key aspects: access to the NHI and MCH as well as nutrition services. The document identified vulnerable social groups and social and cultural issues relevant for the project, including issues and risks concerning ethnic groups, following the World Bank OP 4.10, to ensure that the project provides culturally appropriate benefits and would not have adverse social impacts. Some of the key health sector issues identified by the social assessment include affordability, language and culture, limited health staff, and poor information dissemination. Some specific issues include the following:

(a) For NHI (Component 1), key issues are the following: (i) there is limited access to information on the NHI coverage, (ii) there is limited understanding by the beneficiaries of the certified documents needed to avail the service, (iii) lists of the poor to receive exemption from payment are not up to date and not distributed to the health facilities, (iv) some patients reported paying extra fees on top of co‐payment or user fees, and (v) health facility staff have limited knowledge and capacity regarding NHI implementation.

(b) For the MCH and nutrition services (Component 2), key issues are the following: (i) health care staff have limited capacity to provide basic primary care; (ii) there is a limited number of trained female skilled birth attendant staff to enable access for ethnic women; (iii) health facilities do not have staff who can speak ethnic languages; (iv) the physical environment for birthing rooms is inappropriate, needs to be more culturally acceptable, and must incorporate non‐harmful women’s cultural practices; (v) there is limited awareness of the importance of facility‐based delivery and other MCH services; remote rural communities believe that pregnancy and childbirth are ‘natural’ occurrences and do not require medical


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treatment; and (vi) men have limited understanding in general on the importance of MCH services. In Lao PDR, men hold decision‐making power over whether or not members of a household seek medical care, including MCH services.

To enhance project benefits for vulnerable and underserved population groups, the project has built on the EGDF of the HGNDP, which provides a good foundation for social inclusion for vulnerable groups including ethnic groups. As the exact areas and sequencing of project rollout have not been fully identified, an EGDF for HANSA was publicly disclosed in‐country on December 25, 2019 and was disclosed on January 3, 2020. The EGDF includes the elements of an ‘Indigenous Peoples Planning Framework’ required under OP/BP 4.10 and incorporates procedures for consultations, monitoring, and feedback redress mechanisms during implementation. The MOH will prepare Operations Guidelines which incorporate key principles of the EGDF. The NPCO will also be responsible for preparing the EGDP in all participating provinces once the rollout plans have been decided by the relevant government committee. The EGDPs will be submitted for the World Bank clearance before the implementation of the project in these areas. The project will provide capacity‐building and training support for staff to supervise and implement the project.

Free, prior, and informed consultations were conducted in 23 villages of the four poorer northern provinces where the majority of ethnic groups reside. Discussions focused on the project, key findings from the social assessment, and measures of the EGDF. Main recommendations from the consultations include (a) ensuring that there are ethnic staff at the health facilities to enhance communication with beneficiaries on both NHI and MCH services; (b) having regular outreach teams to provide MCH services and provide more information on the NHI at the communities; (c) having village chiefs and health facility staff discuss with family members or villagers who are still practicing health risk behaviors; (d) having an active emergency number which the poor, ethnic, and illiterate populations can communicate with when facing NHI or MCH issues; (e) ensuring availability of essential drugs and supplies at the health centers; and (f) improving capacity of health staff to manage the implementation of NHI and MCH services.

Overall, participants expressed community support for the project and for measures provided in the EGDF to ensure that the project would benefit the underserved, including women, the poor, and ethnic groups. The EGDF has incorporated recommendations from the social assessment and from the free, prior, and informed consultations as follows: (a) enhancing the project safeguards committee to include representatives from relevant agencies implementing the project, especially the NHIB, the DCDC, and the DHR; (b) providing sufficient budget and training for staff on safeguards at all levels to ensure effective safeguards implementation; (c) developing all the IEC materials in ethnic languages and distributing to health offices at all levels especially at the health centers; (d) recruiting more ethnic staff at the health centers; (e) working closely with the Laos Women’s Union and the Lao Front for National Development to ensure effective outreach to ethnic groups in the operating areas; (f) ensuring that the feedback redress mechanisms are known to local communities and are systematically reported to the safeguard committees; and (g) improving safeguards monitoring by integrating safeguards into the QPS as well as DLIs.


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V. GRIEVANCE REDRESS MECHANISM

Communities and individuals who believe that they are adversely affected by a World Bank supported project may submit complaints to existing project‐level grievance redress mechanisms or the WB’s Grievance Redress Service (GRS). The GRS ensures that complaints received are promptly reviewed in order to address project‐related concerns. Project affected communities and individuals may submit their complaint to the WB’s independent Inspection Panel which determines whether harm occurred, or could occur, as a result of WB non‐compliance with its policies and procedures. Complaints may be submitted at any time after concerns have been brought directly to the World Bank’s attention, and Bank Management has been given an opportunity to respond. For information on how to submit complaints to the World Bank’s corporate Grievance Redress Service (GRS), please visit http://www.worldbank.org/en/projects‐operations/products‐and‐services/grievance‐redress‐service. For information on how to submit complaints to the World Bank Inspection Panel, please visit www.inspectionpanel.org.

D. Gender

HANSA is consistent with the Country Gender Action Plan for FY2017–2021, which includes four main priority areas being addressed: (a) early marriage, adolescent pregnancy, and high maternal mortality rate; (b) low literacy and skills gap among women; (c) equal opportunities for men and women to participate in livelihood activities and wage jobs; and (d) participation of women in planning and decision making at the local level. HANSA will focus on priority (a), (b), and (d) of the Gender Action Plan, through the development and implementation of the QPS at health centers level; provision of the RMNCAH, HIV/AIDS, and TB‐related services through DLIs at all levels; and technical support to the MOH to improve the readiness and capacity of the health facilities and health personnel at frontline level for delivery of quality of health services, reduce financial barriers of patients with chronic diseases such as TB and HIV/AIDS, better FM, and faster disbursement of NHI funds at health center level.

The social assessment carried out for the project identified several important gender gaps that will be addressed by the project, including the limited access to quality and essential family planning, maternal health and nutrition services, limited readiness of health facilities and lack of attention to gender sensitivity and privacy, language barrier for ethnic women, and cultural belief of ethnic community toward the roles of women and violence against women. In general, both women and men in the rural areas of the country have limited access to health care services. Women, girls and boys, and MSM are the main beneficiaries of the project. HANSA will minimize the gender gaps, with particular focus on the targeted beneficiaries in the project areas.

Limited access to quality and essential family planning, maternal health, and nutrition services by women and adolescent girls are risk factors for their morbidity and mortality and translates into inadequate nutrition and immunization for their children. To address these challenges, while HANSA is moving toward the quality of health care service, it will incentivize, through the QPS as well as through DLIs, the delivery of outreach services (including family planning, ANC, immunization, and growth monitoring and counselling); deliveries assisted by skilled birth attendants; and provision of family planning and nutrition commodities. Delivery with assistance by skilled birth attendants is a PDO indicator, and it is also a national indicator monitored by the National Assembly. The PDO results indicators will


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measure the impact of these gender interventions. Intermediate indicators, including exclusive breast feeding, growth monitoring, immunization, nutrition supplements (Vitamin A and iron folic acid), also incorporate and monitor gender aspects of the project. The data will be increasingly differentiated by gender and tracked through the rollout of event capture in the routine DHIS2 system and through household surveys.

Limited readiness of health facilities and challenges around gender sensitivity and privacy discourage the utilization of institutional deliveries and health care services by women and adolescent girls. Ensuring that women receiving the health care services that they need from a qualified and skilled health worker, who can communicate in their language, is critical to promoting gender rights. To do so, the project will need to solve the issues around the lack of basic equipment and supplies; lifesaving drugs for childbirth; appropriate privacy in the delivery and consultation areas at health facility level; and availability of qualified, preferably female health workers. The project will incentivize improvements of the health facility and delivery of quality maternal and reproductive health, HIV/TB screening and advice, and nutrition counseling through the QPS. The QPS will deliver systematic assessment of the health center performance across the key dimension of quality of service delivery and gender, verified by an independent institution. The relevant intermediate indicators to track these activities include the number of women who receive essential health and nutrition services, as well as the various elements of the QPS scorecard and the DLIs on HIV and TB screening and treatment (DLIs J and K) and number of health centers which have at least 85 percent of 30 days stock of agreed list of drugs and commodities.

Language constraints for ethnic minority women are a major access barrier, also preventing them from obtaining knowledge on the importance of ANC, immunization, and adequate nutrition and understanding how HIV/TB/STI is transmitted. Anemic pregnant women are likely to give birth to low birth weight children. Pregnant women are also at risk of HIV infections, and unfortunately only 29 percent of them received screening as part of their ANC. The project will encourage the presence of health workers who can converse in the local ethnic languages and dialects, as well as promote the availability of health information and communication materials in key ethnolinguistic families, adapting the existing materials which have already included messages on nutrition, family planning, antenatal and postnatal care, HIV/TB/STI, and other priority public health challenges disproportionately affecting ethnic minority women. The project will measure the output and outcome of these actions through administrative data from the QPS, as well as from household survey data.

Cultural beliefs of ethnic communities toward the roles of women is a common cross‐cutting gender inequality issue in Lao PDR. The project will try to address this from the health sector perspective, especially as it is related to adolescent pregnancy and the social and culture norms that influence health and nutrition. Early marriage, particularly in rural areas and among ethnic girls, remains widely accepted and is leading to teenage pregnancy, early childbirth, and domestic violence. Cultural belief of ethnic community toward the roles of young women as a wife, a daughter, and granddaughter also affect behavior and decision making toward health seeking behavior, nutrition, and family planning—and are often promoted, or at times reinforced, by influential family members such as grandmothers, mother, and husbands. Food taboos and forbidding of family planning methods are among the most common practices affecting ethnic women. Direct involvement of the community is crucial for addressing such aspects of gender inequality. Following the lessons learned from the HGNDP of having at least two women trained as village facilitators for the MCH and nutrition behavior changes and communication as part of the village SBCC platform has the potential to increase the utilization of institutional delivery, family planning, and


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women’s empowerment. Women closely engage in planning and decision making for SBCC interventions at the community level. Men and village authorities also participate in the SBCC interventions which will be continued under HANSA, wherein they are encouraged to take the responsibility of doing household work while their wife is pregnant or in the lactation period. HANSA will incentivize and also monitor these practices as part of the SBCC platform through DLIs.

In addition to these main activities, the project will further support closure in other gender gaps in accessing health insurance especially among ethnic minority female headed households. Under Component 1, the project will work closely with the NHIB to review the current available sex‐disaggregated data (and also by ethnicity and geographical location, as available) of populations that have accessed and benefitted from the NHI scheme and identify constraints in access and affordability of health insurance, mainly among the poor and near poor, ethnic minorities, and women‐headed households. The project will also aim to reduce the constraints arising from the lack of information and knowledge about the availability and benefits of NHI, by using the SBCC platform and other information‐sharing modalities in the major ethnic languages.

C. KEY RISKS

The overall project risk is considered Substantial based on the governance and political, macroeconomic, sector strategies and policies, technical design, institutional capacity, fiduciary, and stakeholder risks.

(a) Governance and political risks. Uncertainties around the extent of future coordination across technical departments and reporting lines in the MOH that this project necessitates and requires doing things differently from the level of coordination that would normally exist in the ministry. Mitigation measures include assisting GoL in enhancing the coordination efforts, through regular meetings, joint supervisions and harmonization of reporting.

(b) Macroeconomic risks relate to the continued fiscal capacity of the Government to provide adequate financing for the health sector in general and the NHIB in particular, which may adversely affect the project. Resources provided through DLIs should insulate the project from wider macro‐fiscal developments. Continued advocacy for maintaining adequate financing for key social sector interventions and the Government’s own commitment to emerge out of the least‐developed country status will be important mitigating factors.

(c) Sector strategies and policies are seen as a Substantial risk. Though the project is fully aligned with the National HSDP 2021–2025, as well as the strategies of key public health programs, the implementation capacities for sectoral strategies remain modest in relation to the scale of ambition. It is expected that the complete alignment of program priorities combined with the leverage of performance‐based instruments in HANSA will work in synergy and help mitigate this risk.

(d) Technical design. For a large part, HANSA will build on activities and implementation arrangements that have been tested in Lao PDR or elsewhere in the region, and lessons from implementing the predecessor project HGNDP will be considered in the design of HANSA. Introduction of the QPS is a new undertaking in Lao PDR and may require extensive awareness raising and information sharing for the system to be well understood. Mitigation


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measures include awareness raising and adaptive learning and strengthened technical support at both central and subnational levels.

(e) Institutional capacity. The institutional capacity at the NHIB to implement the many functions needed for an NHI system will need considerable strengthening and will be mitigated through ongoing capacity building supported by Component 3 as well as external TA from the development partners. Further, being able to send funds to health center levels may face delays/challenges due to the limited capacity of FM at health center levels. Capacity constraints to effectively use the DLIs as a funding mechanism still exist especially at the subnational levels, albeit with significant improvements in the knowledge and awareness gained through the ongoing HGNDP. There are also continued risks of interpretation gaps in the DLI definitions and verification methodologies, resulting in delays to validate the results. These risks will be mitigated by capacity building of provincial‐ and district‐level authorities in their understanding and management of DLIs, capacity building of health center staff especially in the areas of FM, strengthening of the third‐party verification, and intensified monitoring and supervision.

(f) Fiduciary. Potential delays in the transfer of money earned by DLIs to reach subnational levels, as well as the weak accounting and reporting systems at health facility levels once the money flows to this level with NHIB payments, will be mitigated through intensified support to strengthening the FM capacity from central level down to facility levels. In addition, the ongoing Programmatic Analytical Services and Advisory (PASA) has a TA component to support health financing reforms focusing on capacity strengthening of the MOH and NHIB in managing public financing for health in an efficient, effective, and sustainable manner, which will complement any support provided under HANSA.

(g) Stakeholder risks. One of the key reforms that the project will support is sustaining the consolidation of public health financing schemes into a single NHI scheme. Institutional capacity constraints of the NHIB also pose a risk as the project design requires a fully operational and sustainable NHI system, requiring strengthening of its legal status and institutional mechanisms. Mitigating measures will include strengthening of NHIB's legal status and institutional mechanisms.

.


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VI. RESULTS FRAMEWORK AND MONITORING

Results Framework

COUNTRY: Lao People's Democratic Republic Health and Nutrition Services Access Project

Project Development Objectives(s)

To improve access to quality health and nutrition services in targeted areas of Lao PDR.

Project Development Objective Indicators

RESULT_FRAME_TBL_PDO

Indicator Name DLI Baseline End Target

Improved access to quality healthcare services

Number of deliveries attended by a skilled birth attendant (Number)

114,124.00 119,830.00

Number of health centers scoring above 60% on a standard quality assessment system (Number)

0.00 600.00

Improved access to quality nutrition services

Percentage of children under 2 years of age whose growth is adequately monitored as per national guidelines in the twelve nutrition convergence districts (Percentage)

0.00 80.00

Percentage of pregnant women who receive 4 Antenatal Care contacts in the twelve nutrition convergence districts (Percentage)

52.00 62.00

Increasing the utilization of primary care and improving efficiency of public spending

Share of outpatient cases delivered at the primary healthcare 43.00 50.00


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RESULT_FRAME_TBL_PDO


facilities among the total outpatient services delivered in the country (including hospitals) (Percentage) PDO Table SPACE

Intermediate Results Indicators by Components

RESULT_FRAME_TBL_IO


Integrating Service Delivery Performance with National Health Insurance Payments

Number of health centers that have had regular (twice per year) quality assessment visits and verified (Number)

0.00 800.00

Number of health centers that received their payments within the prescribed timeline in the latest round of quality assessments (Number)

0.00 800.00

Service Delivery and Nutrition Convergence

Number of health centers which have at least 85% of 30 days' stock of agreed list of drugs and commodities (DLI C) (Number) DLI 3 0.00 800.00

Number of health centers assessed and certified in financial management (DLI E) (Number) DLI 5 0.00 800.00

People who have received essential health, nutrition, and population (HNP) services (CRI, Number) 0.00 1,200,000.00

People who have received essential health, nutrition, and population (HNP) services ‐ Female (RMS requirement) (CRI, Number)

0.00 960,000.00

Number of children immunized (CRI, Number) 0.00 200,000.00

Number of women and children who have received basic nutrition services (CRI, Number) 0.00 400,000.00

Number of deliveries attended by skilled health personnel 0.00 400,000.00


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RESULT_FRAME_TBL_IO


(CRI, Number)

Number of villages in nutrition convergence districts wihch have conducted at least 10 monthly SBCC sessions in the last 12 months (DLI F) (Number)

DLI 11 269.00 800.00

Number of villages in Zones 2 and 3 in nutrition convergence districts in which integrated outreach sessions are conducted (DLI H) (Number)

DLI 8 50.00 450.00

Number of notified TB cases in all forms (per 100,000) (Number) 91.00 81.00

Percentage of women in nutrition convergence districts receiving at least 90 iron folic acid tablets at last pregnancy (Percentage) 0.00 70.00

Percentage of children 6‐59 months receiving vitamin A supplementation within the past 6 months in the twelve nutrition convergence districts (Percentage)

0.00 70.00

Percentage of Children 0‐59 months in the twelve nutrition convergence districts exclusively breastfed (Percentage) 56.20 62.00

Percentage Average score on the quality and performance scorecard for all health centers in the twelve nutrition convergence districts (Percentage)

0.00 60.00

Percentage increase over baseline of children who have received DPT3 in nutrition convergence districts (Percentage) 0.00 10.00

Adaptive learning and project management

Number of health centers that undertake MCH tracker or event capture in DHIS2 (DLI F) (Number) 158.00 600.00

Number of citizens providing feedback on services provided at primary health care level (Number) 0.00 25,000.00

IO Table SPACE

UL Table SPACE


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Monitoring & Evaluation Plan: PDO Indicators

Indicator Name Definition/Description Frequency Datasource Methodology for Data Collection

Responsibility for Data Collection

Number of deliveries attended by a skilled birth attendant

Access indicator from National Assembly Indicator list. Baseline based on DHIS2 data covering the period June 1, 2018‐May 30,2019, for 18 provinces combined. End target at 5% increase over baseline.

Data available on a monthly basis.

DHIS2

MOH

Number of health centers scoring above 60% on a standard quality assessment system

Quality measure through the Quality Performance Scorecard (QPS). Baseline is from HGNDP DLI6 (supervisory checklist), covering the period June 1 2018‐May 30, 2019. Data is only for 14 provinces where HGNDP is implemented. End target is 60% increase over baseline, QPS will be rolled out in phases starting from 4 nutrition convergence districts to eventually nationwide at the end of project.

Assessment to be done every 6 months.

DHIS2

PHO/MOH

Percentage of children under 2 years of age whose growth is adequately monitored as per national guidelines in the twelve nutrition convergence districts

Nutrition convergence indicator

Admin data from DHIS2. Data available on

DHIS2

MOH


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a monthly basis

Percentage of pregnant women who receive 4 Antenatal Care contacts in the twelve nutrition convergence districts

Admin data is available on a monthly basis

DHIS2

Share of outpatient cases delivered at the primary healthcare facilities among the total outpatient services delivered in the country (including hospitals)

Indicator of efficiency, primary care performance. Denominator defined as number of new OPD cases for health centers, district hospitals (34%) and central hospitals (7%). Data from DHIS2, baseline period June 1, 2018‐May 31, 2019. Data to be disaggregated by gender.

Data available on a monthly basis

DHIS2

MOH

ME PDO Table SPACE

Monitoring & Evaluation Plan: Intermediate Results Indicators

Indicator Name Definition/Description Frequency Datasource Methodology for Data Collection

Responsibility for Data Collection

Number of health centers that have had regular (twice per year) quality assessment visits and verified

QPS is expected to first be implemented in 4 nutrition convergence provinces, to be scaled up nationwide by the end of project. So baseline is zero.

Quality assessment will be conducted every 6 months.

DHIS2

PHO/MOH


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Number of health centers that received their payments within the prescribed timeline in the latest round of quality assessments

The 'prescribed' timeline for funds transfer will be defined in the QPS manual.

Quality assessment will take place every 6 months,

Number of health centers which have at least 85% of 30 days' stock of agreed list of drugs and commodities (DLI C)

DLI.


DHIS2

Number of health centers assessed and certified in financial management (DLI E)

DLI


DHIS2

MOH

People who have received essential health, nutrition, and population (HNP) services


DHIS2

MOH

People who have received essential health, nutrition, and population (HNP) services ‐ Female (RMS requirement)

Number of children immunized Data available

DHIS2

PHO/MOH


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on a monthly basis. Use DLI immunization indicator (DPT3) as a tracer.

Number of women and children who have received basic nutrition services


DHIS2

PHO/MOH

Number of deliveries attended by skilled health personnel


DHIS2

As this is a CRI, as per its definition baseline will be zero and will track the services delivered within support of the project.

MOH

Number of villages in nutrition convergence districts wihch have conducted at least 10 monthly SBCC sessions in the last 12 months (DLI F)

The monthly SBCSS sessions follow a prescribed set of activities including growth monitoring and promotion


DHIS2

MOH

Number of villages in Zones 2 and 3 in nutrition convergence districts in which integrated outreach sessions are

Integrated outreach services comprise 5 services: ANC, FP, immunization, growth

Data available on a

DHIS2

MOH


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conducted (DLI H) monitoring and monthly basis

Number of notified TB cases in all forms (per 100,000)

DLI J. "All forms" means bacteriologically confirmed and clinically diagnosed new and relapse cases. Current notified rate is 91%, this is expected to increase by some but once treatment starts the number is expected to go down. Hence end target is 81%.


