Photo credit: World Bank/Stanislas Fradelizi
At the time of the project appraisal in 2005, some progress had been recorded on key health indicators in the Lao People’s Democratic Republic. Between 1995 and 2005, the under-five mortality rate fell from 140 to 93 deaths per 1,000 live births, and the maternal mortality ratio decreased from 656 to 530 deaths per 100,000 live births. Despite this progress, maternal and child mortality rates in the Lao People’s Democratic Republic were the highest in Southeast Asia; communicable diseases were pervasive; and undernutrition affected almost 48 percent of children under-five; and geographical, income, ethnic and urban-rural disparities remained. On the supply-side, this poor performance was directly correlated with low quality of care, including poorly trained and demotivated human resources for health, and inadequate equipment and infrastructures. On the demand-side, maternal and child health results were adversely affected by poor access to health services and high levels of out-of-pocket health expenditures (World Bank, 2006).
RBF AT A GLANCE
The Health Services Improvement Project supported the piloting of various results-based financing interventions, including:
- A Free Maternal and Child Health scheme, providing results-based payments for the delivery of key maternal health services;
- Health Equity Funds, using results-based payments to enhance the delivery of healthcare services to the poor;
- A Payment-for-Quality scheme, providing additional payments contingent on the quality of key MCH services.
The Government of the Lao People’s Democratic Republic contracted the Lao Red Cross to coordinate these various schemes. In turn, the Lao Red Cross signed performance agreements with health facilities. RBF payments were disbursed based on the quantity, equity and quality of maternal and child services.
Status and achievements
At completion, operational evidence showed that the HSIP successfully contributed to improving the coverage of maternal and child services between 2011 and 2015. For instance, the Health Equity Fund and Free Maternal and Child Health initiatives contributed to:
- Boosting institutional delivery, creating an increase from 24 to 39 percent in 2015;
- Increasing service utilization among children under-five;
- Improving the coverage of the basic package of health, nutrition and reproductive health services, providing access to care to an additional 791,598 people by 2015;
- Strengthening the quality of care through the provision to 5,426 medical personnel, most of which returned to their duty stations;
- Developing key health infrastructure by building and renovating hospitals and health centers, providing medical equipment, and developing a web-based health information system.
After the Project’s completion, the government of the Lao People’s Democratic Republic maintains features of the results based program in the follow on IDA project. Specifically, the follow on project:
- Ensures intergovernmental fund transfer is performance related and focused on results;
- Concentrates on data for tracking results and relies on monitoring and verification of outputs through third party mechanisms so that only real results are paid for; and
- Focuses on service delivery quantity and quality metrics and uses the tools that the RBF project introduced.
Technical assistance provided for RBF piloting has been instrumental for piloting RBF. It has also helped gather support from the Ministry of Health and from the Ministry of Finance.
Learning from the experience of other countries through country visits and training on RBF can greatly benefit the design of the RBF project.
A stronger focus on social behavioral change and communication, greater community involvement in health service provision and/or management, and interventions to address social and cultural barriers to health service utilization—in addition to the demand-side financing activities employed by the project—are necessary to ensure households, especially poor households, understand when and why to seek care.
Pro-poor project design does not necessarily lead to a reduction of inequalities in health service utilization (and ultimately health outcomes). Despite key project design features associated with intentionally targeting the poor, some inequalities in health service utilization may have actually widened during the project duration (as evidenced by higher utilization of free MNCH services by non-poor compared with the poor). A key lesson for future projects may nevertheless be to specifically analyze the determinants’ health outcomes/health service utilization inequality, including indicators in the monitoring framework for the tracking and monitoring of inequality.
EVALUATION AT A GLANCE
Given the small scale of the project, an impact evaluation was not feasible.