20201203 Annex 1_72048621RFI00001 Concept Note_MCHN Activity.pdf

Annex 1: Concept Note - Laos Maternal Child Health Nutrition Activity Laos

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Annex 1: Concept Note: Laos Maternal Child Health Nutrition Activity

A. Background

Over the past 20 years, Laos has significantly reduced poverty and hunger and improved education and health outcomes. These successes have been driven by strong economic growth. The benefits of growth have, however, not been evenly distributed among the population. Women, especially adolescent women, pregnant and lactating mothers, and children less than five years old are at increased risks of poor health outcomes.

Maternal Health Despite progress made in addressing maternal mortality in the last two decades, Laos still has the highest maternal mortality rate of all ASEAN countries, 151 per 100,000 births.1 On average, the interventions for maternal health in Laos reach less than half of the intended population of pregnant women nationally, and only reach just over a quarter of pregnant women in the poorest groups.2 Maternal undernutrition remains a significant health problem, more than a third of women, age 15-49 years suffer from anemia (39.8%).3 Anemia during pregnancy contributes to adverse maternal and newborn health outcomes.4

Adolescent Health Lao PDR’s adolescent fertility rate, 83 births per 1,000 female adolescents 15-19 years old,5 is among the highest in the ASEAN region due to early marriage and adolescent childbearing.

One in four girls aged 15-19 are married and within that age group, one in 10 girls have begun childbearing. Adolescent pregnancy has a significant impact on girls’ wellbeing including increased risks of dropping out of school, increased risks of morbidity and mortality.6 Adolescent pregnancy also contributes to poor newborn and child health outcomes including child morbidity and mortality.7 Children born to teenage mothers have a higher likelihood of being stunted.

Child Health Neonatal8 and child mortality rates remain the highest in the ASEAN region, with neonatal mortality estimated at 18 per 1,000 live births. As the under-five mortality rate declines from 61.8 per 1,000 live births in 2012 to 46 per 1,000 live births in 2019,9 deaths are increasingly

1 Laos USAID Health Strategy 2019-2023 https://www.usaid.gov/sites/default/files/documents/1861/USAID_Laos_Health_Strategy_2019-2023.pdf 2 UNICEF: Improving health and nutrition outcomes for mothers and children in vulnerable populations.

3 Lao Statistics Bureau. 2018. Lao Social Indicator Survey II 2017, Survey Findings Report. Vientiane, Lao PDR: Lao

Statistics Bureau and UNICEF.

4 Rahman MM, Abe SK, Rahman MS, Kanda M, Narita S, Bilano V, Ota E, Gilmour S, Shibuya K. Maternal anemia and risk of adverse birth and health outcomes in low- and middle-income countries: systematic review and meta-analysis. Am J Clin Nutr. 2016 Feb;103(2):495-504. doi:

5 Lao Statistics Bureau. 2018. Lao Social Indicator Survey II 2017, Survey Findings Report. Vientiane, Lao PDR: Lao

Statistics Bureau and UNICEF.

6 Pregnancy and childbirth complications are the leading cause of death among girls aged 15–19 years globally.

World Health Organisation Adolescent Pregnancy Fact Sheet https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy 7 ibid

8 First twenty-eight days of life.

9 Lao People’s Democratic Republic: Key Demographic Indicators https://data.unicef.org/country/lao/ https://www.usaid.gov/sites/default/files/documents/1861/USAID_Laos_Health_Strategy_2019-2023.pdf https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy https://data.unicef.org/country/lao/

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concentrated in the neonatal period (48% of child mortality is attributed to neonatal mortality10).

This high level of neonatal mortality relative to under-five mortality requires a sharpened focus on care of the newborn.11

Many challenges hinder the well-being of children less than five years old. Vaccination coverage is low, with less than half of children (48%) having been fully vaccinated.12 As with other child health indicators, care seeking behaviors and treatment for child illnesses varies by location (rural vs. urban, provincial variations), wealth quintile, ethno-linguistic groups, and education of the mother.13

Child undernutrition levels in Laos PDR remain some of the highest in the ASEAN region and contribute to 45% of child mortality. About a third of the children less than five years old are stunted (33%),14 an indication of chronic malnutrition and widespread poverty.