DHIS2

MOH

Percentage of women in nutrition convergence districts receiving at least 90 iron folic acid tablets at last pregnancy

Admin data is through DHIS2 and available on a monthly basis

DHIS2. Current definition in DHIS2: Pregnant women received IFA 90 tablets (Both number and %)

Percentage of children 6‐59 months receiving vitamin A supplementation within the past 6 months in the twelve nutrition convergence districts

DHIS2

Percentage of Children 0‐59 months in the twelve nutrition convergence districts exclusively breastfed

Every KAP

KAP data


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Percentage Average score on the quality and performance scorecard for all health centers in the twelve nutrition convergence districts

Every six months once QPS is rolled out

QPS

Percentage increase over baseline of children who have received DPT3 in nutrition convergence districts

DHIS2

MOH

Number of health centers that undertake MCH tracker or event capture in DHIS2 (DLI F)


DHIS2

MOH

Number of citizens providing feedback on services provided at primary health care level

This indicator will be captured through patient exit surveys to be conducted as part of QPS. To be disaggregated by gender.

Every 6 months

QPS

ME IO Table SPACE

Disbursement Linked Indicators Matrix

DLI_TBL_MATRIX

DLI 1 Quality performance and service readiness measurement conducted regularly at health center level (DLI A)

Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount

Process No Text 1,500,000.00 0.00

Period Value Allocated Amount (USD) Formula

Baseline TBC


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(Year 0) Sep 1, 2019 ‐ August 30, 2020

1. DHR and DHPE appointed designated staff for the Quality and Performance Scorecard function2. Quality and Performance Scorecard prepared by DHR and at least fifteen (15) clinical vignettes prepared by DHPE with operation guidelines and road map for implementation of the service delivery performance measurement at health center level all of which have been approved by QHC committee for field testing.DLI value: 300,0001. 150,0002. 150,000

300,000.00

(Year 1) Sep 1, 2020 ‐ May 31, 2021

1. Quality and Performance Scorecard rolled out to at least two hundred (200) health centers in the four (4) nutrition convergence provinces and receive regular quality assessment.2. Baseline for average score of health centers in the twelve (12) nutrition convergence districts established;3. Third party verification guideline approved by QHC Committee.DLI value: 300,0001. 150,0002. 100,0003. 50,000

300,000.00

(Year 2) June 1, 2021 ‐ May 31, 2022

1. Quality and Performance Scorecard rolled out to all health centers in the four (4) nutrition convergence provinces and at least four (4) additional provinces; over ninety percent (90%) of these health centers have had regular (two (2) times/year/health center) quality assessment and random independent third‐party verification;2. Ten (10) percentage points increase in the average score from the baseline score of health centers in the twelve (12) nutrition convergence districts on QPS

400,000.00


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assessment;3. At least twenty‐five (25) additional Clinical cases or vignettes prepared, field tested and finalized.DLI value: 400,0001. 200,0002. 100,0003. 100,000

(Year 3) June 1, 2022 ‐ May 31, 2023

1. Quality and Performance Scorecard rolled out to at least four (4) additional provinces; ninety percent (90%) of these health centers have had regular (two (2) times/year/health center) quality assessment and random independent thirty‐party verification;2. Twenty (20) percentage points increase in the average score from the baseline score of health centers in the twelve (12) nutrition convergence districts on QPS assessment;3. Reduction by thirty percent (30%) of health centers whose verification scores are more than ten percent (10%) lower than the assessment scores.DLI value: 500,0001. 300,0002. 100,0003. 100,000

500,000.00

(Year 4) June 1, 2023 ‐ May 31, 2024

1. Quality and Performance Scorecard rolled out to at least eighty percent (80%) of all health centers nationwide; ninety percent (90%) of health centers have had regular (two (2) times/year/health center) quality assessment and random independent third‐party verification;2. Thirty (30) percentage points increase in the average score from the baseline score of health centers in the twelve (12) nutrition convergence districts on QPS assessment;3. Reduction by thirty percent (30%) of health centers whose verification scores from

0.00 To be added in AF


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previous year are more than ten percent (10%) lower than assessment scores.DLI value: 0 (added in AF)

DLI_TBL_MATRIX

DLI 2 Number of patients who pay out of pocket payment for “Free” Maternal and Child Services reduced (DLI B).


Intermediate Outcome No Text 700,000.00 0.00


Baseline TBD

(Year 0) Sep 1, 2019 ‐ August 30, 2020

1. Definition of “prescribed timeline” and “system to send and monitor the payments to health center” are included in the NHIB guideline; 2. Baseline for number of health centers receiving payments within the prescribed timeline; and for percentage of women not receiving free MCH, is provided in DHIS2. DLI value: 150,000 1. 75,000 2. 75,000

150,000.00

(Year 1) Sep 1, 2020 ‐ May 31, 2021

1. Fifty percent (50%) reduction in the number of health center receiving their payments after the prescribed timeline; 2. Twenty percent (20%) decrease from baseline in the number of women not receiving free MCH fully covered by NHI. DLI value: 150,000 1. 75,000 2. 75,000

150,000.00

(Year 2) June 1, 2021 ‐ May 31, 2022

1. Seventy percent (70%) reduction in the number of health center receiving their payments after the prescribed timeline; 2. Forty percent (40%) decrease from baseline in the

200,000.00


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number of women not receiving free MCH fully covered by NHI. DLI value: 200,000 1. 100,000 2. 100,000

(Year 3) June 1, 2022 ‐ May 31, 2023

1. Eighty percent (80%) reduction in the number of health center receiving their payments after the prescribed timeline;2. Sixty percent (60%) decrease from baseline in the number of women not receiving free MCH fully covered by NHI. DLI value: 200,000 1. 100,000 2. 100,000

200,000.00

(Year 4) June 1, 2023 ‐ May 31, 2024

1. Ninety percent (90%) reduction in the number of health center receiving their payments after the prescribed timeline; 2. Eighty percent (80%) decrease from baseline in the number of women not receiving free MCH fully covered by NHI.


DLI_TBL_MATRIX

DLI 3 Availability of essential drugs and supplies at health center level improved (DLI C)


Output No Text 1,650,000.00 0.00


Baseline TBD

(Year 0) Sep 1, 2019 ‐ August 30, 2020

1. A nationally agreed list of essential drugs and supplies to be available at health center level ;2. Baseline for thirty (30) days stock of essential drugs and supplies available at the health centers in four (4) nutrition convergence provinces based on approved list;3. Terms of reference and composition of national committee for

300,000.00


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monitoring availability of essential drugs and supplies approved by MOH.DLI value: 300,0001. 100,0002. 100,0003. 100,000

(Year 1) Sep 1, 2020 ‐ May 31, 2021

1. At least eighty‐five percent (85%) of all health centers in the four (4) nutrition convergence provinces have eighty five percent (85%) of thirty (30) days’ supply of essential drugs and supplies according to the agreed list;2. Baseline for thirty (30) days stock of essential drugs and supplies available at health centers in four (4) additional provinces based on agreed list. DLI value: US$ 350,000 1. US$ 250,000 2. US$ 100,000

350,000.00

(Year 2) June 1, 2021 ‐ May 31, 2022

1. At least eighty five percent (85%) of all health centers in eight (8) provinces (including the four (4) nutrition convergence provinces) have eighty five percent (85%) of thirty (30) days’ supply of essential drugs and supplies according to the agreed list;2. Baseline for thirty (30) days stock of essential drugs and supplies available at health centers in four (4) additional provinces. DLI value: 450,000 1. 350,000 2. 100,000

450,000.00

(Year 3) June 1, 2022 ‐ May 31, 2023

1. At least eighty five percent (85%) of all health centers in twelve (12) provinces (including the four (4) nutrition convergence provinces) have eighty five percent (85%) of the thirty (30) days’ supply of essential drugs and supplies according to the agreed list; 2. Baseline for thirty (30) days stock of essential drugs and supplies available at health centers in six (6) additional provinces

550,000.00


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based on agreed list. DLI value: 550,000 1. 450,000 2. 100,000

(Year 4) June 1, 2023 ‐ May 31, 2024

1. At least eighty five percent (85%) of all health centers in all provinces have eighty five percent (85%) of thirty (30) days’ supply of essential drugs and supplies according to the agreed list.


DLI_TBL_MATRIX

DLI 4 Number of provinces in which the number of health centers without a clinical health worker, as reported in the DHIS2, has been reduced. l (DLI D).


Intermediate Outcome No Text 800,000.00 0.00


Baseline TBD

(Year 0) Sep 1, 2019 ‐ August 30, 2020

1. Baseline established for number of health centers without a clinical worker;2. Zero draft health services decree prepared by DHP. DLI value: 200,000 1. 100,000 2. 100,000

200,000.00

(Year 1) Sep 1, 2020 ‐ May 31, 2021

1. Ten percent (10%) reduction from baseline of number of health centers without a clinical health worker in four (4) nutrition convergence provinces;2. Field test of the payment mechanism under the draft health service decree conducted in four (4) nutrition convergence provinces. DLI value: 200,000 1. 150,000 2. 50,000

200,000.00


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(Year 2) June 1, 2021 ‐ May 31, 2022

1. Twenty‐five percent (25%) reduction from baseline of number of health centers without a clinical health worker in a total of eight (8) provinces; 2. Health services decree approved by the MOH. DLI value: US$ 200,000 1. US$ 150,0002. US$ 50,000

200,000.00

(Year 3) June 1, 2022 ‐ May 31, 2023

1. Forty percent (40%) reduction from baseline of number of health centers without a clinical health worker in a total of twelve (12) provinces.

200,000.00

(Year 4) June 1, 2023 ‐ May 31, 2024

1. At least sixty percent (60%) reduction from baseline of number of health centers, or at least eighty percent (80%) of all health centers in all provinces have a clinical health worker, nationwide.


DLI_TBL_MATRIX

DLI 5 Improvement of financial management capacity at health center level (DLI E)


Intermediate Outcome No Text 1,000,000.00 0.00


Baseline TBD

(Year 0) Sep 1, 2019 ‐ August 30, 2020

1. Guideline for financial management at health center level prepared, field tested and approved by the MOH; 2. All district financial management staff in four (4) nutrition convergence provinces are trained to coach and supervise health center staff according to the financial management

250,000.00


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guidelines; DLI value: 250,000 1. 150,000 2. 100,000

(Year 1) Sep 1, 2020 ‐ May 31, 2021

1. At least one hundred and fifty (150) health centers in the four (4) nutrition convergence provinces are certified in financial management.DLI value: 250,0001. 150,0002. 100,000

250,000.00

(Year 2) June 1, 2021 ‐ May 31, 2022

1. All health centers in the four (4) nutrition convergence provinces and in at least one hundred fifty (150) health centers in four (4) additional provinces are certified in financial management. DLI value: 250,000 1. 150,000 2. 100,000

250,000.00

(Year 3) June 1, 2022 ‐ May 31, 2023

1. All health centers in a total of eight (8) provinces and in at least one hundred fifty (150) health centers in four (4) additional provinces are certified in financial management.

250,000.00

(Year 4) June 1, 2023 ‐ May 31, 2024

1. At least eighty percent (80%) of all health centers nationwide are certified in financial management.


DLI_TBL_MATRIX

DLI 6 Increase coverage and correctness of event capture report for selected services (DLI F)


Process No Text 1,000,000.00 0.00



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Baseline TBD

(Year 0) Sep 1, 2019 ‐ August 30, 2020

1. Baseline for number of health facilities where event capture is undertaken and reported in DHIS2; 2. Baseline of percentage difference of data reported through event capture and monthly aggregate data for service delivery conducted in health facilities. DLI value: 250,0001. 175,0002. 75,000

250,000.00

(Year 1) Sep 1, 2020 ‐ May 31, 2021

1. Forty percent (40%) of total health facilities in the country apply event capture; 2. Twenty percent (20%) reduction in variance of data reported through event capture and monthly aggregate data from the baseline. DLI value: 250,000 1. 175,000 2. 75,000

250,000.00

(Year 2) June 1, 2021 ‐ May 31, 2022

1. Sixty percent (60%) of total health facilities in country apply event capture; 2. Forty percent (40%) reduction in variance of data reported through event capture and monthly aggregate data from the baseline. DLI value: 250,000 1. 175,000 2. 75,000

250,000.00

(Year 3) June 1, 2022 ‐ May 31, 2023

1. Eighty five percent (85%) of total health facilities in country apply event; 2. Sixty percent (60%) reduction in variance of data reported through event capture and monthly aggregate data from the baseline. DLI value: 250,000 1. 175,000 2. 75,000

250,000.00

(Year 4) June 1, 2023 ‐ May 1. At least ninety five percent (95%) of total 0.00 To be added in AF


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31, 2024 health facilities in country apply event capture; 2.Eighty percent (80%) reduction in variance of data reported through event capture and monthly aggregate data from the baseline. DLI value: 0 (added in AF)

DLI_TBL_MATRIX

DLI 7 Implementation of Social and Behavioral Change Communication and Growth Monitoring and Promotion activities at village‐level (DLI G)


Output Yes Text 1,561,500.00 0.00


Baseline TBD

(Year 0) Sep 1, 2019 ‐ August 30, 2020

1. Up to three hundred (300) villages in twelve (12) nutrition convergence districts have conducted at least ten (10) monthly SBCC sessions in the past twelve (12) months with a prescribed set of activities including growth monitoring and promotion and have reported these in DHIS2. Value: 240,000 (500 USD per village)

240,000.00

(Year 1) Sep 1, 2020 ‐ May 31, 2021

1. Up to eight hundred eighty‐one (881) villages, in twelve (12) nutrition convergence districts have conducted at least ten (10) monthly SBCC sessions in the past twelve (12) months with a prescribed set of activities including growth monitoring and promotion and have reported these in DHIS2. DLI value: 440,500 (500 USD per

440,500.00


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village)

(Year 2) June 1, 2021 ‐ May 31, 2022

1. Up to eight hundred eighty‐one (881) villages, in twelve (12) nutrition convergence districts have conducted at least ten (10) monthly SBCC sessions in the past twelve (12) months with a prescribed set of activities including growth monitoring and promotion and have reported these in DHIS2. DLI value: 440,500 (500 USD per village)

440,500.00

(Year 3) June 1, 2022 ‐ May 31, 2023

1. Up to eight hundred eighty‐one (881) villages, in twelve (12) nutrition convergence districts have conducted at least ten (10) monthly SBCC sessions in the past twelve (12) months with a prescribed set of activities including growth monitoring and promotion and have reported these in DHIS2. DLI value: 440,500 (500 USD per village)

440,500.00

(Year 4) June 1, 2023 ‐ May 31, 2024

1. Up to eight hundred eighty‐one (881) villages, in twelve (12) nutrition convergence districts have conducted at least ten (10) monthly SBCC sessions in the past twelve (12) months with a prescribed set of activities including growth monitoring and promotion and have reported these in DHIS2.



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DLI_TBL_MATRIX

DLI 8 Number of villages in Zones 2 and 3 in nutrition convergence provinces in which integrated outreach sessions are conducted (DLI H)


Output Yes Text 900,000.00 0.00


Baseline TBD

(Year 0) Sep 1, 2019 ‐ August 30, 2020

1. Up to three hundred (300) villages in zones 2 and 3 in nutrition convergence provinces conducted at least three (3) quarterly integrated outreach sessions in a year. Value: 150,000 (500 USD per village)

150,000.00

(Year 1) Sep 1, 2020 ‐ May 31, 2021

1. Up to four hundred (400) villages in zones 2 and 3 in nutrition convergence provinces conducted at least three (3) quarterly integrated outreach sessions in a year. DLI value: 200,000 (500 USD per village)

200,000.00

(Year 2) June 1, 2021 ‐ May 31, 2022

1. Up to five hundred (500) villages in zones 2 and 3 in nutrition convergence provinces conducted at least three (3) quarterly integrated outreach sessions in a year. DLI value: 250,000 (500 USD per village)

250,000.00

(Year 3) June 1, 2022 ‐ May 31, 2023

1. Up to six hundred (600) villages in zones 2 and 3 in nutrition convergence provinces conducted at least three (3) quarterly integrated outreach sessions in a year. DLI. value: 300,000 (500 USD

300,000.00


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per village )

(Year 4) June 1, 2023 ‐ May 31, 2024

1. Up to seven hundred (700) villages in zones 2 and 3 in nutrition convergence provinces conducted at least three (3) quarterly integrated outreach sessions in a year. DLI value: 0 (added in AF)


DLI_TBL_MATRIX

DLI 9 Number of Immunization Target Districts which have increased the Pentavalent 3 and deliveries with Skilled Birth Attendant (DLI I)


Outcome Yes Text 1,800,000.00 0.00


Baseline TBD

(Year 0) Sep 1, 2019 ‐ August 30, 2020

1. Baseline value for the number of children less than twelve (<12) months who received (DPT‐HepB‐Hib) immunization in each of the fifty (50) identified poor coverage Immunization Target Districts as recorded in DHIS2; 2. Baseline value for number of women deliveries by Skilled Birth Attendant in the fifty (50) Immunization Target Districts. DLI value: 300,000 1. 150,000 2. 150,000

300,000.00

(Year 1) Sep 1, 2020 ‐ May 31, 2021

1. Number of districts among the fifty (50) Immunization Target Districts which have achieved an increase of five (5) percentage points in the number of children less than twelve (<12) months covered by DPT‐HepB‐Hib over the

500,000.00


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baseline or maintained a coverage with DPT‐HepB‐Hib of ninety‐five percentage (95%) or more.2. Number of districts in the fifty (50) Immunization Target Districts which have received an increase of three (3) percentage points in the number of women delivered by Skilled Birth Attendant over the baseline or maintained a coverage with Skilled Birth Attendant deliveries of ninety percent (90%) or more.DLI value: 500,000Scalable at USD 5000 per district per achieved increase on each indicator

(Year 2) June 1, 2021 ‐ May 31, 2022

1. Number of districts among the fifty (50) Immunization Target Districts which have achieved an increase of eight (8) percentage points in the number of children less than twelve (<12) months covered by DPT‐HepB‐Hib over the baseline or maintained a coverage with DPT‐HepB‐Hib of ninety‐five (95%) or more.2. Number of districts in the fifty (50) Immunization Target Districts which have received an increase of five (5) percentage points in the number of women delivered by Skilled Birth Attendant over the baseline or maintained a coverage with Skilled Birth Attendant deliveries of ninety percent (90%) or more. DLI value: 500,000 Scalable at USD 5000 per district per achieved increase on each indicator

500,000.00

(Year 3) June 1, 2022 ‐ May 31, 2023

1. Number of districts among the fifty (50) Immunization Target Districts which have achieved an increase of ten (10) percentage

500,000.00 https://spappscsec.worldbank.org/sites/ppf3/PPFDocuments/For


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points in the number of children less than twelve (<12) months covered by DPT‐HepB‐Hib over the baseline or maintained a coverage with DPT‐HepB‐Hib of ninety‐five percent (95%) or more2. Number of districts in fifty (50) Immunization Target Districts which have received an increase of seven (7) percentage points in the number of women delivered by Skilled Birth Attendant over the baseline or reached or maintained a coverage with Skilled Birth Attendant deliveries of ninety percent (90%) or more. DLI value: 500,000 Scalable at USD 5000 per district per achieved increase on each indicator

(Year 4) June 1, 2023 ‐ May 31, 2024

1. Number of districts among the fifty (50) Immunization Target Districts which have achieved an increase of twelve (12) percentage points in the number of children less than twelve (<12) months covered by DPT‐HepB‐Hib over the baseline or maintained a coverage with DPT‐HepB‐Hib of ninety‐five percent (95%) or more. 2. Number of districts in fifty (50) Immunization Target Districts which have received an increase of nine (9) percentage points the number of women delivered by Skilled Birth Attendant over the baseline or reached or maintained a coverage with Skilled Birth Attendant of ninety percent (90%) or more.



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DLI_TBL_MATRIX

DLI 10 Number of notified TB cases of all forms (i.e. bacteriologically confirmed and clinically diagnosed new and relapse cases) (DLI J).


Process No Text 3,600,000.00 0.00


Baseline TBD

(Year 0) Sep 1, 2019 ‐ August 30, 2020

1. Baseline information on TB notified cases by province is established through DHIS2; 2. Baseline information on the proportion of presumptive TB/MDR‐TB patients examined by GeneXpert by province; 3. Joint protocol for increased use of GeneXpert (management and maintenance) as well as cross‐program usage drafted jointly by the TB and HIV units. DLI value: 800,000 1. 200,000 2. 200,000 3. 400,000

800,000.00

(Year 1) Sep 1, 2020 ‐ May 31, 2021

1. Provinces that achieved the targeted number of notified TB cases of all forms); 2. Provinces which have achieved an increase of twenty (20) percentage points over the previous year; or reached or maintained one hundred percent (100%) GeneXpert coverage. DLI value: 950,000 1. 750,000 2. 200,000

950,000.00

(Year 2) June 1, 2021 ‐ May 31, 2022

1. Provinces that achieved the targeted number of notified TB cases of all forms; 2. Provinces which have achieved an increase of twenty (20) percentage points over the previous year; or

950,000.00


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reached or maintained one hundred percent (100%) GeneXpert coverage. . DLI value: 950,000 1. 750,000 2. 200,000

(Year 3) June 1, 2022 ‐ May 31, 2023

1. Provinces that achieved the targeted number of notified TB cases of all forms; 2. Provinces which have achieved an increase fifteen (15) percentage points over the previous year; or reached or maintained one hundred percent (100%) GeneXpert coverage. DLI value: 900,000 1. 700,000 2. 200,000

900,000.00

(Year 4) June 1, 2023 ‐ May 31, 2024

1. Provinces that achieved the targeted number of notified TB cases of all forms; 2. Provinces which have reached or maintained one hundred percent (100%) GeneXpert coverage. DLI value: 0 (added in AF)

0.00

DLI_TBL_MATRIX

DLI 11 Increased coverage of a) HIV testing among key populations (female service women (FSW)) and men having sex with men (MSM)); b) and HIV treatment among people living with HIV (DLI K)


Outcome No Text 2,900,000.00 0.00


Baseline TBD

(Year 0) Sep 1, 2019 ‐ August 30, 2020

1. Baseline established for: (a) the percentage of FSW that have received an HIV test in the past twelve (12) months and know their results by province; (b) the percentage of MSM that have received an HIV test in the past twelve (12)

800,000.00


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months and know their results by province; and (b) number of HIV positive cases currently on treatment nationwide. 2. Standard operating procedure for HIV/AIDS case finding and management (including health center, district and provincial level with easy access to Point of Care) approved by MOH. 3. Mechanism for DPC to subcontract civil society organizations in place. DLI value: US$ 800,000 1. US$ 300,000 2. US$ 500,000 3. US$ 200,000

(Year 1) Sep 1, 2020 ‐ May 31, 2021

1. Two (2) percentage point increase over the previous year in HIV testing coverage of estimated FSW during the past twelve (12) months2. Five (5) percentage points increase over the previous year in HIV testing coverage of estimated MSM during the past twelve (12) months3. Four (4) percentage points increase over the previous year in number of HIV positive cases receiving ARV treatment nationwide.DLI value: 800,0001. 200,0002. 400,0003. 200,000

800,000.00

(Year 2) June 1, 2021 ‐ May 31, 2022

1. Two (2) percentage points increase over the previous year in HIV testing coverage of estimated FSW during the past twelve (12) months;2. Six (6) percentage points increase over the previous year in HIV testing coverage of estimated MSM during the past twelve (12) months;3. Four (4) percentage points increase over the previous year in number of HIV positive cases receiving ARV treatment nationwide. DLI value: 800,000 1. 200,000 2. 400,000 3. 200,000

800,000.00


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(Year 3) June 1, 2022 ‐ May 31, 2023

1. Two (2) percentage points increase over the previous year in HIV testing coverage of estimated FSW during the past twelve (12) months; 2. Eight (8) percentage points increase over the previous year in HIV testing coverage of estimated MSM during the past twelve (12) months; 3. Five (5) percentage points increase over the previous year in number of HIV positive cases receiving ARV treatment nationwide. DLI value: 500,000 1. 100,000 2. 300,000 3. 100,000

500,000.00

(Year 4) June 1, 2023 ‐ May 31, 2024

1. Two (2) percentage points increase over the previous year in HIV testing coverage of estimated FSW during the past twelve (12) months; 2. Ten (10) percentage points increase over the previous year in HIV testing coverage of estimated MSM during the past twelve (12) months; 3. Five (5) percentage points increase over the previous year in number of HIV positive cases receiving ARV treatment nationwide. DLI value: 0 (added in AF)


DLI_TBL_MATRIX

DLI 12 Increase in national readiness for health security in responding to pandemics and health emergency at international boundaries (airports and ground crossings) (DLI L)


Output No Text 389,500.00 0.00


Baseline TBD


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(Year 0) Sep 1, 2019 ‐ August 30, 2020

1. Standard operating procedure for health emergency contingency at points of entry approved by MOH..DLI value: 89,500

89,500.00

(Year 1) Sep 1, 2020 ‐ May 31, 2021

1. SOP for health emergency contingency at point of entry (airports and ground crossings with less than one hundred fifty (<150.000) travelers per year and more than one hundred fifty (> 150.000) travelers per year)) field test and finalize;2. Simulation exercises held at 2 international airports and 2 formal ground crossings with more than one hundred fifty (>150,000) travelers per year. DLI value: US$ 100,000 1. US$ 50,000 2. US$ 50,000

100,000.00

(Year 2) June 1, 2021 ‐ May 31, 2022

1. Training activities as per national SOPs conducted at three (3) formal ground crossings with less than one hundred fifty (<150,000) travelers per year;2. Simulation exercises held at two (2) additional international airports and two (2) additional formal ground crossings with more than one hundred fifty (>150,000) travelers per year.DLI value: 100,0001. 50,0002. 50,000

100,000.00

(Year 3) June 1, 2022 ‐ May 31, 2023

1. Training activities as per national SOPs conducted at four (4) additional formal ground crossings with less than one hundred fifty (<150,000) travelers per year; 2. Simulation exercises held at two (2) international airports and three (3) additional formal ground crossings with more than one hundred fifty (>150,000) travelers per year.D DLI value: 100,000 1. 50,000

100,000.00


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2. 50,000

(Year 4) June 1, 2023 ‐ May 31, 2024

1. Training activities as per national SOPs for four (4) additional formal ground crossings with less than one hundred fifty (<150,000) travelers per year. 2. Simulation exercises held at two (2) international airports and two (2) additional formal ground crossings with more than one hundred fifty (>150,000) travelers per year. .. DLI value: 0 (added in AF)


Verification Protocol Table: Disbursement Linked Indicators

DLI 1 Quality performance and service readiness measurement conducted regularly at health center level (DLI A)

Description

Compliance Condition: In year 0, DHR in collaboration with other departments will prepare a Quality and Performance

Scorecard and DHPE will prepare clinical cases/vignettes for assessment of service quality at the health center level. A

guideline for conducting these measurements, training of assessors, monitoring, performance assessment and verification,

including bonus payment and penalty levying mechanisms will be prepared, field tested. The subsequent regular quality

performance measurement will be rolled out to additional provinces in line with MOH quality of health care strategy and

five year plan, and documented in the form of a joint rollout plan agreed between DHR, DHPE, DPC, DOF, FDD and NHIB, as

amended from time to time. Compliance Specification: Guidelines, tools and relevant compliance documentation as well as

details of staffing for the management of the quality performance scorecard process will be approved by the Minister of

Health. Half‐yearly reporting of performance scores for individual health centers will be reported in the DHIS2; quality

performance and service readiness measurement and scores will be verified by an independent third‐party contracted by

the NHIB. Scoring will be done on a portable device. Rollout of quality and performance scorecard must be aligned with the

rollout of the financial management guidelines so that the efforts focus on the same provinces jointly, and a functional NHIB

payment mechanism in health centers would be the prerequisite for such payments. Targets for each year from year 1 to

year 4 will also need an achievement of at least 90 health centers in the 12 nutrition convergence districts to be part of the


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overall targets specified in the DLI.The provision of partial achievement for this DLI is not applicable if this requirement of at

least 90 HCs in the 12 convergence districts is not achieved. Means of verification: The performance score will be captured

on portable device and uploaded to DHIS2 server.

Data source/ Agency DHIS2 report; MOH

Verification Entity IAI verification agency

Procedure Performance scores will be verified using a mix of random and risk‐based sampling. Independent third party verification will

certify the scores reported in the DHIS2.

DLI 2 Number of patients who pay out of pocket payment for “Free” Maternal and Child Services reduced (DLI B).

Description

Compliance Condition: Out of Pocket payment for free MCH services refer to occurrences of payment by patients for

maternal and child health services which are to be provided free. National health insurance guidelines provide the norms

and standards for timely receipt of NHIB payment at the health center level; the guidelines also specify that co‐payment is

exempted for all pregnant women and children <5 years. For the purpose of this DLI only the ANC, delivery and postnatal

care will be recorded. Compliance Specification: NHIB to provide information on what exactly is in the NHIB guideline on

timely payment; guideline is under revision and will be finalized by December 2019. Means of verification: DHIS2 will record

the source of payment for maternal and child health services by funding source (i.e. NHIB, other insurance or out of pocket

by the patient). ATD records number of MCH services which are charged to patients. NHIB will receive quarterly reports

from the provinces which include information on the date of the latest reimbursement from NHIB to individual health

centers.

Data source/ Agency DHIS2/MOH

Verification Entity IAI verification

Procedure

Quarterly reports of date of payment from the NHIB to individual health centers; quarterly reports on source of payment for

maternal child health services at health center level. IAI will on a sample basis compare the data reported with records held

at health center level and on a sample basis confirm such data through interview with individual patients.


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DLI 3 Availability of essential drugs and supplies at health center level improved (DLI C)

Description

Compliance Condition: A list of essential drugs and supplies to provide the agreed package of services at the health center

level based on the essential services package, with stock not below the minimum requirement of 30 days, must be available

at the health center level; stock levels are reported on a monthly basis in DHIS2. Compliance Specification: The list of

essential drugs and supplies based on the essential services package has been endorsed by the health minister. Rollout of

this system must be aligned with the rollout of the Quality and Performance Scorecard. Targets for each year from year 1 to

year 4 will also need an achievement of at least 90 health centers in the 12 nutrition convergence districts to be part of the

overall targets specified in the DLI.The provision of partial achievement for this DLI is not applicable if this requirement of at

least 90 HCs in the 12 convergence districts is not achieved. Means of verification: Stock availability of the essential drugs at

the health center level is to be reported monthly in DHIS2.



Procedure IAI on a sample basis will compare the DHIS2 reports with drugs and supplies available at health centers through physical

count and inventory record.

DLI 4 Number of provinces in which the number of health centers without a clinical health worker, as reported in the DHIS2, has been reduced. l (DLI D).

Description

Compliance Condition: While the MOH norm is to have at least 1 clinical health worker in each health center, this indicator

will measure annual reduction in the number of health centers with no clinical health worker posted. A decree which

reviews at least the grade and compensation of health service staff, local contractual appointments and incentive payments

will be prepared by the Health Personnel Department. During year 0 a first draft will be prepared through consultant

services and consultations across the ministry. In year 1 there will be external consultation with MOHA and MOF. The

payment mechanisms will be discussed and field tested in 4 provinces and the decree revised and notified based on this

experience. Targets for the four nutrition convergence provinces from year 1 to year 4 will be particularly focused on the 12

nutrition convergence districts, forming a predominant part (>75%) of the overall provincial targets specified in the DLI. The

provision of partial achievement for this DLI is not applicable if this requirement of at least 75% in the 12 convergence

districts is not achieved. Compliance Specification: The MOH norm is that at least 1 clinical health worker must be posted in

every health facility. In this context we will limit the specification to at least 1 clinical health worker posted in every health


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center. The clinical workers will include medical assistant, primary health care high level, medical doctor or all clinical

specialists or family doctor. Clinical health workers can be employed directly by the MOH or employed locally on a

contractual or voluntary basis; records on level, seniority, compensation, posting etc. are maintained at the MOH on an

annual basis. Availability of clinical health workers at the health centers is reported annually through the DHIS2 or through

Department of Health Personnel’s information system once it is fully developed to also record non‐government staff. The

decree will address grade and salary structure of health service staff and the contractual relationship of health staff to

formalize a wider range of employment: it will also address the options of incentivizing health service staff. Means of

verification The provinces will on an annual basis report through the DHIS2 on the health centers that have a clinical

health worker posted; Medical Civil Service decree available.



Procedure

The provinces will on an annual basis report through the DHIS2 on the health centers that have a clinical health worker

posted; Medical Civil Service decree available.

DLI 5 Improvement of financial management capacity at health center level (DLI E)

Description

Compliance Condition:Definition of financial management practice at health center level will be finalized in year 0. A

training module which specifies the skills requirement and training plan for training health center staff in financial

management will be completed in year 0. The process and regularity of certification will also be defined. Targets for each

year from year 1 to year 4 will also need an achievement of at least 90 health centers in the 12 nutrition convergence

districts to be part of the overall targets specified in the DLI. The provision of partial achievement for this DLI is not

applicable if this requirement of at least 90 HCs in the 12 convergence districts is not achieved. Compliance Specification:

The knowledge and skills required for basic bookkeeping at the health center level will be specified in the FM training

guideline for health center level; it will as a minimum include norms for bookkeeping, cash management, fund use and

financial reporting. The guideline will be approved by the Health Minister. Means of verification: Basic bookkeeping at the

health center will follow the guidelines on financial management at health center level; financial reporting will be through

the DHIS2 .


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Procedure

IAI will monitor that basic bookkeeping practices at the health center level are in accordance with guidelines and have been

certified according to the specified criteria, on sample basis, and compare the financial report at health centers with DHIS2

reports.

DLI 6 Increase coverage and correctness of event capture report for selected services (DLI F)

Description

Compliance Condition: Event capture means computerized anonymous individual patient record. Correctness of event

capture means consistency of data reporting into the DHIS2 and alignment between the sum of the individual records and

the aggregate records of the same data. Health Facility (HF) means central hospitals, provincial hospitals, district hospitals

and health centers. In case of district that do not have district hospital, the event data will be entered at the District Health

Office (DHO). Compliance Specification: Patient specific events that include number of births attended by skilled birth

attendant (doctors, nurses or midwives); children under 1 year received vaccine pentavalent 3, children under 1 year

received vaccine MCV1 (measles containing vaccine for children under 1 year); number of children dying before reaching

the age of five in a specific year; number of children dying before reaching the age of one in a specific year; number of

women who die from any cause related to or aggravated by pregnancy or its management (excluding incidental or

accidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the

duration the pregnancy is recorded directly in the DHIS2 by the health center. Targets for year 1 to year 4 will also need an

achievement of at least 90 health centers in the 12 nutrition convergence districts to be part of the overall targets specified

in the DLI. The provision of partial achievement for this DLI is not applicable if this requirement of at least 90 HCs in the 12

convergence districts is not achieved.



Procedure The IAI will, on a sample basis, verify that the sum of event capture data recorded in DHIS2 is the same as record in the

logbook (sum of logbook data) and aggregate in DHIS2.


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DLI 7 Implementation of Social and Behavioral Change Communication and Growth Monitoring and Promotion activities at village‐level (DLI G)

Description

Compliance Condition: The Strategy and Planning Framework for the Integrated Package of Maternal, Neonatal and Child

Health Services specifies that monthly weighing of children from age 0 – 59 months includes nutrition counselling to

mothers of these children. Since 2016 this activity has been conducted monthly at village level in the 4 nutrition

convergence provinces by village facilitators. Compliance Specification: The ministry has developed standard operating

procedures for monthly SBCC sessions with a prescribed set of activities including growth monitoring and promotion at

village level by village facilitators. International best practice on growth monitoring and promotion of children < 5 years

includes nutrition counselling, and this will continue to be recommended practice. Verification protocols will rely on (i)

regular recording of events and participants by village facilitators and (ii) maternal recall of growth recording and nutrition

counselling having taken place and (iii) plotting the growth into the child’s growth charts (at least the weight for age and

height for age charts). Means of verification: Reporting of monthly SBCC sessions with a prescribed set of activities including

growth monitoring and promotion at village level by village facilitators is reported through the village facilitator monthly

reports to the health center. These will be reported in DHIS2.



Procedure IAI will on a sample basis verify the growth monitoring and promotion at village level by village facilitators through interview

with village leaders and mothers and through verification of the plotting of growth charts.

DLI 8 Number of villages in Zones 2 and 3 in nutrition convergence provinces in which integrated outreach sessions are conducted (DLI H)

Description

Compliance Condition: The integrated outreach package of services includes EPI, FP, ANC, PNC, growth monitoring and

promotion for children <5 years. These services must be provided to each village at least three times in one year. Zone 2 is

5‐10 km from the health center; Zone 3 is more than 10 km from the nearest health center; the health center team has to

stay overnight to reach villages in Zone 3. DHIS2 and district health offices have records of all villages in these zones.

Compliance Specification: Guidelines which specify services to be delivered and equipment required for conducting

integrated outreach must be available in the province and provided to all health facilities. Zone 2 and Zone 3 villages from

the 12 nutrition convergence districts are the main focus of this DLI and will be prioritized for the measurement of

achievement. A maximum of 100 villages each in year 0 to year 2, and upto 200 villages in years 3 and 4, can be accepted as


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achievements from other districts located in the four nutrition convergence provinces. Means of verification: Integrated

outreach listing village name and the services provided is recorded monthly in DHIS2. The province and district also holds

registers of conducted outreach to zone 2 and 3 villages.



Procedure

The IAI will compare the data recorded in DHIS2 with the health facility registers and verify the information through visits to

selected villages to confirm that there has been integrated outreach conducted three times in the past year and that the

five prescribed services have been provided.

DLI 9 Number of Immunization Target Districts which have increased the Pentavalent 3 and deliveries with Skilled Birth Attendant (DLI I)

Description

Compliance Condition: Immunization for Pentavalent 3 (DPT‐HepB‐Hib) according to International WHO standards; LAO PDR

has an accreditation system for Skilled Birth Attendants. Doctors, nurses and community midwives who have completed

their basic education receive accreditation as Skilled Birth Attendant. The number of women delivered by a skilled birth

attendant is registered at either health center, district hospital, provincial hospital, police and military hospital as per

national guidelines, and reported in DHIS2. Compliance Specification: The correct procedure for and time for providing

immunization is described in the Immunization in Practice for Laos. The Immunization Target Districts are the 50 districts

which have the lowest coverage of pentavalent 3 (DPT‐HepB‐Hib) for the period January to December 2019 as per DHIS2

records. A Skilled Birth Attendant must have conducted the delivery at a facility or at home. Means of verification:

Immunization coverage for each district is recorded monthly through the DHIS2; Delivery attended by Skilled Birth

Attendant is recorded monthly in DHIS2.



Procedure

The IAI will review child immunization records at selected health facilities and compare these to DHIS2 reports; they will

also visit a sample of children to confirm that they received the immunizations on or before their first birthday and that this

is recorded in their MCH Pink book or on the immunization ´yellow card´ registration form which is available with the

parent/guardien of the child.


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They will also review records at selected facilities of women delivered by Skilled Birth Attendants and compare these to

DHIS2 reports. They will also visit a sample of women and confirm that their delivery was conducted by a skilled birth

attendant.

DLI 10 Number of notified TB cases of all forms (i.e. bacteriologically confirmed and clinically diagnosed new and relapse cases) (DLI J).

Description

Compliance Condition: The term “notification” means that TB is diagnosed in a patient and is registered in the TB register at

either provincial hospital, district hospital, police and military hospital in the province as per national tuberculosis

guidelines, and reported in DHIS2. The term “GeneXert coverage” means the total number of identified presumptive TB

cases recorded in the TB examination laboratory register whose specimen was tested by GeneXpert. Compliance

Specification: Routine TB screening at health facility would provide presumptive TB patients access to the WHO endorsed

rapid diagnostic test, (GeneXpert®, Cepheid) for early diagnosis and treatment of drug sensitive and drug resistant TB and

for interruption of TB transmission in the community. Notification also is essential for routine surveillance and for

determining the burden of TB in a community, province or country, as well as for planning, implementing and evaluating of

the TB activities., province or country, as well as for planning, implementing and evaluating of the TB activities. Means of

verification: Notified TB cases all forms (bacteriologically confirmed and clinically diagnosed new and relapse) are reported

in the DHIS2; identified presumptive TB patients examined by Xpert MTB/RIF test are reported in DHIS2.



Procedure

1. IAI will review records of notified TB cases in TB patient register and compare them with DHIS2 reports

2. IAI will verify in TB laboratory register the number and proportion of presumptive TB patients examined by Xpert

MTB/RIF and compare them to DHIS2 reports

IAI will also contact a sample of registered TB patients to confirm that they were tested for TB and notified TB cases

received TB treatment.

DLI 11 Increased coverage of a) HIV testing among key populations (female service women (FSW)) and men having sex with men (MSM)); b) and HIV treatment among people living with HIV (DLI K)

Description Compliance Condition: National HIV guidelines detail standard procedures for HIV testing and treatment, while HIV case

identification, finding and management using existing health infrastructure, including when necessary CSOs. SOP will be


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developed for HIV/AIDS case finding and management (including HC, district and provincial level with easy access to Point of

Care). Compliance Specification: HIV testing, both outreach and routine activities, provided to key populations (FSW and

MSM) as per the national HIV guidelines. FSW and MSM (TG is included in MSM) tested for HIV in the reporting period and

reported through DHIS2 would be counted. All the people living with HIV, regardless of when they were diagnosed, who

never received HIV treatment are put on HIV ART as per the national HIV treatment guidelines and captured in the DHIS2

patients tracker. Means of verification: DHIS2 will capture information on HIV testing for key populations (FSW and MSM)

by province. The number of HIV positive patients are registered for ART and reported in the DHIS2.



Procedure

The IAI will review records (VCT logbook and ART logbook) and compare them to DHIS2 reports.

The annual verification of key populations (FSW and MSM/TG) tested for HIV will be based on the triangulation of data

collected through phone call/social media/conducted study among population randomly selected from implementation

sites. The details of methodology will be defined collectively by IAI and CHAS, approved by The National Ethics Committee

for Health Research.

IAI will also contact a sample of patients, in compliance with the National Ethics Committee for Health Research

requirements, to confirm that they were receiving ART, with consent of the patients. If patient refuses, the next sample will

be selected.

DLI 12 Increase in national readiness for health security in responding to pandemics and health emergency at international boundaries (airports and ground crossings) (DLI L)

Description

Compliance Condition: The standard operating procedures (SOP) will be developed to define actions to be taken by each

division across multi‐sectors in the event of epidemic and outbreak at international point of entries. The SOP will also define

human resources and equipment needs enabling rapid implementation when the epidemic and outbreak occur. An action

plan will be developed as part of the SOP to lay out the timelines and readiness preparation activities to be implemented.

Compliance Specification: The SOP will be developed in consultation with multi‐sectors in pursuant to Prime Minister’s

decree no. 558 on border checkpoints and international airports, and in accordance with the Communicable Diseases

Control and Prevention Law of Lao PDR, Emerging Infection Diseases Action Plan, and ministrial decision on staff allocation

at international points of entry. Means of verification: SOP available in Lao and English on both electronic and hardcopy,

and checklist to assess the simulation scores. The report will be developed following each training and simulation exercise


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with photos and video evidence approved by MoH.



Procedure

Draft SOP approved by MoH for field testing while final SOP approved and signed by the MoH.

IAI will verify the reports and photos or/and video evidence to confirm that the trainings and simulation exercises have

taken place.


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ANNEX 1: Implementation Arrangements and Support Plan

COUNTRY: Lao People's Democratic Republic Health and Nutrition Services Access Project (HANSA)

Institutional and Implementation Arrangements

1. The project will use Investment Project Financing (IPF) with a mix of input and results‐based financing, including Disbursement Link Indicators (DLIs) as well as a performance‐based payment mechanism at the health center level. In consideration of the current IDA cycle, the project will be front‐loaded with the available resources in IDA18, including retroactive financing, and an Additional Financing (AF) will have to be undertaken according to need and resource availability.