B. Purpose

The Maternal Child Health and Nutrition (MCHN) Activity seeks to address the inequitable health outcomes of the most underserved segments of the population through a targeted health system strengthening approach. The MCHN Activity15 is expected to demonstrate innovative models while building on lessons learned from previous USG or other international development partners’ investment to improve health and nutrition outcomes of women and children under 5 years old, along the life cycle, with a definite focus on the 1,000 days (pregnancy to the first two years of life).16

The Activity builds on the latest evidence that improving quality of care requires a system-wide action at all levels: community, district, provincial, and national, including policies and reforms that act on the foundations of the system.17

The Activity is expected to scale up evidence-based Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition (RMNCAHN) interventions and test realistic innovations to improve health outcomes. Innovations could include adapting global practices to Laos and piloting and/or expanding new approaches. For example, to promote country-led innovations, USAID is interested in ways that an “Partnerships and Innovation Fund” may be established and managed by the Activity in collaboration with the Ministry of Public Health (MOH) and USAID.

10 Levels and Trends in Child Mortality. Report 2020. Estimates developed by the UN Inter-Agency Group for Child

Mortality Estimation https://data.unicef.org/resources/levels-and-trends-in-child-mortality/ 11 Ending Preventable Newborn Deaths and Stillbirths by 2030. WHO and UNICEF 2020.

12 Lao Statistics Bureau. 2018. Lao Social Indicator Survey II 2017, Survey Findings Report. Vientiane, Lao PDR:

Lao Statistics Bureau and UNICEF.

13 Ibid

14 Ibid

15 The MCHN Activity will be referred to in the following text as ‘The Activity.’

16 Continuum of Care refers to adolescent girls, pregnant and lactating women, newborn, children less than five years of age.

17 High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Global

Health Commission, Vol 6 November 2018.

https://data.unicef.org/resources/levels-and-trends-in-child-mortality/

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The Activity will take an iterative approach to learning and implementation to constantly respond to the needs of the system. This approach will promote a focus on promising strategies and models, all towards strengthening the health system to be sustainable, resilient and equitable. It will also take in consideration the lessons learned from previous USAID and other development partners’ investments. The Activity is designed to complement current USAID-funded activities and leverage other international development partners’ programs.

Priority Issues:

The MCHN Activity is expected to address priority issues that hinder equitable access and quality of reproductive, maternal, newborn, child, adolescent health and nutrition (RMNCAHN) services.

● Inequitable Access and Utilization of Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition (RMNCAHN) Services:

Addressing health inequities is paramount to the new activity. As the latest data from the Lao Social Indicators Survey II (2017) show the determinants associated with health inequities are multiple and complex.18

Rural-Urban Divide: Negative health outcomes are among the poorest Lao people living in rural and remote areas, far from roads. These remote, scattered villages depend mostly on outreach preventive and curative health services.19

Ethnic-Linguistic Disparities: Data shows that smaller linguistic ethnic groups - e.g. the Hmong- Mien, Chinese-Tibetan, etc. - have poorer health outcomes than the largest groups - e.g. the Lao-Tai and Mon-Khmer.20

Economic Status: There are large health outcomes disparities and access to services, based on economic status. For example, 95% of pregnant women in the richest wealth quintile delivered in a health facility compared to a third (33%) of women in the poorest wealth quintile. Nearly half of the children less than five-years old in the poorest wealth quintile are stunted (48%) as compared to 14% in the richest wealth quintile.21

Education Status of the Mother: Health outcomes are closely associated with women’s education status. For example, the adolescent birth rate (number of births per 1,000 young women ages 15-19) with no education is estimated at 176 as compared to 3 for young women with higher levels of education. Delivery with a skilled birth attendant is estimated at 35% for women with no education compared to nearly universal skilled birth attendants for women with higher levels of education (97.7%).22

18 Lao Statistics Bureau. 2018. Lao Social Indicator Survey II 2017, Survey Findings Report. Vientiane, Lao PDR:

Lao Statistics Bureau and UNICEF.