2. The institutional arrangement of the project will follow a similar mechanism as that of the ongoing HGNDP. At the national level, the existing National Project Coordination Office (NPCO) in the Department of Planning and Cooperation (DPC) will continue to be responsible for overall project management, fiduciary aspects, administration, coordination of implementation of project activities and achievement of DLIs in close coordination with the Ministry of Health (MOH) technical departments and those Provincial Health Offices (PHOs) and District Health Offices (DHOs) participating in the project implementation, and M&E. HANSA will use the existing structures of the MOH such as the overarching steering committee of the MOH and the QHC technical oversight committee (“QHC committee”) for all quality initiatives of the ministry.

3. The National Health Insurance Bureau (NHIB) and Department of Healthcare and Rehabilitation (DHR) will play a central role in the design and implementation of the Quality and Performance Scorecard (QPS), in close coordination with other key technical departments, as centers under these departments that will likewise play a critical role in the implementation of activities in their respective technical areas. The Department of Finance (DOF) will increasingly take a larger role, both taking on more fiduciary management responsibilities and also coordinating and taking on the oversight role for building Financial Management (FM) capacity at subnational levels, especially at the health center level.

4. The Steering Committee of the MOH is a high‐level committee which is chaired by the Minister of Health and has senior representation from all departments of the ministry. The Steering Committee takes the final decision on any high‐level issue in the sector including oversight of major projects. HANSA will use the existing structures of the MOH such as the overarching Steering Committee of the MOH and the QHC Committee for all quality initiatives of the ministry.

5. The QHC Committee is chaired by the Director General of Health Care and Rehabilitation Department and has representation from all relevant departments/centers, World Bank, Global Fund (GF), and selected development partners. The role of the committee is to (a) provide feedback and finally approve the QPS, vignettes, user manual, training manual, overall implementation guideline, and the road map for implementing the QPS; (b) review and approve periodical implementation instructions; (c) discuss and validate results of half‐yearly QPS assessments, and submit for approval and payment; (d) discuss and validate results of third‐party verification, and identify penalties to be applied to each health facility, and


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submit recommended penalties for approval; (e) participate in the annual review of the QPS organized by the DHR; (f) and review suggestions for changes in the scorecards, vignettes, manuals, or other operational documents.

6. DOF will monitor the Eligible Expenditure Program (EEP) for DLIs under the project and ensure that these are reported to the World Bank at the time of submitting the DLI payment request and for the audit thereof. At the subnational level, the PHOs and DHOs will continue to assume the roles for monitoring and supervision, especially in the implementation of DLIs and QPS.

7. Enhanced coordination between provincial levels and district levels will be important for HANSA. The PHOs will be responsible for (a) the implementation of project activities including the achievement of DLIs at the provincial level, (b) the monitoring and reporting to the MOH of project activities and achievement of DLIs at the provincial level, and (c) the provision of technical support to the DHOs in the implementation of project activities at the district level and village level. The DHOs will be responsible for (a) the implementation of project activities including the six‐monthly quality assessments at the district and health center levels and (b) the supervision and provision of technical support to health facilities in their delivery of health and nutrition services including the SBCC activities at the village level.

8. In view of the joint co‐financing from the GF and the use of HANSA as a mechanism for sustainable financing of priority public health programs, the implementation modalities for HANSA will include the Country Coordination Mechanism (CCM) used for HIV, TB, and malaria as a key stakeholder. The CCM is intended as a regular mechanism during implementation support missions for sharing information and seeking feedback from the project and the wider stakeholders. In line with the GF processes, the CCM will also play a role in the submission of funding request of the co‐financing share of the GF.


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Figure 1.1. HANSA Governance Structure

Note: CHAS = Center for HIV/AIDS and STI; DHP = Department of Health Personnel ; NTC = National Tuberculosis Center

Monitoring and Evaluation Arrangements

9. The DPC will continue to be responsible for overall M&E of the project. The project will continue tracking the results of DLIs through District Health Information System version 2 (DHIS2), with further expansion of the system to accommodate other results captured at different levels of the health system, including reporting on financial accounting, gender‐disaggregated data, and village Social and Behavioral Change Communication (SBCC) sessions. Event capture will be extended to all the four priority provinces, allowing more disaggregated data to be available for analysis from these remote areas.

10. A comprehensive ‘nutrition convergence’ M&E framework has been established specifically to (a) track the convergence of the Government of Lao PDR (GOL)‐World Bank nutrition convergence at the village level; (b) report on process as well as outcome nutrition indicators; and (c) quantify the impact of the convergence approach, its cost‐effectiveness, and effectiveness of individual interventions that are associated with individual projects. This will be achieved by tracking the delivery of interventions at the village level, monitoring the process, measuring household‐ and individual‐level outcomes, and imbedding impact evaluations in the projects to measure attributable impacts of the portfolio interventions.

11. The evidence base for the proposed project and overall convergence approach will build on the results of the KAP survey under Health Governance and Nutrition Development Project (HGNDP)


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(P151425); the first Knowledge, Attitude, and Practices (KAP) survey was conducted in the 12 priority districts in July–August 2017. The information gathered from this survey is informing the design of the SBCC and overall program design. A follow‐up KAP survey is scheduled for 2020 (last year of HGNDP implementation). These studies will enable a deeper understanding of the sociocultural norms, behaviors, enabling environments, and obstacles to improved health and nutrition‐related practices. The follow‐on survey will serve as the baseline for the proposed nutrition multisectoral programmatic approach, and resources would be provided under this project to finance one more round of the KAP as the end line for Phase 1 of nutrition convergence. This subcomponent will also finance qualitative studies in the 12 selected districts, which will be designed to complement parallel quantitative data gathering efforts.

Financial Management

12. Country issues. The 2018 Public Expenditure and Financial Accountability (PEFA) report noted that in recent years, the Public Financial Management (PFM) system has been reasonably effective in maintaining macro fiscal discipline. This consistency has made possible some improvement in Lao PDR’s external debt position, although risks of debt distress remain high. Besides, the PFM system has not been well adapted to secure the optimum allocation of scarce resources to contribute to both the growth of the economy and the improvement of public services. The development of public services in Lao PDR continues to experience numerous constraints. They include lack of resources, weak policy‐based budgeting, mediocre procurement practices, lack of information to frontline service providers and the general public about resources provided for service delivery, and a general lack of information about or scrutiny of the results achieved.

13. Lao PDR has embarked on an ambitious plan for PFM improvement. The Public Financial Management Strengthening Program aims to address many of the problems identified in the PEFA. With the support of the World Bank, ADB, and other development partners, Lao PDR is reforming budgeting, taxation (the introduction of value added tax), treasury, financial reporting and accounting, and public procurement systems at the central and provincial levels.

14. FM assessment scope and objective. An FM assessment of the MOH was carried out for HANSA, in accordance with the ‘Financial Management Practices in Bank Policy/Directives: Investment Project Financing. The assessment was carried out in the DOF, NHIB, NPCO, Paklai District, health centers in Xayabouly Province, and health care centers in Kham District in Xiengkhuang Province. The objective of the FM assessment is to determine whether the MOH, DOF, and NHIB, as the lead implementing agencies, have acceptable FM systems including accounting, financial reporting, and auditing systems to provide the World Bank reasonable assurance that funds will be used for the intended purpose and enable Project Development Objectives (PDOs) to be met.

15. Risk rating. The assessed FM risk of the project is considered High. With the proposed mitigation measures included in the design of the FM arrangements, the risk falls residually to Substantial. The main FM risks identified are weak capacity and lack of experience at all levels, from the central level to the district level. In addition, the FM assessment identified weak segregation of duties among the staff members performing financial accounting and reporting roles at all levels. The weak capacity results from limited number of qualified personnel for accounting and financial reporting tasks. The limited staff has


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also contributed to lack of segregation as the same staff members perform incompatible duties. Limited staffing strength and capacity together with weak internal controls have contributed to a weak control environment at all levels assessed. All these inadequacies can lead to noncompliance risk to fiduciary requirements, unsatisfactory accounting records, and misuse of funds.

16. Risk assessment and mitigation. The result of the FM assessment prepared for the project is based on an amalgamation of the response and information gained from the assessment of the NHIB, DOF of the MOH, NPCO, and DHO; two health centers in Paklai District, Xayyabouly Province; two health centers in Kham District; and a health center in Peak District, Xiengkhuang Province.

17. Risk mitigation proposed includes the following:

(a) Retain NPCO, which is currently the Project Implementation Unit (PIU) of the Health Governance and Nutrition Project as the PIU for the first year of the project.

(b) Provide hands‐on training to the staff of the DOF and NHIB by the NPCO to help build their capacity in project FM in the first year of the project.

(c) Recruit a qualified finance advisor and accountants to complement the NPCO‐provided training and support to assigned staff at the DOF and NHIB for the first year. The consultant will also provide FM training at provincial and district levels.

(d) Put in place acceptable Financial Management Manual (FMM) for the project and FM guidelines for implementation of activities at the field level.

(e) Ensure submission and approval by the World Bank of an FM improvement plan with milestones and predetermined periodic progress reporting.

(f) Conduct annual audit, which will include audit of activities implemented at the village level on a sample basis, carried out by a qualified independent audit firm.

(g) Conduct World Bank FM team supervision.

18. The summary of FM assessment risk and the recommendations for mitigation measures is listed in table 1.1. The level of risk is assessed according to four levels: High, Moderate, Substantial, and Low.

Table 1.1. FM Risks and Mitigation Measures

Type of Risk Risk Rating Risk Mitigating Measures Residual Risk Rating at

Effectiveness

Inherent risk is the risk susceptibility of the project FM system arising from factors of the country such as rules and regulations and the entity working environment.

Country level High High

The change of the government structure, policy, and lack of ownership will affect the achievement of the project.

The broader governance risk may not be mitigated in the current environment.


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Effectiveness

The ambiguous segregation of duty in the government PFM framework weakens governance and also internal control environment. This has led to fraud and corruption in the Government in some cases. Recently, the State Audit Organization (SAO) has published that a huge amount of government budget has been allocated to many fake projects.

PFM reforms in budget preparation, budget execution, and fiscal reporting supported by the World Bank and development partners will help address systemic weaknesses in the control environment across government in the medium to long term. Proposed reforms include implementing a financial management information system, introducing medium‐term planning, and strengthening the capacity of the MOF’s Departments of Budget and Fiscal Policy to prepare realistic budgets and also better guide spending entities in budget proposals preparation. These reforms will however take time to mature and have an impact on the PFM environment.

Weak budget, budget execution planning, and monitoring system processes

PFM reforms in budget preparation, budget execution, and fiscal reporting supported by the World Bank and development partners will help address systemic weaknesses in the control environment across the Government in the medium to long term. Proposed reforms include implementing a financial management information system, introducing medium‐term planning, and strengthening the capacity


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Effectiveness

of the MOF’s Departments of Budget and Fiscal Policy to prepare realistic budgets and also better guide spending entities in budget proposals preparation.

Entity level High Substantial

Multiple implementing agencies, some (such as the NHIB and DOF) with no experience in implementing World Bank‐financed projects, pose the risk of weak coordination and proper supervision capacity, especially at the province level. This may affect the achievement of project goals and effective supervision of FM responsibilities of components that are to be implemented at the province level.

NPCO, which is the PIU for the current health project, will be retained as the PIU for this project for at least the first year, during which the capacity of the DOF and NHIB and facilities is strengthened.

The World Bank team will maintain close supervision in the first year of the project and support implementation of a coordination framework to be included in the Project Operations Manual.

Project level High Substantial

NHIB, DOF, PHO, DHO, and health centers staff have limited capacity and World Bank project FM experience. This may affect timely financial reports submission and submission of withdrawal applications.

Training and support from the finance advisor will be provided to ensure that FM systems are adequately addressed. The PMU and Country Management Unit will ensure adequate FM personnel in the central and field offices who will facilitate FM requirements and monitor financial reporting requirements.

In addition, NPCO, which has good experience in managing World Bank projects, will be twinned with new entities for training and knowledge sharing.

Overall inherent risk High Substantial


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Effectiveness

Control risk is the risk that the project’s FM system is inadequate to ensure funds are used economically and efficiently for the intended purpose.

Budgeting Substantial Moderate

Weak link between the budget and project activities may result in delay in budget approval which may result in delays in funds release and cash availability at the treasury offices.

In addition, lack of skill and capacity of FM staff also increases the risk of budget not being properly prepared on timely.

The budget preparation and reporting guideline will be included in the FMM. In addition, the Project Appraisal Document will have a well‐costed plan of all the project activities that will guide the preparation of project forecast of cash needs.

The FM advisor will train designated staff on how to prepare a proper budget that meets the requirement of the World Bank.

Annual work plan and budget should be approved by the World Bank.

Accounting High Substantial

Manual records keeping may result in failure to maintain accurate and timely accounting information. This may also result in unreliable financial reports.

NPCO will use ACCPAC for all project accounting and reporting. If FM responsibilities are transferred, it will be ensured that an adequate system of accounting is in place at the successor entities that will be responsible for accounting and financial reporting.

The FMM will clearly state documents required for financial records keeping and reporting.

The roles and responsibilities of FM personnel in the central and field offices will also be defined the FMM and monitored during supervision.


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Effectiveness

Internal control High Substantial

Weak internal controls may increase the risk of funds misappropriation and undetected errors in financial reporting.

Internal controls guideline and procedure should be well elaborated in the FMM. The World Bank team will test transactions on a sample basis for adequacy of controls during supervision.

Audit findings and recommendations will be followed upon to ensure action is within a reasonable time frame.

Funds flow Substantial Moderate

Funds flow from the central DOF to NHIB and to provinces and districts may delay. This may lead to implementation delays.

Service standards for cash transfers and response to queries will be stated in the FMM. In addition, the World Bank team will support the central agencies in preparing and submitting timely withdrawal applications.

Effective and efficient banking system to be established. DA will be opened at the Bank of the Lao—managed by Treasury—MOF.

Financial reporting High Substantial

There is a risk of delayed IUFR submission and unreliable supporting schedules.

This risk will be mitigated through training to be imparted by a financial advisor, mentoring by NPCO, the use of ACCPAC, and relevant supplementary Excel templates for reporting.

Auditing High Substantial

External audit for the MOH is done by the SAO. The SAO is the government audit agency and has weak capacity. This

A qualified independent audit firm will be hired to conduct the audit of the


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Effectiveness

may lead to delayed submission of audited reports.

project. The TOR for the audit will be agreed to and cleared by the World Bank‐designated FM specialist.

Overall control risk High Substantial

Overall risk High Substantial

19. Strengths, weaknesses, and action plan. The MOH leadership is fully committed to implementing the required arrangements to support effective and successful project implementation. The DOF also has strong leadership and ownership of its role and is willing to develop the required competencies to support the project’s implementation. Moreover, the experience of the NPCO in implementing World Bank‐financed projects in the MOH is an asset. The NPCO will be twinned with the DOF and NHIB to train them on FM responsibilities and also transfer relevant project FM skills. The weaknesses and the corresponding actions are summarized n the annex.

20. Budgeting. On a country level, the budget is a unitary budget, covering all of the expenditure of line ministries as well as provinces and districts. Under the 2006 Budget Law, donor assistance is treated as part of the budget. The budget is prepared for each component annually and covers the period of the GOL fiscal year (January to December) and in accordance with the approved annual work plan.

21. The DOF‐MOH is the key department at the MOH that is directly responsible for budget consolidation and budget allocation to budget units under the MOH. At the provincial level, the PHO is responsible for consolidating budget plans from line budget units such as PHOs and DHOs and reviewing, approving, and submitting them to the DOF‐MOH for final review before submission to the MOF. However, the budget submission often delays due to lack of capacity as a result of the quality of budget forecasting and lack of accuracy of financial information.

22. The NPCO’s experience in preparing budgets for World Bank‐financed projects would help address all the budgeting requirements of the project and also strengthen the DOF’s budget preparation capacity. In addition, the World Bank team will finalize costing of activities and components of the project which will be included in the Project Appraisal Document. Along with the approved Procurement Plan for the project, the costing and budgeting preparation of the project will be well supported.

23. Accounting and financial reporting. As part of the country system arrangements, the MOH and NHIB use cash basis of accounting, and this will also be used by the project with provisions for accrual at year‐end to prepare financial statements. The DOF and NHIB staff have no experience in using the accounting software yet. The NPCO, however, has an automated ACCPAC accounting software that will be used to record transactions and produce project financial reports. As part of the transition of FM responsibilities to the DOF later during implementation, the NPCO will train the DOF and NHIB FM staff assigned to the project on both Excel‐based templates and the ACCPAC accounting software to record


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transactions and to enable automatic download of financial data. In addition, separate books of accounts will be maintained for the project in ACCPAC.

24. Internal controls. Payment procedures and internal controls systems are not documented in a single manual. However, there are instructions issued by the MOF departments, in particular, National Treasury in relations to making and requesting payments. There are also internal approval procedures to control expenditure individually developed and may differ from one place to another. Although, there appear to be written job descriptions, roles and responsibilities, line of reporting, and limits of authority are not well defined. Moreover, there is no clear segregation of duties especially in places where staff number is limited. Bank reconciliation and system of safeguarding of assets are also not practiced, especially at the provincial and district levels.

25. An FMM will be prepared by project effectiveness. The FMM should clearly define the roles and responsibilities of FM personnel in the central and field offices. The manual will also document the specific reporting requirements, funds flow instructions, and audit requirements necessary to show accountability of transactions.

26. External audit. The State Audit Organization (SAO) audits the MOH. The PHOs are also to be audited by the SAO as part of audit of the province accounts. With limited staff and capacity, audit of ministries is often in arrears. In view of this, a qualified independent audit firm will be hired to conduct the audit of the project. The TOR for the audit will be agreed to and cleared by the World Bank‐designated FM specialist.

Disbursement Arrangements and Fund Flow

27. The total financing of the proposed project is US$36 million equivalent. IDA (US$23 million equivalent), the GF (US$10 million), and the Integrating Donor‐Financed Health Programs (IDFHP) (US$3 million to be financed in installment) will jointly co‐finance the project. As the funding will be available at different stages of the project implementation, the disbursement percentage will be changed from time to time. A retroactive financing clause for an amount not exceeding SDR 3,360,000 will be included in the Financing Agreement to allow for payments made prior to the Signature Date but on or after April 1, 2019.The co‐financing approach is a joint financing classified by three clusters: Cluster 1 (before April 1, 2020) ‐ the project will be financed 100 percent by IDA; Cluster 2 (from April 1, 2020 until before the signing of the GF) ‐ the project will be financed by proportion of which IDA is 90 percent and Trust Fund is 10 percent; and Cluster 3 ‐ after the signing of the GF ‐ the tentative financing percentages of IDA/Trust Fund and GF are specified in the Disbursement and Financial Information Letter. Since the GF will not be negotiated at the same time with IDA and Trust Fund and the GF financing will not be administered by the World Bank, the expected percentage of Cluster 3 is for reference. This percentage may be changed when the Legal Agreement between the GF and the Lao PDR is signed. The specific percentage of each financing source will be recorded in the Disbursement and Financial Information Letter.

28. The project will be disbursed against the following disbursement categories:


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Table 1.2. Project Disbursement

Allocated Amount in US$

Categories IDA Credit IDFHP Grant The Global Fund

Percentage of Expenditures to Be Financed (Inclusive

of Taxes)

(1) Goods, works, non‐consulting services, consulting services, Performance‐based Transfers, Operating Costs, and Training under Parts 1 and 3 of the Project

11.6 1.6 5 Up to 100 percent of the Financing’s and Grant’s agreed share of the cost specified in the Disbursement and Financial Information Letter

(2) Eligible Expenditure Programs under Part 2 of the Project

11.4 1.4 5 Up to 100 percent of the Financing’s and Grant’s agreed share of the cost specified in the Disbursement and Financial Information Letter

(3) Emergency Expenditures under Part 4 of the Project

0 Not applicable Not applicable 100 percent

Total 23,000,000 3,000,000 10,000,000

29. For Components 1, 3, and 4, a Designated Account (DA) will be set up at the Bank of the Lao PDR to channel project funds to the DOF in the MOH to be used for making payments for project activities. The IDA and MDTF funds will be pooled in one DA. The GF may set up and pool its DA with IDA or keep it separately. All draw‐downs would have two signatories: Panel A ‐ project manager, assistant project manager, or a designated MOH officer for the project and Panel B ‐ Deputy Director General of the DOF or FM specialist. Such arrangements should be mirrored at the targeted provincial level and at district levels of the NHIB where DAs shall also be set up as a transitional measure until the direct electronic transfers to health centers are fully functional.

30. Disbursement under Component 2 relating to EEP will be based on reimbursement basis and on the MOH fulfilling the following requirements:

(a) Adopting the Project Operations Manual, in form and substance satisfactory to the World Bank

(b) Furnishing evidence satisfactory to IDA that it has achieved the respective DLIs targets, including a memorandum of understanding, in form and substance satisfactory to the World Bank, which has been duly executed between the MOH, the target province, and health facilities


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(c) Furnishing to the World Bank the IUFRs documenting the incurrence of EEPs against which withdrawal is requested.

31. If the EEP is lower than the DLI values, the disbursement of IDA will be adjusted accordingly—a situation which is not expected to occur. The proposed EEP, which will be set forth in the Project Operations Manual, would consist of the GOL’s expenditure line Chapter 60 (wages, salaries for government health staff). The budget figure for Chapter 60 (wages, salaries for government health staff) is adequate for the EEPs. The IUFR will also include evidence of the additionality that IDA funds bring to the central and the provincial level allocation of the GOL and provincial budget (not applicable in the first year).

32. Funds disbursed for the central‐level DLIs will be transferred from the MOF to the MOH at the central level. For the subnational DLIs, funds will be disbursed from the MOF directly to the PHO. The PHO will disburse to the DHOs and relevant health centers for their DLIs achieved following the GOL funds flow procedures. For reimbursing against achievement of DLIs, a memorandum of understanding including a province‐specific DLI matrix will be prepared and signed between the MOH and the provincial governor for each target province. To ensure sufficiency and timely release of funds, a bank account at the provincial, DHO, and facility levels is required to be opened specifically to receive transfer of funds from the MOH for the project.

33. For transfer to the MOH at the central level, the amount will be based on the value of the central‐level DLIs achieved. Based on verification reports, the MOH will make a request to the MOF for the transfer of the DLI amounts. For Component 1 funds, once the verification agency assesses applicable health centers, the scores will be compiled by the NHIB and shared with the QHC committee. Based on these inputs, the DHR will calculate the total performance payment to be added to the capitation payment of the respective health centers and organize the payment for the same through the DOF and NHIB. The NHIB will set up a bank account to receive funds from the DOF and subsequently transfer the funds to all applicable health centers.

34. The report‐based disbursement method (IUFRs) will be used as a basis for the withdrawal of credit and grant proceeds under Components 1, 3, and 4. The project provides for the use of ‘advances, reimbursements, and special commitments’ as applicable disbursement methods, and these will be specified in the Disbursement and Financial Information Letter. An initial advance from IDA sources will be provided for the implementing entity, based on a forecast of eligible expenditures against each of these components, linked to the appropriate disbursement category. These forecasts will be premised on the annual work‐plans that will be provided to IDA and cleared by the World Bank task team leader. Replenishments, through fresh withdrawal applications to the World Bank and the GF, into the DAs will be made subsequently at semiannual intervals, but such withdrawals will equally be based on the net cash requirements that are linked to approved work‐plans and percentage contribution by each source of funding to the total project funds. Supporting documentation will be retained by the implementing agencies for review by the joint IDA and GF missions and external auditors. For DLIs, each partner will contribute an amount proportionate to their overall contribution to the project funds upon achievement and certification.


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Table 1.3. QPS Disbursement‐related Steps

Date QPS Implementation and Payment‐related Steps

Biannual

January–February

July–August DHOs assess health centers using the QPS and PHO, review scores, and submit to DHR.

February 28 August 31 Third party identifies a sample of health centers for verification using random and risk‐based sampling methods.

March 15 September 15 DHR prepares report of QPS scores of all health centers, including bonus payments to be assessed during January–February.

March–April September–October Third‐party verification agency visits health centers during July and August.

April 15 October 15 QHC Committee holds consultations on the DHR report and certifies the scores and related bonus.

May 15 November 15 DOF/NHIB releases bonus payments directly to health centers.

May 15 November 15 Third‐party verification report submitted to QHC Committee for decision on penalties to be applied to health centers in the following round.

The above steps are repeated annually.

Review and evaluation

Biannually Health center chief conducts individual staff evaluation of all health center staff eligible for bonus payments.

Biannually Districts and provinces prepare plan, including related logistics expenditures needed for DHO assessors to visit health centers.

Biannually Provincial meeting with districts to review performance

Biannually DHR meeting with provinces to review performance, including performance on QPS

Annually DHR meeting with provinces and DHO assessors to review performance and review QPS criteria

Table 1.4. DLI Disbursement‐related Steps

Estimated Time Line

DLI Disbursement‐related Steps

2020 DPC and IAI hold consultations on the verification procedure for that year’s round in April 2020 and ensure that the protocol is agreed upon. IAI fields data collection during July and August.

January 1, 2021 Disbursement against Year 0 achievements for central level and provinces (according to the allocation formula) is based on achieved DLI targets for Year 0 as reported by DPC, IAI report, and documented unaudited EEPs for 12 months before project effectiveness.

Subsequent years

April 15 DPC and IAI hold consultations on the verification procedure for that year’s round and ensure that the protocol is agreed upon. IAI fields data collection during July and August.

June 15 Both central technical departments and provinces prepare report on eligible expenditures and document that IDA funding has been in addition to regular government funding.

July 1 Central technical departments and provinces prepare a report on annual DLI performance (covering the period June–May) based on DHIS2 reported DLIs.


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September 1 IAI submits the verification report to DPC; DPC prepares a DLI report package which includes the NPCO DLI report, eligible expenditure report, and the IAI report to IDA and GF.

November 1 IDA and GF review the DLI package and validate the DLI achievements. World Bank prepares a memo to obtain internal clearance on the validation of the results achieved and a draft letter for authorization of payment for Country Director signature. Any DLI payments that require additional evidence will be subject to supplementary review, clearance, and disbursement once the evidence is submitted.

November 15 IDA and GF send letter of authorization to MOF for disbursement against DLI targets achieved.

November 20 DPC prepares the withdrawal applications to IDA and GF.

Review and evaluation

Every month Health centers and districts prepare and enter the required data into DHIS2.

Quarterly Districts and provinces report on score from the QPS.

Quarterly District meeting with health centers to review performance

Quarterly Provincial meeting with districts to review performance

Biannually DPC meeting with provinces to review performance

35. When deciding on the amount to be disbursed based on DLI achievement, the following arrangement will be made in respect of those DLIs that are not scalable; this will also be reflected in the Project Operations Manual:

For DLIs A, B, C, D, E, F, J, K, and L, a discrepancy of up to 5 percent between the internal and the external verification will be accepted as having achieved the target. In the case of partial achievement of a DLI target in a given year, a minimum value of 60 percent of the DLI target must be achieved to qualify for payment. In cases of achieving less than 100 percent but more than 59 percent, the center/province will receive 50 percent of the DLI value (rounded to the nearest whole number); the amount not disbursed can be rolled over to the following year and disbursed in case the level of achievement of the following year’s target equals or exceeds the previous year’s target (in case of cumulative targets). If targets are noncumulative, that is, they need to be attained in each year separately, then the amount not disbursed can be rolled over to the following year and be disbursed in case the target in the following year is overachieved by at least the same margin as it was underachieved in the previous year. If, by Year 4, all funds for Component 2 have not been disbursed due to non‐achievement of DLIs, then after any required adjustments for unfavorable foreign exchange fluctuations, the remaining amount may be cancelled, or the project restructured.

For DLIs G, H, and I (fully scalable and fungible with a defined value for each unit of output), the reliability percentage of the number of units sampled by the external verification agent would be applied to the total number reported. If targets are not fully achieved in a given year, and as these DLIs are noncumulative, the undisbursed amount from the year will automatically be rolled over to the following year and disbursed in case the target is overachieved in the following year. This will be done keeping the dollar value per unit of that DLI constant and subject to a cap of 50 percent above the assigned value of the DLI. If, at the end of the project, all funds for Component 2 have not been disbursed due to non‐


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achievement of DLIs, the remaining amount may be cancelled or the GOL may request for restructuring to use the unspent amount.

36. For Component 1 funds, once the verification agency assesses applicable health centers, the scores will be compiled by the NHIB and shared with the QHC committee. Based on these inputs, the DHR will calculate the total performance payment to be added to the capitation payment of the respective health centers and organize the payment for the same through the DOF and NHIB. The NHIB will set up a bank account to receive funds from the DOF and subsequently transfer the funds to all applicable health centers.


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Figure 1.2. HANSA Governance Structure

GF World Bank

MOH Technical

D t t

MOF account for Components 1, 3,

and 4

NPCO Components 1, 3,

and 4

PHOs Components 1, 3,

and 4

DHOs Components 1, 3,

and 4

MCH, NNC, CCEH, and MPSC

PHOs Component 2

MOF account for Component 2

CHAS, NTC

NHIB Component 1

WA ‐ SOEs

WA ‐ DLI payment

DLI report compiled by

NPCO

Third‐party

DLI transfer

DHR Component 1

DHOs Component 2

Fund flow for Component 2

Flow of working advance for Components 1, 3, and 4

Payment flow for Component 1

Document flow for Component 2

Statement of expenditure for Components 1, 3, and 4

Request for payment for Component 1

Villages

Health centers


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Procurement

37. Procurement under the project will be carried out in accordance with the World Bank Procurement Regulations for IPF Borrowers, dated 1, July 2016, revised on November 2017 and August 2018, and according to the provisions stipulated in the Financing Agreement. The World Bank standard procurement documents shall be used for procurement international market approach and selection of consultants involving international competition under the project. The Government standard Harmonized Bidding Documents and Request for Quotations with the World Bank’s additional provisions about the environmental, social, health, and safety where required will be used for procurement of goods, works, and non‐consulting services for Request for Bids national market approach and Request for Quotations, respectively, under the project. All procurement activities under the proposed project will be entered into, tracked, and monitored online through the World Bank’s STEP system.

38. The MOH has prepared a Project Procurement Strategy for Development (PPSD) with the support from the World Bank team, and the document has been approved by the procurement hub leader. The PPSD presents how major procurement activities under the project will support the development objective of the project and deliver the best value for money under a risk‐based approach. In addition, the PPSD includes the rationale for procurement decisions including the selection of the approach to market and procurement methods. The PPSD shall be updated once the major contracts in the project have been identified, and the Procurement Plan of the project shall be regularly updated as appropriate during the project implementation.

39. Most of the procurable activities to be financed from HANSA will involve extending existing contracts for key consultants, maintaining internet connectivity for districts and health centers, and engaging a consulting firm for supporting the operation and modification of DHIS2 procured under the HGNDP project. New procurable activities will include two consulting services packages using Quality‐ and Cost‐Based Selection method and some small packages of goods and individual consultants.

40. The procurement risk is considered moderate and is manageable. The NPCO has over 20 years of experience implementing World Bank‐financed projects. The effective and efficient procurement operation can contribute to build capacity of the MOH officials and avoid the conflicts of interest and impartiality in procurement. The key risks and proposed risk mitigation measures are shown in table 1.3 :

Table 1.3. Procurement‐related Risks and Mitigation Measures

Risk Description Risk Rating Description of Mitigation Risk Owner

Limited experience of staff in the DPC and the local consultant with World Bank’s new regulations

Moderate (a) DPC staff and the local consultant will be provided with procurement training initially by the World Bank.

World Bank and DPC

(b) Procurement capacity‐building plan shall be prepared and MOH procurement staff shall join the World Bank’s monthly procurement training.

DPC

Delays in procurement

Moderate (a) Careful procurement planning and scheduling, procurement advanced as much as possible.

DPC


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Risk Description Risk Rating Description of Mitigation Risk Owner

process (b) Procurement monitoring using STEP; all time lines specified in STEP for each stage per each procurement method shall be clear to all tender committee members.

DPC

(c) Closer coordination between Implementing departments and IDA and supervisions and follow‐up by IDA.

World Bank and DPC

Governance risks associated with conflict of interest, fraud, and corruption

Moderate (a) Enhanced disclosure of procurement information, including publication of the annual Procurement Plan and a quarterly summary of the contract award information for all procurement packages on the MOH’s website and in newspapers.

DPC

(b) Require staff involved in procurement to declare their interest and sign a declaration form.

DPC

(c) Monitoring and reporting on implementation of actions for strengthening transparency and procurement training for the project.

DPC

Limitation of value for money and transparency in extension of existing contracts

Low (a) Due diligence by both World Bank and MOH before extension of contracts

World Bank and MOH

(b) Contract negotiation shall be carried out in accordance with the provisions stated in the contract format, and minutes of contract negotiation shall be prepared accordingly.

DPC

Low quality of goods received

Moderate (a) Prepare technical specifications properly, request for manufacturer’s certificate, and include a third‐party inspection company’s certificate in the list of required documents.

DPC

(b) Examine technical specifications offered by bidders carefully, to ensure that they all meet the requirements.

DPC

(c) Check product quality (and probably also the production status) in the factory, before shipment/delivery.

DPC

Limited number of qualified consultants submitted proposals

Moderate (a) Careful procurement planning and scheduling, preparing TOR, Request for Expression of Interest, and Request for Proposals advanced as much as possible

DPC

(b) Widely advertise and post Request for Bids and Request for Expression of Interest on the ministry’s website and local newspapers and at the same time inform the known qualified consultants directly.

DPC

(c) Allow more time for consultants to prepare their proposals.

DPC


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41. Procurement Plan. Based on the findings and recommendations of the PPSD, which is prepared by the DPC, the initial Procurement Plan for the first 18 months of the project is prepared and agreed by the World Bank. The Procurement Plan will be entered in STEP and updated at any time as needed by the DPC to (a) reflect project implementation, (b) accommodate changes that should be made, and (c) add new packages as needed for the project. All Procurement Plans, their updates, or modifications shall be subject to World Bank’s prior review and no‐objection. The World Bank will carry out procurement post reviews on an annual basis with an initial sampling rate of at least 7 percent, which will be adjusted periodically during project implementation, depending on the performance of the agency and the result of the reviews. The detailed Procurement Plan is available in a separate project document.

Strategy and Approach for Implementation Support

42. The collaborative approach of the operations and the engagement with different actors will require intensive implementation support particularly for the MOH technical department that is new to the World Bank IPF with DLIs in the initial stages of the project. The team composition and the expected time allocation required for project supervision are described in table 1.4. The implementation support proposed focuses on implementing the risk mitigation measures, more specifically as follows:

Implementation capacity. The World Bank core team will work in close collaboration with the NPCO to ensure effective design and setup of the project. The NPCO will provide intensive supportive supervision to the MOH technical departments that are new to the World Bank project use of DLIs.

Coordination. The World Bank core team will closely monitor project implementation to promote coordination and detect possible lack of communication, duplication of efforts, and delays in implementation.

M&E. The function of M&E will be significant for the project and for the overall nutrition convergence approach and therefore requires specialized support. The full‐time specialist will be a core team member of the World Bank task team and work closely with the NPCO to monitor the project performance across the project components.

FM. During implementation support, the World Bank’s financial management specialist will support the implementing agency (including with ad hoc training) and routinely review the project’s financial management capacity, including, but not limited to, accounting, reporting, and internal controls to ensure that they are satisfactory to the World Bank.

Procurement. The World Bank’s procurement specialist will work closely with the implementing agencies to build capacity and support them in the periodic procurement activities.

Social and environmental safeguard. During the project preparation, social assessment, ethnic group development framework, and environmental management framework were conducted, consulted, and disclosed. Measures to enhance inclusion of ethnic groups, infection control, and HCWM were also integrated in the QPSs of the health centers. A safeguard committee with representative from the MOH technical departments has been


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established for the project. A safeguard consultant will be recruited to provided capacity building to the committee and ensure the safeguard compliance during the project implementation.

Implementation Support Plan

43. Key World Bank task team members involved in implementation support will be based in Cambodia, Myanmar, Washington, DC, and the Lao PDR country office to ensure timely, efficient, and effective implementation support. The core team is expected to conduct four formal implementation support missions during the first year of implementation, including field visits. After the first year, the periodicity of the implementation support missions is expected to be reduced to two missions a year and maintained throughout the project. Detailed inputs from the World Bank team are outlined as follows:

(a) Technical inputs

(i) Technical experts and professionals to support the elaboration of TOR (consultant and non‐consultant services)

(ii) Field visits to follow implementation of the planned operational enhancements

(iii) TA to the systems’ components

(iv) Organization of technical workshops to share best practices and support the evaluation agenda

(b) Fiduciary requirements. During preparation, the World Bank team identified capacity‐building needs to strengthen FM capacity and improve procurement management in the context of World Bank operations. Support will be provided from the World Bank office in Lao PDR. Formal implementation support of FM reports and procurement will be carried out semiannually, while prior review will be carried out for contracts specified in the Procurement Plan as required.

(c) Social safeguards. During implementation, the social specialist will closely monitor the implementation of the project to ensure full inclusiveness of indigenous groups and women.

44. The project will require the following implementation support in the first year. The Implementation Support Plan will be revised after the first year of implementation.

Table 1.4. Required Project Supervision

Skills Needed Number of Staff Weeks

Number of Trips Comments

Senior health specialist (task team leader)

14 4 Senior health specialist will oversee entire operation, ensure the project performance toward the PDO, and manage partner relationships.

Senior health specialist/senior

10 4 Senior health specialist/senior operations officer will oversee project operations and compliance to


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Skills Needed Number of Staff Weeks

Number of Trips Comments

operations officer World Bank requirements and supervise technical and fiduciary aspects.

Senior economist 6 4 Senior economist will provide implementation guidance for public financial management for the health programs that are supported by the project.

Senior nutrition specialist

6 4 Senior nutrition specialist will ensure the quality of the nutrition services and coordinate the nutrition activities with the World Bank nutrition convergence framework.

Public health specialist

18 0 Public health specialist will provide overall support to the design and implementation of the HIV/TB‐related interventions under the project.

Senior procurement specialist

6 0 Senior procurement specialist will support the implementing agencies on related issues.

Senior FM specialist 6 2 Senior FM specialist will support the implementing agencies on related issues.

Safeguards specialist 3 2 Safeguards specialist will ensure effective inclusion of indigenous peoples and women into project design and implementation.

Operations analyst 10 0 Operations analyst will provide the day‐to‐day hands‐on support to the MOH and NPCO and ensure the performance of the project indicators is on track, as well as monitor the compliance based on the Financing Agreement.


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ANNEX 2: Disbursement Linked Indicators under the project

DLI

Year 0 Indicators Due Date

September 1, 2020

Year 1 Indicators Due Date September 1, 2021

Year 2 Indicators Due Date September

1, 2022


September 1, 2023


September 1,2024

Means of Verification

DLI A: Quality performance and service readiness measurement conducted regularly at health center level.

1. DHR and DHPE appointed designated staff for the Quality and Performance Scorecard function

2. Quality and Performance Scorecard prepared by DHR; at least fifteen (15) clinical vignettes prepared by DHPE with operation guidelines and road map for implementation of the service delivery

1. Quality and Performance Scorecard rolled out to at least two hundred (200) health centers in the four (4) nutrition convergence provinces and received regular quality assessment as per the operation guidelines.

2. Baseline for average score of health centers in the twelve (12) nutrition convergence districts established.

3. Third party verification guideline approved by QHC committee.

1. Quality and Performance Scorecard rolled out to all health centers in the four (4) nutrition convergence provinces and at least four (4) additional provinces; and over ninety percent (90%) of the said health centers have had regular (two (2) times/year/health center) quality assessment and random independent third‐party verification.

2. Ten (10) percentage points increase in the average score

1. Quality and Performance Scorecard rolled out to at least four (4) additional provinces; and over ninety percent (90%) of the said health centers have had regular (two (2) times/year/health center) quality assessment and random independent thirty‐party verification.

2. Twenty (20) percentage points increase in the average score from the baseline score of health

1. QPS rolled out to at least eighty percent (80%) of all health centers nationwide; and over ninety percent (90%) of health centers have had regular (two (2) times/year/health center) quality assessment and random independent third‐party verification.

2. Thirty (30) percentage points increase in the average score from the baseline score of health centers in the

DHIS2 report; IAI verification


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performance measurement at health center level; and all of which have been approved by committee for field testing.

from the baseline score of health centers in the twelve (12) nutrition convergence districts on QPS assessment.

3. At least twenty‐five (25) additional clinical cases or vignettes prepared, field tested and finalized.

centers in the twelve (12) nutrition convergence districts on QPS assessment.

3. Reduction by thirty percent (30%) of health centers whose verification scores are more than ten percent (10%) lower than the assessment scores.

twelve (12) nutrition convergence districts on QPS assessment.

3. Reduction by thirty percent (30%) of health centers whose verification scores from previous year are more than ten percent (10%) lower than assessment scores.

DLI value: US$300,000 1. US$150,000 2. US$150,000

DLI value: US$300,000 1. US$150,000 2. US$100,000 3. US$50,000

DLI value: US$400,000 1. US$200,000 2. US$100,000 3. US$100,000

DLI value: US$500,000

1. US$300,000 2. US$100,000 3. US$100,000

DLI value: 0 (added in AF)

US$ 1,500,000


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DLI B: Number of patients who pay out of pocket payment for “Free” Maternal and Child Services reduced.

1. Definition of “prescribed timeline” and “system to send and monitor the payments to health center” included in the guideline issued by NHIB.

2. Baseline for: (a) number of health centers receiving payments within the prescribed timeline; and (b) for percentage of women not receiving free MCH provided in DHIS2.

1. Fifty percent (50%) reduction in the number of health center receiving payments after the prescribed timeline.

2. Twenty percent (20%) decrease from baseline in the number of women not receiving free MCH fully covered by NHI.

1. Seventy percent (70%) reduction in the number of health center receiving payments after the prescribed timeline.

2. Forty percent (40%) decrease from baseline in the number of women not receiving free MCH fully covered by NHI.

1. Eighty percent (80%) reduction in the number of health center receiving payments after the prescribed timeline.

2. Sixty percent (60%) decrease from baseline in the number of women not receiving free MCH fully covered by NHI.

1. Ninety percent (90%) reduction in the number of health center receiving payments after the prescribed timeline.

2. Eighty percent (80%) decrease from baseline in the number of women not receiving free MCH fully covered by NHI.

DHIS2 IAI

verification

DLI value: US$ 150,000

US$ 75,000

DLI value: US$ 150,000 1. US$ 75,000 2. US$ 75,000

DLI value: US$ 200,000 1. US$ 100,000 2. US$ 100,000


1. US$ 100,000


700,000


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US$ 75,000 2. US$ 100,000

DLI C Availability of essential drugs and supplies at health center level improved.

1. A nationally agreed list of essential drugs and supplies to be available at health center level

2. Baseline for thirty (30) days stock of essential drugs and supplies available at the health centers in four (4) nutrition convergence provinces based on approved list.

3. Terms of reference and composition of national committee for monitoring availability of

1. At least eighty‐five percent (85%) of all health centers in the four (4) nutrition convergence provinces have eighty five percent (85%) of thirty (30) days’ supply of essential drugs and supplies according to the agreed list.

2. Baseline established for thirty (30) days stock of essential drugs and supplies available at health centers in four (4) additional provinces based on agreed list.

1. At least eighty five percent (85%) of all health centers in eight (8) provinces (including the four (4) nutrition convergence provinces) have eighty five percent (85%) of thirty (30) days’ supply of essential drugs and supplies according to the agreed list.

2. Baseline established for thirty (30) days stock of essential drugs and supplies available at health centers in four (4) additional provinces based on the agreed list.

1. At least eighty five percent (85%) of all health centers in twelve (12) provinces (including the four (4) nutrition convergence provinces) have eighty five percent (85%) of the thirty (30) days’ supply of essential drugs and supplies according to the agreed list.

2. Baseline established for thirty (30) days stock of essential drugs and supplies available at health centers in six (6) additional

1. At least eighty five percent (85%) of all health centers in all provinces have eighty five percent (85%) of thirty (30) days’ supply of essential drugs and supplies according to the agreed list.

To be reported through

DHIS2 on a quarterly basis.


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essential drugs and supplies approved by MOH.

provinces based on agreed list.


1. US$ 100,000

2. US$ 100,000

3. US$ 100,000

DLI value: US$ 350,000 1. US$ 250,000 2. US$ 100,000

DLI value: US$ 450,000 1. US$ 350,000 2. US$ 100,000


1. US$ 450,000

2. US$ 100,000


US$ 1,650,000

DLI D: Number of provinces in which the number of health centers without a clinical health worker, as reported in the DHIS2, has been reduced.

1. Baseline established for number of health centers without a clinical worker.

2. Zero draft health services decree prepared by DHP.

1. Ten percent (10%) reduction from baseline of number of health centers without a clinical health worker in four (4) nutrition convergence provinces.

2. Field test of the payment mechanism under the draft health service decree conducted in four (4) nutrition convergence provinces.

1. Twenty‐five percent (25%) reduction from baseline of number of health centers without a clinical health worker in a total of eight (8) provinces.

2. Health services decree approved by the MOH.

1. Forty percent (40%) reduction from baseline of number of health centers without a clinical health worker in a total of twelve (12) provinces.

1. At least sixty percent (60%) reduction from baseline of number of health centers, or at least eighty percent (80%) of all health centers in all provinces have a clinical health worker, nationwide.


1. US$ 100,000

2. US$

DLI value: US$ 200,000 1. US$ 150,000 2. US$ 50,000

DLI value: US$ 200,000 1. US$ 150,000 2. US$ 50,000


1. US$ 150,000

2. US$ 50,000


US$ 800,000


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100,000

DLI E. Improvement of financial management capacity at health center level

1. Guideline for FM at health center level prepared, field tested and approved by the MOH.

2. All district FM staff in four (4) nutrition convergence provinces are trained to coach and supervise health center staff according to the financial management guidelines.

1. At least one hundred and fifty (150) health centers in the four (4) nutrition convergence provinces are certified in FM.

1. All health centers in the four (4) nutrition convergence provinces and in at least one hundred fifty (150) health centers in four (4) additional provinces are certified in FM.

1. All health centers in a total of eight (8) provinces and in at least one hundred fifty (150) health centers in four (4) additional provinces are certified in FM.

1. At least eighty percent (80%) of all health centers nationwide are certified in FM.

DHIS2; IAI

verification


1. US$ 150,000

2. US$

DLI value: US$ 250,000 1. US$ 150,000 2. US$ 100,000

DLI value: US$ 250,000 1. US$ 150,000 2. US$ 100,000


1. US$ 150,000

2. US$


US$ 1,000,000


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100,000 100,000

DLI F: Increased coverage and correctness of event capture reports for selected services

1. Baseline for number of health facilities where event capture is undertaken and reported in DHIS2

2. Baseline of percentage difference of data reported through event capture and monthly aggregate data for service delivery conducted in health facilities.

3.

1. Forty percent (40%) of total health facilities in the country apply event capture

2. Twenty percent (20%) reduction in variance of data reported through event capture and monthly aggregate data from the baseline.

1. Sixty percent (60%) of total health facilities in country apply event capture

2. Forty percent (40%) reduction in variance of data reported through event capture and monthly aggregate data from the baseline.

1. Eighty five percent (85%) of total health facilities in country apply event

2. Sixty percent (60%) reduction in variance of data reported through event capture and monthly aggregate data from the baseline.

1. At least ninety five percent (95%) of total health facilities in country apply event capture;

2. Eighty percent (80%) reduction in variance of data reported through event capture and monthly aggregate data from the baseline.

DHIS2 Annual project report; IAI

verification


1. US$ 175,000

2. US$ 75,000

DLI value: US$ 250,000 1. US$ 175,000 2. US$ 75,000

DLI value: US$ 250,000 1. US$ 175,000 2. US$ 75,000


1. US$ 175,000

2. US$ 75,000


US$ 1,000,000


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DLI G: Implementation of Social and Behavioral Change Communication and Growth Monitoring and Promotion activities at village‐level.

1. Up to three hundred (300) villages in twelve (12) nutrition convergence districts have conducted at least ten (10) monthly SBCC sessions in the past twelve (12) months with a prescribed set of activities including Growth Monitoring and Promotion; and have reported the said sessions in DHIS2.

1. Up to eight hundred eighty‐one (881) villages in twelve (12) nutrition convergence districts have conducted at least ten (10) monthly SBCC sessions in the past twelve (12) months with a prescribed set of activities including Growth Monitoring and Promotion; and have reported said sessions in DHIS2.

1. Up to eight hundred eighty‐one (881) villages in twelve (12) nutrition convergence districts have conducted at least ten (10) monthly SBCC sessions in the past twelve (12) months with a prescribed set of activities including Growth Monitoring and Promotion; and have reported said sessions in DHIS2.

1. Up to eight hundred eighty‐one (881) villages, in twelve (12) nutrition convergence districts have conducted at least ten (10) monthly SBCC sessions in the past twelve (12) months with a prescribed set of activities including Growth Monitoring and Promotion; and have reported said sessions in DHIS2.

1. Up to eight hundred eighty‐one (881) villages, in twelve (12) nutrition convergence districts have conducted at least ten (10) monthly SBCC sessions in the past twelve (12) months with a prescribed set of activities including growth monitoring and promotion; and have reported said sessions in DHIS2.

DHIS2 IAI

Verification;

Value: US$ 240,000 (500 US$ per village)

DLI value: US$ 440,500 (500 US$ per village)




US$ 1,561,500


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DLI H: Number of villages in Zone 2 and Zone 3 in nutrition convergence provinces in which Integrated Outreach Sessions are conducted.

1. Up to three hundred (300) villages in Zone 2 and Zone 3 in nutrition convergence provinces conducted at least three (3) quarterly Integrated Outreach Sessions in a year.

1. Up to four hundred (400) villages in Zone 2 and Zone 3 in nutrition convergence provinces conducted at least three (3) quarterly Integrated Outreach Sessions in a year.

1. Up to five hundred (500) villages in Zone 2 and Zone 3 in nutrition convergence provinces conducted at least three (3) quarterly Integrated Outreach Sessions in a year.

1. Up to six hundred (600) villages in Zone 2 and Zone 3 in nutrition convergence provinces conducted at least three (3) quarterly Integrated Outreach Sessions in a year.

1. Up to seven hundred (700) villages in Zone 2 and Zone 3 in nutrition convergence provinces conducted at least three (3) quarterly integrated outreach sessions in a year.

DHIS2; IAI

verification

Value: US$ 150,000 (500 US$ per village)



DLI. US$ 300,000 (500 US$ per village)


US$ 900,000

DLI I: Number of Immunization Target Districts which have increased the Pentavalent 3 and deliveries with Skilled Birth Attendant.

1. Baseline value for the number of children less than twelve (<12) months who received (DPT‐HepB‐Hib) immunization in each of the fifty (50) identified poor coverage Immunization Target Districts

1. Number of districts among the fifty (50) Immunization Target Districts which have achieved an increase of five (5) percentage points in the number of children less than twelve (<12) months covered by DPT‐HepB‐Hib over the baseline or maintained a coverage with DPT‐HepB‐Hib of ninety‐five percentage (95%) or more.

1. Number of districts among the fifty (50) Immunization Target Districts which have achieved an increase of eight (8) percentage points in the number of children less than twelve (<12) months covered by DPT‐HepB‐Hib over the baseline or

1. Number of districts among the fifty (50) Immunization Target Districts which have achieved an increase of ten (10) percentage points in the number of children less than twelve (<12) months covered

1. Number of districts among the fifty (50) Immunization Target Districts which have achieved an increase of twelve (12) percentage points in the number of children less than twelve (<12) months covered

DHIS2; IAI

verification;


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as recorded in DHIS2.

2. Baseline value established for number of women deliveries by Skilled Birth Attendant in the fifty (50) Immunization Target Districts.

2. Number of districts in the fifty (50) Immunization Target Districts which have received an increase of three (3) percentage points in the number of women delivered by Skilled Birth Attendant over the baseline or maintained a coverage with skilled birth attendant deliveries of ninety percent (90%) or more.

maintained a coverage with DPT‐HepB‐Hib of ninety‐five (95%) or more.

2. Number of districts in the fifty (50) Immunization Target Districts which have received an increase of five (5) percentage points in the number of women delivered by Skilled Birth Attendant over the baseline or maintained a coverage with skilled birth attendant deliveries of ninety percent (90%) or more.

by DPT‐HepB‐Hib over the baseline or maintained a coverage with DPT‐HepB‐Hib of ninety‐five percent (95%) or more.

2. Number of districts in fifty (50) Immunization Target Districts which have received an increase of seven (7) percentage points in the number of women delivered by Skilled Birth Attendant over the baseline or reached or maintained a coverage with skilled birth attendant deliveries of

by DPT‐HepB‐Hib over the baseline or maintained a coverage with DPT‐HepB‐Hib of ninety‐five percent (95%) or more.

2. Number of districts in fifty (50) Immunization Target Districts which have received an increase of nine (9) percentage points the number of women delivered by skilled birth attendant over the baseline or reached or maintained a coverage with skilled birth attendant of ninety percent (90%) or more.


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ninety percent (90%) or more.


1. US$ 150,000

2. US$ 150,000

DLI value: US$ 500,000 Scalable at US$ 5000 per district per achieved increase on each indicator




US$ 1,800,000

DLI J: Number of notified TB cases of all forms (i.e. bacteriologically confirmed and clinically diagnosed new and relapse cases).

1. Baseline information on TB notified cases by province is established through DHIS2.

2. Baseline established for information on the proportion of presumptive TB or MDR‐TB patients examined by GeneXpert by province

Joint protocol for

1. Provinces that achieved the targeted number of notified TB cases of all forms.

2. Provinces which have achieved an increase of twenty (20) percentage points over the previous year; or reached or maintained one hundred percent (100%) GeneXpert coverage.


2. Provinces which have achieved an increase of twenty (20) percentage points over the previous year; or reached or maintained one hundred percent (100%) GeneXpert coverage.


2. Provinces which have achieved an increase fifteen (15) percentage points over the previous year; or reached or maintained one hundred percent (100%) GeneXpert coverage.


2. Provinces which have reached or maintained one hundred percent (100%) GeneXpert coverage.

DHIS2 IAI

Verification


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increased use of GeneXpert (including, management and maintenance) as well as cross‐program usage drafted by the TB and HIV units. DLI value: US$ 800,000

1. US$

200,000

2. US$

200,000

3. US$

400,000

DLI value: US$ 950,000 1. US$ 750,000 2. US$ 200,000

DLI value: US$ 950,000 1. US$ 750,000 2. US$ 200,000


1. US$ 700,000 2. US$ 200,000


US$ 3,600,000

DLI K: Increased coverage of a) HIV testing among key populations (female service women [FSW)) and men having sex with men [MSM)); b) and HIV

1. Baseline established for: (a) the percentage of FSW that have received an HIV test in the past twelve (12) months and know their results by province; (b) the percentage

1. Two (2) percentage point increase over the previous year in HIV testing coverage of estimated FSW during the past twelve (12) months.

2. Five (5) percentage points increase over the previous year in HIV testing coverage of estimated MSM during the past twelve (12) months.

1. Two (2) percentage points increase over the previous year in HIV testing coverage of estimated FSW during the past twelve (12) months.

2. Six (6) percentage points increase over the previous year in HIV testing coverage of estimated MSM


2. Eight (8) percentage points


2. Ten (10) percentage points

DHIS2 IAI

verification


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treatment among people living with HIV.

of MSM that have received an HIV test in the past twelve (12) months and know their results by province; and (b) number of HIV positive cases currently on treatment nationwide.

2. Standard operating procedure for HIV/AIDS case finding and management (including health center, district and provincial level with easy access to Point of Care) approved by MOH.

Mechanism for

3. Four (4) percentage points increase over the previous year in number of HIV positive cases receiving antiretroviral treatment nationwide.

during the past twelve (12) months.

3. Four (4) percentage points increase over the previous year in number of HIV positive cases receiving antiretroviral treatment nationwide.

increase over the previous year in HIV testing coverage of estimated MSM during the past twelve (12) months.

3. Five (5) percentage points increase over the previous year in number of HIV positive cases receiving antiretroviral treatment nationwide.

increase over the previous year in HIV testing coverage of estimated MSM during the past twelve (12) months.

3. Five (5) percentage points increase over the previous year in number of HIV positive cases receiving antiretroviral treatment nationwide.


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DPC to subcontract CSOs in place.


1. US$

300,000

2. US$

500,000

3. US$

200,000

DLI value: US$ 800,000 1. US$ 200,000 2. US$ 400,000 3. US$ 200,000

DLI value: US$ 800,000 1. US$ 200,000 2. US$ 400,000 3. US$ 200,000


1. US$ 100,000 2. US$ 300,000 3. US$ 100,000


US$ 2,900,000

DLI L: Increase in national readiness for health security in responding to pandemics and health emergency at international boundaries (airports and ground crossings)

1. Standard operating procedure for health emergency contingency at points of entry approved by MOH.

1. Standard operating procedure for health emergency contingency at point of entry (airports and ground crossings with less than one hundred fifty (<150,000) travelers per year and more than one hundred fifty (> 150,000) travelers per year)) field tested and finalized.

2. Simulation exercises held at 2 international airports and 2 formal ground crossings with more than one hundred fifty (>150,000) travelers per year.

1. Training activities as per the national standard operating procedures conducted at three (3) formal ground crossings with less than one hundred fifty (<150,000) travelers per year.

2. Simulation exercises held at two (2) additional international airports and two (2) additional formal

1. Training activities as per the national standard operating procedures conducted at four (4) additional formal ground crossings with less than one hundred fifty (<150,000) travelers per year.

2. Simulation exercises held at

1. Training activities as per the national standard operating procedures for four (4) additional formal ground crossings with less than one hundred fifty (<150,000) travelers per year.

2. Simulation exercises held at two (2)


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ground crossings with more than one hundred fifty (>150,000) travelers per year.

two (2) international airports and three (3) additional formal ground crossings with more than one hundred fifty (>150,000) travelers per year.

international airports and two (2) additional formal ground crossings with more than one hundred fifty (>150,000) travelers per year.


DLI value: US$ 100,000 1. US$ 50,000 2. US$ 50,000

DLI value: US$ 100,000 1. US$ 50,000 2. US$ 50,000

DLI value: US$ 100,000 1. US$ 50,000 2. US$ 50,000


US$ 388,500


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ANNEX 3: Country Portfolio Results Chain for an Integrated Approach to Tackling Childhood Stunting

COUNTRY: Lao People's Democratic Republic

Health and Nutrition Services Access Project (HANSA)

1. The GOL‐World Bank multi‐sectoral nutrition convergence approach supports the Government’s

National Nutrition Strategy (2016‐2025) and Plan of Action (NNSAP) to accelerate the reduction of under‐

5 stunting from 44 percent to an ambitious target of 25 percent by 2025, by enabling the implementation

nutrition‐specific and nutrition‐sensitive interventions known to reduce stunting in select high‐stunting

burden provinces. The key elements in the causal results chain to the achievement of the stunting target

will be to address the immediate, underlying and as we all as some of the basic causes of child

undernutrition in Lao‐PDR (Figure 3): at the immediate level, nutritional status will ultimately be

determined by the availability of nutrients to the body to meet its requirements and the status of health;

while the underlying and basic causes are related to access, availability and utilization of food maternal

and child caring practices, water and sanitation and personal hygiene; these determinants are heavily

influenced by the social status of women as well as economic. Achievements in these areas of

interventions supported by necessary systems and capacity improvements, should result in improved

nutrition and reduced illness and disease of pregnant women and children, which, in turn, should result

in reduced prevalence of stunting and better child physical and cognitive development.

2. The overall goal for the World Bank financed multi‐sectoral nutrition convergence approach will

be to show case that with an integrated approach in four years stunting rates would be reduce by 20

percent in the target areas and 1.75 percent nationally. The proposed four sectoral operations (Table 3.1)

will all contribute to tackling the immediate and underlying causes of malnutrition in provinces with the

highest share and absolute numbers of stunted children. The selected evidence‐based interventions

proposed under the convergence approach are expected to reduce by over 20 percent stunting rates in

the target areas by 2024, which will correspond to close to 2 percent reduction nationally.

Guiding Principles • Focus on high‐stunting districts and on vulnerable and poor households • Use of a common Social Behavioral and Change strategy, action plan and tools • Leveraging each project’s delivery platforms, foe‐example, established community‐based

structures • Use of a common monitoring and evaluation Framework


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Figure 3.1. Causal Framework to Reducing Stunting in Lao‐PDR


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Table 3.1. Country Portfolio Results Chain for an Integrated Approach to Tackling Childhood Stunting

Country Program Goal

Overall Country Portfolio Objective

Expected Sector‐specific Results

Key Indicators Relevant Project Activities

Reduce stunting prevalence in children under 2 years of age in targeted regions by 20 percent.

To enable the GOL to implement nutrition‐specific and nutrition‐sensitive interventions by key sectors to address the immediate and underlying determinants of childhood undernutrition in an integrated and coordinated manner

Health and Nutrition Increased supply and utilization of essential MCH and nutrition services

Percentage of children under five years of age whose growth is adequately monitored

Percentage of women who attended at least 4 ANC session during their most recent pregnancy

Percentage of infants 0–5 months who are exclusively breastfed

Percentage of children 6–59 months receiving vitamin A supplementation within the past 12 months

SBCC for optimal infant and child feeding, maternal nutrition, and hygiene

Improve availability and access to ANC and PNC services

Provision of essential micronutrients to women and children

Treatment of infections (for example, diarrhea and malaria)

Deworming of children and pregnant women

Social Protection Reduced (nutritional) vulnerability of poor households and increase the demand for and utilization of health and nutrition services and access to diverse diets

Percentage of households with periodically updated socio‐economic survey information reported in the social registry

Number of beneficiaries of social safety net programs

Percentage of children 6–23 months from cash transfer beneficiary households consuming foods from four or more recommended food groups

Number of villages in project districts where at least three convergence projects have been implemented

Deliver cash transfers and improve SBCC delivery to generate/increase demand for and improve access to essential health and nutrition services

Target social protection services/interventions to the poorest and most nutritionally vulnerable population in rural areas

SBCC improved in its delivery for optimal infant and child feeding, maternal nutrition, and hygiene and use of


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cash for nutrition inputs

Advocacy and provision of technical support to other ministries on nutrition issues

Finance mechanisms to coordinate and monitor nutrition convergence

WASH Interrupted routes of fecal‐oral contamination among infants and young children 0–24 months

Number of people provided with access to improved water sources

Number of people with access to improved sanitation services

Percentage of the target population practicing handwashing with soap after using the latrine

Percentage of water supply systems that meet project service levels

Number of villages where at least three nutrition convergence projects have been implemented

Construct/rehabilitate water supply systems

Support and promote the use of improved sanitation facilities and handwashing stations

Construct toilets and handwashing facilities in health centers and schools

SBCC to promote handwashing with soap for all household members at critical times, that is, before preparation of food, before feeding of infant/young child, after cleaning of floors, and after use of latrine

Agriculture/PRF Improve access to basic services, increased production and consumption of diverse and nutritious foods for poor households

Percentage of children 6–23 months from SHG and Farmer Nutrition Group households consuming foods from four or more recommended food groups

Seed grant finance and FM capacity building for investment in agriculture and livestock production


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Income from the sale of SHG and Producer Group‐financed production

Agriculture, livestock and handicraft production by SHG member households

Percentage of SHG members with year‐round production from home nutrition gardens

Percentage of women in leadership positions with SHGs and Village SHG Management Committees (VSMCs)

for consumption and sale

Material (i.e. seeds and basic garden tools), training, monitoring and support on home nutrition gardens

Establishment and support to Farmer Nutrition Groups comprised mainly of pregnant women and women with children less than 24 months of age focusing on SBCC and peer support/learning on the growing, processing, cooking and feeding of diverse and nutritious foods to themselves (especially when pregnant) and their children

Investment in infrastructure that will facilitate access to markets for the sale of production and access to services (i.e. roads and bridges) as well as enhanced production (i.e. irrigation, animal shelter and fencing, storage facilities)


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Table 3.2 World Bank Nutrition‐related portfolio in Lao PDR and expected synergies with the proposed operation31

Sector Projects and activities Nutrition‐related elements Synergies

Health

Lao PDR Health Governance and Nutrition Development Project (P151425) Ongoing, US$ 26.4 million) AF of HGNDP (US$ 15 million) Health and Nutrition Services Access (HANSA) Project (P166165) Pipeline, US$ 36 million.

Strengthening primary health care, improving both the coverage and the quality of maternal and child health (MCH) services mostly at the facility level; includes support for nutrition‐related indicators in the DLIs and support development of an integrated national strategy and implementation plan for SBCC to improve nutrition as well as implementation of the strategy at the national level and at the village level in all 881 villages in the 12 selected priority districts in four norther provinces, including Phongsaly, Oudomxay, Xiengkhuang, and Huaphan. This proposed operation’s PDO will be to “improve access to quality health and nutrition services in targeted areas of Lao PDR”. A major component of this operation will be to strengthen and improve quality of service delivery for UHC, with a focus on MCH services, including nutrition

HGNDP will continue focusing on provision of quality essential health care services especially clinical services at facility level and during outreach, while this operation will focus on: (i) increasing demand for those services known to improve nutritional outcomes; and (ii) further strengthening mainly community‐based preventive and promotive services through nutrition SBCC monthly session. The availability of nutrition specific interventions will be crucial to maximize impact of financial incentives for poor households. As quality health and nutrition service become available in the selected geographic convergence areas, co‐responsibilities on utilization of those same services will be added as a condition for beneficiaries to receive cash transfers.

WASH

Scale‐up Water Supply, Sanitation and Hygiene Project (P164901) Ongoing , US$ 25 million

Improving access to sanitation and clean water, and improving hygiene practices, especially in rural areas. The project will also take a sector wide approach to reducing open defecation and behavior change and communications.

The project is being designed to overlap with the geographic areas HGNDP and where this proposed project will be implemented. Using the Nutrition Social Behavioral Change and Communication Strategy and Action plan and tools as a base, the project will explore the use of state‐of‐the‐art behavior change methods and insights from behavioral economics for the expansion and intersection of nutrition and WASH messaging, and provision of clean water.

31 In the agriculture sector, synergies will be applied with a donor financed project (IFAD) on food and nutrition security implemented by MAF in the same geographic areas of intervention.


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SURR

Poverty Reduction Fund (PRF) IV (P157963) Ongoing, US$ 30 million AF of the PRF IV Ongoing, US$ 22.5 million

The overall development objective of the project is to improve access to basic services for the project’s targeted poor communities, through including community and local development processes. One component finances provision of capacity building assistance to village Self Help Groups (SHGs), with a focus on women’s SHGs in selected communities, to develop and implement nutrition sensitive livelihood activities. The project also supports existing SHGs start or further develop nutrition sensitive livelihood activities such as the production of small livestock (for example, poultry and fish) and home gardens, and increase their capacity to manage them

The PRF will be the service delivery partner for this proposed project as it provides an effective service delivery platform at the local level. Moreover, PRF activities will also complement this project by supporting the improvement of dietary diversity and food intake of pregnant and breastfeeding mothers and children below the age of two years.

Education

Early Childhood Education Project (P145544) Ongoing, US$ 28 million

The overall development objective of the project is to increase coverage and improve the quality of early childhood education services for 3 to 5‐year‐olds in target districts. The project is also piloting two early childhood education (ECE) modalities that are new in Lao context– a non‐formal Community Child Development Playgroup for children of ages 2 to 4 years, and a formal delivery of multi‐age teaching (MAT) to groups of children of ages varying from 3 to 5 years; and community awareness campaign to promote good childcare and health practices and emphasize the importance of early cognitive stimulation. All of the piloting activities (implemented in the selected villages in the proposed four northern provinces) are being rigorously evaluated.

The project overlaps with some of the geographic areas of HGNP and therefore where this proposed project will be implemented. The projects will coordinate on the SBCC at community level.

Social Protection

Reducing Rural Poverty and Malnutrition Project (P162565) Ongoing, US$ 27 million

The Project Development Objective is to support the design and implementation of a nutrition‐sensitive social assistance program toimprove nutrition behaviors, and enhance the convergence of nutrition‐focused interventions. Component 2 of the project will provide cash which is condition on the attendance of the nutrition SBCC monthly session, utilization of antination care, grow mornitoring and counseling for children underfive years of age. The component will also finance the development of additional nutrition SBCC module and crate an innovative audio‐visual tool to deliver the existing key nutrition SBCC modules. Component 3 of the project will support the nutrition coordination and overall moniroting and evaluation of both nutritoin sensitie and nutrition specific interventions financed by the World Bank.

The project will gendera demand for health care and nutrition service throught the provision of the cash transfers to the poorest and most uritional vulerable population in the rural areas, as well as improve SBCC delivery to generate/increase demand for and improve access to essential health and nutrition services in the same geographical areas which cover same 881 villages in the 12 selected districts in the four nothern provinces.


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ANNEX 4: Monitoring and Evaluation Framework for the Nutrition convergence approach


Health and Nutrition Services Access Project (HANSA) 1. The World Bank will closely monitor the implementation of this multispectral nutrition convergence approach. A comprehensive M&E framework will be established specifically to: (a) track the convergence of the World Bank’s portfolio of nutrition interventions at the village level; (b) report on nutrition indicators; and (c) quantify the impact of the convergence approach, its cost‐effectiveness, and effectiveness of individual interventions that are associated with individual projects. This will be achieved by tracking the delivery of interventions at the village level, process monitoring, measuring household‐ and individual‐level outcomes, and imbedding impact evaluations in the projects to measure attributable impacts of the portfolio interventions. An overall summary of the M&E Framework is provided in Figure 4.1 below.

Figure 4.1. Overview of the M&E Framework

2. Monitoring activities shall focus on monitoring the delivery of interventions to assess the achievement of convergence and tracking progress on the utilization of nutrition‐specific and nutrition‐sensitive services and nutrition outcomes. Thus, the monitoring system shall track input and output delivery and nutrition outcomes committed in the list of convergence result indicators and related intervention activities. The evaluation framework is set up to measure the impact at the portfolio level and the project level. The portfolio‐level evaluation assesses the effectiveness of the convergence


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approach on nutrition outcomes while the project‐level evaluation assesses the impact of specific interventions on the achievement of intermediate outcomes, as well as process or delivery mechanism evaluation. Monitoring of Outcomes

3. The monitoring framework will be designed to regularly report on the progress in improving nutrition behaviors and outcomes at the individual and household levels in program areas. Some of the outcome indicators will be obtained from administrative data sources, especially the projects’ management information systems (MIS), but the majority shall be monitored using harmonized household surveys (see table 4.1). The harmonized household surveys will include a standardized set of questions in separate modules, to measure the key indicators for the convergence result indicators and project‐specific indicators, depending on the final implementation arrangements. The definitions and measurement methodology for each of those indicators will be based on the project‐specific guidelines for such measures, with teams from each of the four projects taking leadership in the design of the modules of their respective projects. The convergence M&E team will take overall responsibility on the survey design and field implementation plans.

Table 4.1. Monitoring Plan for Convergence Result Indicators Indicator Name (Disaggregated

by Gender, Ethnicity, and Welfare Status)

Data Source Frequency Start Year End Year

Under 2 years old stunting rate Harmonized household survey

3 times 2019 2024

Percentage of children under two years of age whose growth is adequately monitored

Harmonized household survey

3 times 2019 2024

Percentage of pregnant women with at least 4 ANC during pregnancy


3 times 2019 2024

Percentage of infants 0–5 months who are exclusively breastfed


3 times 2019 2024

Percentage of children 6–59 months receiving vitamin A supplementation within the past 12 months


3 times 2019 2024

Number of households with pregnant women and/or children 0–2 years in target provinces receiving cash transfers

Social protection project MIS

Annually 2020 2024

Percentage of project beneficiaries who participate in community nutrition sessions at least once per month


Annually 2020 2024


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Indicator Name (Disaggregated by Gender, Ethnicity, and

Welfare Status)

Data Source Frequency Start Year End Year

Percentage of children 6–23 months of age consuming foods from four or more recommended food groups


3 times 2019 2024

Percentage of households with access to improved sanitation


3 times 2019 2024

Percentage of households with access to clean water


3 times 2019 2024

Proportion of households with soap at handwashing stations


3 times 2019 2024

Proportion of households that use proper disposal techniques for child and animal feces


3 times 2019 2024

Percentage of households with a mean household dietary diversity score > 4


3 times 2019 2024

Percentage of pregnant women and mothers of children under two years of age in targeted communities participating in Mother and Children Nutrition Groups and Self‐Help Groups (SHGs)

PRF MIS Annually 2019 2024

Percentage increase of income (or overall consumption) of SHG members


3 times 2019 2024

Percentage of SHG member food production which is consumed by members (agriculture, livestock, fisheries and aquaculture)

PRF Project MIS data

Annually 2021 2024

Percentage increase in the availability of nutritious foods


3 times 2019 2024

Percentage increase in the consumption of nutritious foods


3 times 2019 2024

Percentage of time saved and reduced workload for women (including pregnant and breastfeeding)


3 times 2019 2024

4. At least three surveys would be needed, corresponding to the baseline, midline, and end line of the program implementation. The exact timing of these surveys will factor the rollout process of the four projects to maximize synergies. The surveys ought to be representative of all the 12 program districts and


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include both household‐ and village‐level questionnaires. Thus, the surveys would ideally have a sample size of around 2,500–3,000 households.

Monitoring Delivery of Interventions

5. Monitoring delivery of interventions will focus on tracking the achievement of convergence activities at the village level. This establishes a system for tracking the provision of inputs and outputs produced at the village level, assessing the adequacy of delivery mechanisms and the program take up, and utilization of delivered services. The main goal would be to assess and provide regular feedback on the achievement of convergence activities in terms of totality of delivery of key interventions at the village level, the number of villages, and to the extent possible the number of households where convergence has been achieved and the duration of that coverage between 2019 and 2014, during which period the four projects will be implemented. Four main tools will be used for this purpose:

Village score cards; Iterative Beneficiary Monitoring (IBM); Administrative data ‐ sector and program MIS; and Spot checks and key informant interviews.

6. Village score cards shall be employed as a tool for regularly reporting on interventions being delivered in each of the villages in the 12 districts covered by at least one of the four planned projects, providing a village‐level mapping of ongoing interventions. A bottom‐up approach will be employed to collect data using village score cards, taking advantage of implementation arrangements of current and planned projects by the World Bank and other agencies that already use village facilitators to coordinate and deliver some interventions at the village level. Among the World Bank’s own portfolio, both the HGNDP and the ECE project have village facilitators, which provides a pool of potential data collectors for the village score card. The PRF also has Kumban Facilitators and Village Self‐Help Group Management Committees to potentially draw upon. The score card will focus on a few input indicators (see Table 4.2.) selected from a list of overlapping indicators in the convergence result indicators framework and the national nutrition surveillance system that the MOH is currently developing with TA from UNICEF and the World Food Programme (WFP). The World Bank plans to collaborate with the WFP to develop a simple mobile‐based tool, acquire the appropriate mobile devices, and train and assign one of the village facilitators in each village to periodically report on ongoing nutrition‐sensitive programs at the village level, so that data could be captured locally and uploaded into a centralized database. 7. This concept offers some significant advantages. Beyond the initial development, equipment, and training expenses, the running costs are very low, requiring only token expenses for data airtime credit and top‐up incentives. The village facilitators are already sensitized on nutrition interventions, given their various roles in SBCC and other functions they perform in their communities, for which they may receive payment under the current projects. The M&E budget could be used to provide incremental allowances for performing the data collection at a lesser cost than hiring professional enumerators. Reporting can be more frequent, since the village facilitators reside in villages where they work, unlike when a survey firm is hired to undertake initial data collection. The downside is that village facilitators are not trained


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enumerators. However, the simplicity of the tool, combined with some training, validation, and incentives for good performance, can mitigate this. Setting up the system and collecting the data are envisaged to take about six months, after which data can be collected on a semiannual basis. This involves the following processes:

Design of tools in consultation with the Government, especially the NNC; Software application development (both the field mobile‐based application that village

facilitators will use for recording data in the field and the end user web‐based interface, for receiving, processing, and reporting the data) and repository set;

Training of selected staff at the province and district levels on collecting data using the mobile application and on how to supervise and validate this data so they can later be field trainers and supervisors;

Pretesting to validate the quality of data collected, assess the limits and scope for expansion of the application, and review the application’s performance under different conditions, including the mobile network variability and digital illiteracy; and

Training of village facilitators on using the data collection tool and implementation of data quality control mechanisms.

8. IBM shall be employed to obtain continuous feedback from program beneficiaries about the challenges and adequacy of delivery mechanisms for the interventions. IBM is done using quick, small, and targeted surveys that track a narrow set of indicators and can be implemented in a three‐week period at a cost of US$3,000–US$5,000. A different set of indicators could be tracked in each survey. This allows for continuous monitoring of delivery of interventions at the household level and for improved utilization of services. It will also be used for process monitoring by including targeted questions on either satisfaction with implementation arrangements or whether processes are being followed. It will be used to quickly assess challenges in program take‐up too. Two such surveys are envisaged every fiscal year, from the time of effectiveness of the first of the four projects under preparation, which mostly could be run with a local team of Lao consultants or partner institutions. 9. Administrative data shall also be used for monitoring program outputs, supply of some inputs, and program take‐up. This includes both the sector‐wide and project‐specific administrative data and MIS. PRF already has an MIS for tracking various inputs and outputs (that is, SHG and Mother and Children Nutrition Group members and their activities), and this will be enhanced through the AF to cover a wider geographic area and new interventions. Both the Scaling‐up Water Supply, Sanitation and Hygiene project and the Reducing Rural Poverty and Malnutrition project will build MISs that could be used to monitor key outcomes such as number of households receiving benefits and number of handwashing stations/facilities constructed. Meanwhile, delivery of most interventions in the health sector will be captured from the HANSA Project Results Framework, HANSA DLIs, and DHIS2 data. This could be complemented with information obtained from key informant interviews at the district and village levels.

10. Table 4.2 provides a summary of the interventions from the portfolio results chain that will be monitored, their data sources, time frame, and frequency of monitoring. Delivery of most interventions can be monitored on a semiannual basis according to this monitoring plan. Thus, a semiannual


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convergence monitoring report will be produced to report and update management and the government principals on progress toward achieving convergence outcomes. This will report on the number of villages where convergence outcomes resulting from portfolio interventions have been achieved and highlight any implementation challenges discovered.

Table 4.2. Monitoring Plan for Delivery of Interventions at the Portfolio Level Intervention Data

Sources Period Frequenc

y Village

Score Card

IBM Administrative Data

Key Informant Interview

s

Start Year

End Year

SBCC for optimal infant and child feeding, maternal nutrition, and use of cash for nutrition inputs

2018 2024 Semi‐annually

SBCC to promote handwashing with soap for all household members at critical times


SBCC to increase production and consumption of diverse foods


Improvement of availability and access to ANC and PNC services

DHIS2 2018 2024 Semi‐annually

Provision of essential micronutrients to women and children


Treatment of infections (for example, diarrhea and malaria)


Deworming of children and pregnant women


Delivery of cash transfers to generate/increase demand for and improve access to essential health and nutrition services


Target social protection services/interventions to the poorest and most nutritionally vulnerable population in rural areas



Advocacy and provision of 2019 2024 Annually


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Intervention Data Sources

Period Frequency

Village Score Card

IBM Administrative Data

Key Informant Interview

s

Start Year

End Year

technical support to other ministries on nutrition issues Support and promote villages to achieve 100 percent use of improved sanitation facilities

WASH project CLT data


Provision/construction of handwashing stations/facilities


Promotion of use of household‐level treatment of water before use, for example, chlorination and boiling


Dissemination of nutrition information to communities/households through the agricultural extension and other outreach systems


Provision of financing, facilitation support, and TA for income‐generating activities including the production and sale of small livestock (for example, poultry and fish) and vegetables


Incentive for regular group food processing, cooking, and eating among pregnant women, mothers, and infants


Provision of seeds, TA, and SBCC to increase production and consumption of nutritious and diverse foods


Finance for construction and rehabilitation of livelihood‐oriented infrastructure to improve access to markets and services


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Evaluation of Convergence Approach

11. Project design practicalities will necessarily result in variations in the number and type of interventions received at the village level as the four projects roll out. This provides opportunities to embed an experimental evaluation design of the convergence approach to assess the impact of World Bank interventions collectively and the cost‐effectiveness of the convergence approach and identify the combination of interventions with the greatest impact on nutrition outcomes given their cost. 12. Two main features of the program implementation result in this varying intensity of convergence. The first is the varying geographical coverage of the four projects. HANSA and Reducing Rural Poverty and Malnutrition Project will cover all villages in the 12 districts. On the other hand, the PRF III AF will cover up to 601 of the overlapping villages depending upon resource availability, while the Scaling‐Up Water Supply, Sanitation and Hygiene Project will likely cover 450 villages, depending upon community demand. Thus, only 450 of the 881 villages will receive all interventions at full implementation of all the four projects. Additionally, the rollout pace differs across programs either because some interventions can be prepared and implemented much quicker than others or due to phased rollout of interventions within projects. For example, setting up the payment system might take up to 12 months, while SBCC is anticipated to be implemented much earlier. When the cash transfer is rolled out, it is anticipated to cover only half of the eligible beneficiaries at the beginning. Careful planning and coordination of this rollout process (for example, randomizing phase‐in) permits embedding an evaluation of the impact and cost‐effectiveness of the convergence approach. Project‐level Evaluations

13. Such evaluation will focus on evaluating the impact of specific interventions on the achievement of intermediate outcome indicators and the effectiveness of different delivery mechanisms. This will be done using three approaches depending on the context.

Experimental designs can be built in by exploiting any phased approach to implementation within projects. In this case, phased implementation can be carefully planned to accommodate an impact evaluation, randomizing selection of villages in each phase for example.

Quasi‐experimental designs that exploit arbitrary discontinuities introduced by program eligibility criteria. For example, age‐based cutoff points for eligibility of cash transfer in the first phase of the Reducing Rural Poverty and Malnutrition project make it possible to use regression discontinuity analysis to evaluate the impact of the interventions for people around the cutoff point. Similarly, using PMT thresholds for eligibility for subsidies for the construction of sanitary facilities under the Scaling‐Up Water Supply, Sanitation and Hygiene Project also makes use of regression discontinuity applicable for impact evaluation of interventions.

Nimble experiments. Small experiments can also be run without significantly changing the


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nature of program implementation and still answer questions on how best to implement key interventions. For example, by taking advantage of changes to existing interventions such as SBCC, which is already being done, the impact of a new module can be assessed compared to current practice by making small changes to the operation procedures across locations, for example, how and who delivers an intervention.

Implementation arrangement

14. The Reducing Rural Poverty and Malnutrition Project will finance the data collection and overall M&E of the convergence approach. Subcomponent 3.2 of the project therefore includes financing of three rounds of harmonized surveys covering data needs of all four projects, the costs of regular implementation of the village score cards (twice a year) to monitor the achievement of convergence, and IBM (twice a year) to obtain regular beneficiary feedback. The surveys will be organized and designed to also serve the data needs of impact evaluations of the convergence approach given the rollout plans of the four projects. 15. The MPI will lead these overall convergence M&E activities as part of the overall coordination of the convergence portfolio of projects in the four target provinces, working with multi‐sectoral convergence coordinating committee. The project will hire a M&E expert to provide technical support to the MPI in consultation with other sectors, on developing the survey instruments, methodology, supervision and reporting plans, and aggregation of relevant statistics produced from administrative data sources. Primary data collection activities like the harmonized surveys and IBM will be implemented by a survey firm based on the established methodology and instruments, while administrative and project MIS data, shall be generated by the responsible sector ministries. The World Bank technical teams from the four projects, and the poverty team shall work closely with the MPI in this process also, to ensure timely and high‐quality implementation of the M&E activities. 16. Strong coordination across projects and implementing agencies is crucial for successful implementation of the M&E Framework. Experimental approaches require coordinated rollout of project implementation across projects. The four project teams will therefore develop a geographic, intervention, and time‐specific rollout plan, keeping in mind that total convergence should be achieved within a given time frame of the project. Regular convergence workshops with the Government would also be crucial for instilling a shared vision for the M&E of convergence of nutrition interventions.

17. The early stages of implementation will focus on developing a concrete roll‐out plan across sectors as the projects await effectiveness and developing monitoring instruments such as the harmonized surveys and village score cards. Project MIS systems will also be established that will later provide information used to compute some key convergence indicators. Baseline data collection for the harmonize surveys and first village score cards will then be implemented. These activities should be completed within the first 12 months of the project’s approval by the Board. Routine data collection, monitoring and reporting activities such as the semi‐annual implementation of the village score card, IBM, spot checks and reporting from administrative data will then follow. Information they will generate shall


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be summarized into a semi‐annual monitoring bulletin, providing crucial information for the convergence coordinating committee discussions. In the final stages, M&E activities will mostly focus on analytics for impact evaluations for the portfolio level outcomes, assess the impact of the convergence approach and draw lessons for future implementation. 18. Since the portfolio of interventions will be implemented phased multi‐sectoral approach spanning three phases, the M&E activities in this first phase are naturally centered on developing and establishing instruments for M&E, and generating knowledge and lessons learnt to improve implementation of nutrition interventions in the future. The village score card, harmonized surveys and IBM are both instruments that will be developed and used for the first time. This phase of the program will help establish them for monitoring of interventions in future. Impact evaluations activities, will help to assess the cost effectiveness of the convergence approach, identify which interventions work and how delivery of interventions could be improved for greater impact. Thus, great emphasis shall be placed on rigorously measuring the impact of the convergence approach, impacts of different ways of delivering interventions, documenting and sharing the supporting evidence and lessons learnt.


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ANNEX 5: Framework for the Design of a Common Nutrition Social Behavioral Change and Communication Strategy for the Overall World Bank‐Financed Nutrition Convergence Approach


Health and Nutrition Services Access Project (HANSA) 1. Creating a common vision of planning and implementing a strong and coordinated evidence‐based Nutrition SBCC Strategy and Action Plan as outlined in the multi‐sector nutrition convergence framework [1] would be critical for the success of the overall convergence approach. The proposed SBCC approach is behavior centered to facilitate individuals, households, groups, and communities in adopting and sustaining nutrition‐related practices. It complements the National Social and Behavior Change Multisectoral Communication Strategy for Nutrition by designing an approach for four World Bank‐supported operations: HGNDP (P151425)/HANSA (P166165), Reducing Rural Poverty and Malnutrition Project (P162565), Scaling‐Up Water Supply and Sanitation and Hygiene Project (P164901), and the Poverty Reduction Fund III AF (P168620).

Box 5.1. Social and Behavior Change and Communication

SBCC activities can be categorized into two primary types—mass media and community‐based approaches—and successful campaigns are best delivered in a complementary manner. In addition, SBCC also includes advocacy activities for nutrition, targeted at different levels of leaders and decision makers. Mass media approaches can be in the form of ‘edutainment’ or social marketing campaigns. Edutainment is characterized by radio and television messages, dramas aired on radio or television, and songs containing relevant messages and may also include social media. In contrast, community‐based approaches leverage social networks, outreach activities, and peer influence to promote discussion among communities, within households, and among peers. They aim to influence the utilization of services and behaviors through norms, information, emotional drivers, and social and peer support. These approaches can be delivered in the form of community edutainment events, community discussion groups, peer groups, or one‐on‐one exchanges and are often targeted at specific subpopulations (such as pregnant women, women with children under a certain age, men, and adolescents). In the 12 districts of the four priority provinces, the HGNDP supports community‐based SBCC activities aimed at contributing to improvements in infant and young child feeding and caring practices, maternal nutrition and related caring practices, appropriate sanitation and personal as well as environment‐related hygiene behaviors, household air pollution through use of near smokeless cookstoves, dietary diversification, and other determinants of nutrition at the village level. Village‐based facilitators (VFs), who comprise mostly female village health volunteers and/or members of Lao Women’s Unit, support the SBCC implementation at the village level, under the guidance of district health staff. The VFs are responsible for organizing communications sessions at least monthly, conducting home visits for follow‐up on pregnant women and children under two years of age, supporting the organization of edutainment community events, and coordinating with relevant district line ministries.

2. Convergence for an effective delivery of SBCC will be achieved in the following manner:

Thematic convergence. The thematic convergence builds on UNICEF’s framework to address the underlying, basic, and immediate causes of malnutrition, all of which are behavior related (see Figure 5.1). All projects are designed to include nutrition‐specific and nutrition‐sensitive interventions to improve (a) care and feeding practices, (b) household food security, and (c) household environment and health services. The related SBCC interventions will be carried


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out in a coordinated and phased manner.

Figure 5.1. Framework for the SBCC Delivery Pathways to Improved Behaviors and Nutritional Status

Note: SP = social protection; WB = World Bank; WRA = women in reproductive age. 3. Communications convergence through coordinated SBCC planning and implementation:

a) Identification of messages based on sector (and which is therefore nutrition‐specific or nutrition‐sensitive) but linked to overarching behaviors that contribute to the nutrition agenda in Lao PDR. Figure 4.1 provides key practices per sector, which can be grouped into seven clusters. These clusters are: (i) maternal nutrition; (ii) health care seeking behavior; (iii) breastfeeding and complementary feeding practices; (iv) WASH and environmental health; (v) nutrition‐sensitive


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agriculture practices (including food processing); (vi) income/household expenditures/savings; and (vii) women empowerment. The evidence supporting the positive relationship between each practice and nutritional status has been documented in other documents of the World Bank convergence approach. It is important to note that the practices presented in Figure 4.1 are not exhaustive; there are many sub‐practices that can be added at a later stage.

b) Complementary messaging by the various projects using primary messaging from one’s own sector to meet specific project and sector goals, supplemented by secondary/support messaging from other projects/sectors. These complementary messages feed into the same behavior change. Using this method serves to provide the beneficiary with many more reasons to change their behavior/adopt the new behavior and also reiterates the message from a new angle (avoids communication fatigue, which is a result of straightforward repetition).

c) Communication will be coordinated to focus on the behaviors of those who need to practice the desired behaviors, for example, mothers and other caregivers and also those who can influence decisions. The SBCC framework identified four types of audiences (see figure 5.1): The primary audience includes women in reproductive age (women ages 15–49 years, in particular those who are pregnant and with children under two years of age) and other caregivers. The secondary audience includes other family members and peers/group members—this will include those producing food (farmers). As the tertiary audience, the focus is on community leaders (for example, Village Development Committee, VDC) who can mobilize or allocate resources as well as local GOL service providers (including primarily MCH, WASH, and agricultural service provision). As the final target group, central GOL, private sector, and other development partners will be targeted.

d) Same or similar delivery platforms from national to community level (see figure 5.2). Develop and improve communication for better coordination between the PMUs of different projects and the line ministries at the national, provincial, and, in particular, the district and village levels. This can be done by using an existing committee and inviting convergence project personnel to its meetings, by using a common planner at the village level to earmark main meetings, by coordinating high‐level visits, and so on. At the village level, a concerted effort should be made to coordinate village groups, in particular, with a view on sustainability.[2]


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Figure 5.2. Framework for Common Nutrition SBCC Strategy

Note: IEC = Information, Education and Communication, WB = World Bank. 4. Under this multisectoral nutrition convergence approach, the convergence projects will endeavor to coordinate their planning to dovetail efforts at the community level, thereby enhancing synergy and reducing redundancy and message fatigue. Some of the areas wherein this can be achieved include:

a) Coordinating village‐level SBCC action plans and, to the extent possible, having all projects working within an agreed time frame to deliver the various SBCC interventions to the same households in any particular village[3]

b) Jointly carrying out certain activities with other projects or combining project activities in one event at the village level, thereby increasing visibility for all projects, and helping reinforce the impact of SBCC. For example: health, social protection, WASH, and PRF could jointly do village cleaning or PRF village planning meeting.


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c) In continuation, trying to achieve a common branding (including logo and legend) for the multisector nutrition agenda (see Figure 4.2) and using it both at the national level (for example, for the National Sanitation Campaign planned under the Water Supply and Sanitation‐ project) as well as for the village level (to increase interest and recall)

d) In continuation of points (a) and (b), using similar and standardized communication tools and channels at the village level, which are simple to use. Different projects could be using a similar communication style across projects. For example, pictorial and similar in their look and usage. Short audio‐visuals could be used to deliver complementary messaging, which can be shown at meetings of any project and would still be relevant; and

e) Conducting joint training and orientation of project staff at various levels, to increase synergy and strengthen the institutional links between PMUs/line ministries.

Overall Communication Strategy for the World Bank‐financed Nutrition Convergence Approach

5. All projects would have to be aligned in the overall communication on the multisectoral nutrition convergence approach. National‐level advocacy for the World Bank multisector approach on nutrition and increasing communication within the Government and within the stakeholder community through workshops, publications, sharing of key learnings through common social media platforms, discussion groups with development partners, and so on will need to be fully coordinated. [1] World Bank’s Multi‐Sector Nutrition Engagement Framework for Lao PDR. [2] Example: PRF’s proposed wireless communication and networking groups (WCNGs) can be a good forum for WASH to promote safe water practices or the building of household‐level handwashing stations. The ongoing HGNDP already supports the implementation at the community level of the national nutrition SBCC plan in the form of community edutainment events, community discussion groups, peer groups, or one‐on‐one exchanges that are often targeted at specific subpopulations (such as pregnant women, women with children under a certain age, men, and adolescents) and community‐led total sanitation (CLTS) in the 12 selected districts (10 of these districts overlap with the PRF districts). Starting in 2019, the Water and Sanitation for Health Project will expand these efforts in the 12 districts. In the villages that do not have a WASH project, CLTS can be carried out by the other projects such as the HGNDP, HANSA, or PRF. [3] The cycle should be no longer than 2 years to deliver all the messages.


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ANNEX 6: Economic and Financial Analysis

1. The HANSA project aims to improve access to quality health and nutrition services in four northern

provinces of Lao PDR. The projects components include (a) integrating service delivery performance with NHI payments, (b) strengthening nutrition service delivery and priority public health programs using results‐based financing mechanisms, and (c) strengthening project management.

Rationale for Public Intervention and Financing

2. Public financing and provision of health and nutrition services focusing on women, children, and

vulnerable populations are justifiable due to market failures, externalities, and equity grounds. The focus of this project is on high‐impact and cost‐effective RMNCAH, HIV/TB, and nutrition interventions, which have positive externalities. These interventions can yield broad and long‐standing benefits beyond immediate health outcomes and improvement in nutrition status, such as better protection against catastrophic health spending, reduction of inequality through more equal access to RMNCAH and nutrition services and strengthening of the health system generally for example through service integration, helping pave the way toward achieving UHC.

3. There is a strong commitment from the GOL and the World Bank to address financing and delivery bottlenecks for nutrition and health services in Lao PDR under the convergence agenda. The growing understanding of the links between ill health and high stunting rates at young ages and the lifelong negative consequences and costs to society of these conditions have cemented the political commitment. The design leverages and builds on existing institutional structures and service delivery mechanism both at the facility and community levels. While the proposed expansion of health and nutrition services can be ambitious, the focus on decentralizing financing to the frontlines increases the capacity of frontline service providers and improves the overall quality and performance of health service delivery.

Project Development Impact

4. The proposed project will contribute to the development of Lao PDR through the following pathways: improved child survival and reduced maternal deaths; reduced health care costs resulting from poor quality, ineffective care, and avoidable hospital admissions; increased health system efficiency; improved health equity; and increased labor productivity and GDP growth.

5. The project will contribute to improving MCH and nutritional outcomes by increasing access and utilization of quality health and nutrition services. Access to quality health services has been recognized as an important health system priority. Mortality in LMICs due to poor care surpasses

mortality attributable to lack of access to care. According to the recent study by Kruk et al (2018),32

32 Kruk, Margaret E., et al., 2018: "Mortality due to Low‐quality Health Systems in the Universal Health Coverage Era: A Systematic Analysis of Amenable Deaths in 137 Countries." The Lancet 392 (10160): 2203–2212.


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8.6 million people die from treatable conditions in LMICs annually, 3.6 million from lack of access and the remaining 5 million from insufficient care.

6. Interventions aimed at improving MCH and nutrition have been identified as some of the most cost‐

effective interventions. The global investment framework for RMNCAH finds that US$1 invested in the essential package of MCH and nutrition interventions is estimated to yield about US$9 in economic benefits. Similarly, economic evaluations of nutrition interventions have estimated favorable benefit: cost ratios for nutrition‐specific interventions aimed at reducing stunting and micronutrient deficiencies which will be financed by this project. Increased coverage of effective MCH interventions such as immunization, integrated management of childhood illnesses, and ANC coupled with increased nutrition services will contribute to improving child survival.

7. Investing in improvement in quality of care is cost‐effective. Poor quality of care not only reduces the effectiveness of health care in achieving good health outcomes but also has substantial cost implications for health systems. Apart from contributing to additional direct treatment costs to the health systems, the loss of productivity alone in LMICs due to low quality of care is estimated at between US$1.4 trillion and US$1.6 trillion annually. Although few studies estimating the costs and benefits of quality improvement interventions exist, these studies have shown that improving the quality of health and nutrition services makes economic sense and results in higher returns of public expenditure on health. For example, a study by Peabody et al (2006)33 found that improvements in clinical practice for detection and treatment of acute respiratory illness and treatment for diarrhea in children can be very cost‐effective resulting in as much as 5 percent annual reduction in child mortality rates.

8. The project will contribute to reduced morbidity and mortality from TB and HIV by supporting

improved case finding and treatment for TB, and increasing coverage of HIV testing among high‐risk populations, and treatment for persons living with HIV. The project will also contribute to saving health care costs related to treating TB by focusing on controlling the spread of TB through improving case detection rates. Existing evidence suggests improved case finding and treatment for TB would substantially reduce the economic burden of tuberculosis—reflecting reductions in direct costs and reductions in income loss from early identification and effective treatment. 34 Similarly, several

33 Peabody, J. W., M. M. Taguiwalo, D. A. Robalino, et al. 2006. “Improving the Quality of Care in Developing Countries.” In Disease Control Priorities in Developing Countries. 2nd edition, edited by D. T. Jamison, J. G. Breman, A. R. Measham, et al., editors, Chapter 70. Washington, DC: The International Bank for Reconstruction and Development / The World Bank. 34 Menzies, Nicolas A., et al. 2016. “Cost‐effectiveness and Resource Implications of Aggressive Action on Tuberculosis in China, India, and South Africa: A Combined Analysis of Nine Models.” The Lancet Global Health. https://doi.org/10.1016/S2214‐109X(16)30265‐0.


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national studies35 have suggested that HIV prevention programs targeted at high‐risk groups at scale are cost‐effective.

9. The project will contribute to improvements in health system efficiency. Increased investment in public health programs has largely been associated with lower health care costs and improved population health outcomes. Improving access to quality primary health care services plays a critical role in improving the efficiency and productivity of the health system to maximize health outcomes and health equity. Technical efficiency and productivity improvements are achieved from better utilization of available health resources.

10. Through its focus on geographic convergence, the project will contribute to improved allocative

efficiency and health equity by targeting resources where they are needed the most. The project will initially cover four nutrition convergence provinces in northern Lao PDR: Oudomxay, Phongsaly, Huaphan, and Xiengkhuang, which account for 15.7 percent of the total population of the country and are characterized by particularly high rates of stunting. The DLIs will be rolled out in phases and will be implemented nationwide during the project implementation period. Specifically, the project addresses major bottlenecks in the provision of health services, especially at the health center level where service readiness has been found to be low.

11. At the macro level, this project will generate long‐term economic benefit by reducing national

economic losses attributed to increased morbidity and mortality and decreased cognitive ability which directly reduce educational attainment and labor productivity in adults. In Lao PDR, a recent study estimated economic losses associated with undernutrition of at least US$200 million annually,

representing about 2.4 percent of the country’s GDP.36

Economic benefits of investing in select maternal, child health and nutrition services

12. An evaluation of the impact of select interventions financed through this project on health and nutrition outcomes was conducted, and the net present value of the project, the internal rate of return, and the benefit‐cost ratio calculated. Specifically, the analysis employs the LiST, to estimate the impact of the project in terms of the number of deaths averted by the different health interventions. LiST was used to model the impact of expanding the coverage of the following MCH and nutrition‐specific interventions: iron supplementation in pregnancy, skilled birth attendance, health facility delivery, exclusive breastfeeding of children below one month, injectable antibiotics for neonatal sepsis/pneumonia, and oral rehydration solution for the treatment of diarrhea.

35 Prinja, S., P. Bahugana, Rudra et al.2011. “Cost‐effectiveness of Targeted HIV Prevention Interventions for Female Sex Workers in India.” Sex Transm Infect 2011 (87): 354–361; Fung, I. C., L. Guinness, P. Vickerman, et al. 2007. “Modelling the Impact and Cost‐effectiveness of the HIV Intervention Programme among Commercial Sex Workers in Ahmedabad, Gujarat, India.” BMC Public Health 2007 (7): 195; Vassall, Anna, et al. 2014. “Cost‐effectiveness of HIV Prevention for High‐risk Groups at Scale: An Economic Evaluation of the Avahan Programme in South India.” The Lancet Global Health 2 (9): e531–e540. 36 Bagriansky, Jack, and Saykham Voladet. June 2013. The Economic Consequences of Malnutrition in Lao PDR: A Damage Assessment Report. NERI and Unicef Working Paper.


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13. The analysis uses population data (table 6.1) and a number of assumptions to estimate the benefits

of select interventions. The following sets of assumptions and scenarios were used to estimate the benefits:

i. The project scenario assumes that coverage rates of the included interventions increase at the

annual rate necessary to reach the targets as outlined in the National RMNCAH strategy, 2016–2025 over 2020–2024. This scenario reflects the investment of US$ 36 million.

ii. The “baseline” scenario assumes coverage rates constant at 2019 level. iii. Annual GDP growth rate is assumed at 6.7 percent, the average annual growth between 2018 and

2022 projected by the International Monetary Fund for Lao PDR.

Table 6.1: Number of beneficiaries in project provinces

Province

Population

Women in child bearing age

Expected live births

Phongsaly 179,235 40,068 5735 Oudomxay 312,236 71,423 9992 Huaphanh 290,263 66,002 9579 Xiengkhuang 246,152 55,575 7877 Total 1,027,886 233,068 33,183

Source: National Health Statistics Report

14. The assumptions on the effectiveness of interventions used for this analysis are set in accordance with

the current academic literature. Coverage rates for ANC, skilled birth attendance, and share of births at health facilities are assigned no direct impact by themselves, but are used to calculate the availability of other interventions during pregnancy (syphilis detection and treatment; and management of hypertension, pre‐eclampsia, and malaria) or at the time of giving birth (clean birth practices; labor and delivery management; neonatal resuscitation, immediate assessment and stimulation of the new‐born; active management of the third stage of labor, induction of labor for pregnancies lasting more than 41 weeks; antibiotics in case of premature rupture of the membranes; and so on).

15. One DALY saved was valued as one times GDP per capita. One case of anemia prevented was valued as 20 percent for women engaged in heavy physical labor, and 4 percent for women engaged in non‐physical labor. In the base‐case scenario, it was assumed that 40 percent engaged in heavy physical labor, and 60 percent engaged in other non‐physical labor. The following equation summarizes the approach to the valuation of health outcomes and calculation of monetary benefits:

B = LS*(1−P) *GDPpc*DS + LS*P*GDPpc*(1−S) *L*DS + CS*GDPpc*S*L + VA*GDPpc*AH*H*L +

GDPpc*AO*O*L where: B = monetary benefits LS = unique lives saved


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DS= DALYs saved per under‐5 death averted CS = unique cases of stunting prevented VA = additional children who benefited from Vitamin A supplementation P = prevalence of stunting GDPpc = GDP per capita S = percentage of wage income gained as a result of the child not being stunted AH = percentage of wage income gained as a result of anemia prevented in women engaged in heavy physical labor H=percentage of women engaged in heavy physical labor AO = percentage of wage income gained as a result of anemia prevented in women engaged in other (non‐physical) labor O=percentage of women engaged in other (non‐physical) labor, and L = proportion of income from labor

Net present value was calculated using the following formula:

𝑁𝑃𝑉 𝐵𝑒𝑛𝑒𝑓𝑖𝑡𝑠 𝐶𝑜𝑠𝑡𝑠

1 𝑟

where: r = discount rate, t = year, and n = analytic horizon (in years)

16. The impact modelling using LiST showed that the project would result in 2,226 child deaths averted

(904 of whom were less than one month and 28 maternal deaths averted over 2020–2024.

17. The impact of the project on health and nutrition status of women and children would translate into

substantial economic benefits. Table 6.2 summarizes the expected net benefits of child mortality alone and benefit‐cost‐ratios for discount rates of 0 percent, 3 percent, and 10 percent.

Table 6.2: Expected net‐benefits and benefit‐cost ratios (only considering the reduction of child mortality)

Discount Rates

Project cost: US$36 million

Net benefits (US$ millions)

Benefit‐Cost Ratios

0 percent 59.6 1.66 3 percent 51.4 1.43 10 percent 37.0 1.03

18. The results indicate that each dollar invested by the project would generate at least US$ 1.03 in

benefits and could generate up to US$ 1.66. If only the impact of the program on child mortality is


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considered, one under‐five death would be averted at US$ 16,200 and a DALY would be saved at the cost of US$ 990. According to the WHO criteria,37 an intervention that averts one additional DALY at a cost of less than GDP per capita is considered as "very cost‐effective" and an intervention that averts one additional DALY at a cost of between one‐ and three‐times GDP per capita is deemed "cost‐effective" and representing "good value for money". According to this benchmark the project could be considered as "very cost‐effective" from its impact on child mortality alone.

19. The specific DLIs of the project regarding HIV and TB of the project, still being defined, are not assessed

in the analysis. However, interventions addressing HIV prevention and treatment of high‐risk key populations – female service women and men who have sex with men – have been shown to be cost‐effective. As a high risk of contracting HIV might be associated with a probability of passing on HIV among high risk groups such interventions are particularly cost‐effective when averted secondary infections are considered.

Financial Sustainability

20. Government expenditure on health in Lao PDR has increased by about 23 percent in nominal terms from US$241 million in FY2012/13 to US$296 million in FY2018. This expenditure in FY 2018/19 is equal to nearly 2 percent of GDP or 8.3 percent of GGE. According to the State Budget Plan, GGHE is projected to increase to US$326 million in FY2019/20. Despite the recent increase in government expenditure on health, domestic public investment in health and nutrition in remains low and funding for key health programs such as immunization, HIV and TB is highly fragmented due to high reliance on external financing.

21. The financial implications of the proposed project investment over 2020–2024 was assessed using three scenarios: (1) GGHE remains at the current level of 7.9 percent of GGE, (2) GGHE reaches 9 percent of GGE as per commitment by the GOL, and (3) GGHE as per the 9th HSDP. The proposed project financing accounts for about 1.8 percent of the government expenditure on health over 2020–2024 if GGHE remains at the current level (Scenario 1); 1.6 percent if GGHE reaches 9 percent of GGE according to commitment by the GOL (Scenario 2); and 1.2 percent if GGHE is set according to the 9th HSDP (Scenario 3). Figure 6.1 summarizes the annual share of the project investment of government expenditure on health.

37 WHO. 2002. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva: WHO.


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Figure 6.1: Share of Project Costs of Projected GGHE

Source: author’s calculation

22. If the project investment is spread evenly across the project period it would increase government per

capita spending in 2024 by US$ 0.94, from US$ 60.02 to US$ 60.96 in scenario (1), from US$ 70.72 to US$ 71.66 in scenario (2), and from US$ 92.33 to US$ 93.26 in scenario (3) (See Figure 6.2).

Figure 6.2: Projected Government Expenditure

Source: Department of Finance, Ministry of Health (2019)

1,723 1,974 2,184 2,460 2,775 3,131 3,5333,985

2,5162,769

3,0723,375

3,7154,089

4,5014,953

3,1573,502

3,8484,236

4,6635,132

5,648

4,382

5,059

5,828

6,700

7,687

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

2018 2019 2020 2021 2022 2023 2024 2025

Billion LAK

Current funding ODACurrent funding domesticCurrent funding total9% of GGEHSD Budget Plan


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23. The increase in per capita spending is relatively small and it is, therefore, expected that this project

will be financially sustainable. Further, the project contributes to financial sustainability of priority public health programs by mainstreaming investments of TB and HIV programs through government systems and giving greater autonomy in programming of these funds using government systems.