19 Ibid

20 Ibid

21 Ibid

22 Ibid

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● Limited Quality of RMNCAHN Services at Health Center and District Hospital Levels

Healthcare workers at health center and district levels need the skills and competencies to provide quality care, including during delivery complications, care for sick newborns, or treatment of children severely malnourished. However, to date, reports show that healthcare workers lack skills and competencies, including cultural competencies, to provide integrated respectful quality care for adolescent girls, pregnant women, lactating mothers, newborns and children less than five years old.23

While this Activity will integrate interventions to build healthcare provider skills in providing quality RMNCAHN services, the focus on reproductive health will be limited and could include for example, strengthening counseling for healthy timing and spacing of pregnancy during postnatal care, or family planning counseling tailored to adolescent married women to delay the first birth.

Accountability systems are limited at all levels, central, provincial, district, and health facilities.

Systems to monitor, coach, mentor health care providers to adhere to protocols and guidelines need to be strengthened.

● Limited Capacity of the Public Sector as a “Steward” of the Health System at all Levels: Central, Provincial, and District

Health care is predominantly provided by the public sector. In the public sector, there are 1060 health centers, 135 district hospitals, 17 provincial hospitals and 8 tertiary hospitals located in Vientiane. The private sector consists of 29 private hospitals, 1050 private clinics (two types: 24 hour and after work hours) and an estimated 2000 private pharmacies.24

The Ministry of Health (MOH) is organized through three administrative levels: central, provincial, and district. The MCHN Activity will provide technical assistance to MOH at these three levels to address priority gaps.

Central Level

The MOH central level is responsible for developing the national health plan and budget and controls budget allocation for the maternal child health, adolescent health and nutrition programs. MOH’s capacity to plan, develop, and budget for priority needs and track expenditures is critical to be strengthened. To promote a common vision of quality of care (QOC) among stakeholders at all levels--i.e. central, provincial, districts and villages--the MOH’s leadership skills will require significant improvement. This includes improving the use of data to identify priorities, as well as enhancing the MOH’s capacity to convene and collaborate with

23 “The quality of health service is below the regional level, resulting in low uptake of public health services due to low capacity of the health workforce, low investment in service infrastructure and environment, and gaps in quality treatment and care standards.” Overview of Lao health system development 2009-2017. Manila, Philippines. World Health Organization Regional Office for the Western Pacific. 2018. Licence: CC BY-NC-SA 3.0 IGO 24 Service Trade Forum, Tokyo 2019: Health and Social Services: Lao

PDR.https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjByKKvzY_tAhXjFFkFHZ ZmC6oQFjAEegQIAxAC&url=https%3A%2F%2Fwww.asean.or.jp%2Fja%2Fwp-content%2Fuploads%2Fsites%2F2%2F03_Lao_PDR_20191127.pdf&usg=AOvVaw0m3hs5rDb_lBJxR9uzj3dw https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjByKKvzY_tAhXjFFkFHZZmC6oQFjAEegQIAxAC&url=https%3A%2F%2Fwww.asean.or.jp%2Fja%2Fwp-content%2Fuploads%2Fsites%2F2%2F03_Lao_PDR_20191127.pdf&usg=AOvVaw0m3hs5rDb_lBJxR9uzj3dw https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjByKKvzY_tAhXjFFkFHZZmC6oQFjAEegQIAxAC&url=https%3A%2F%2Fwww.asean.or.jp%2Fja%2Fwp-content%2Fuploads%2Fsites%2F2%2F03_Lao_PDR_20191127.pdf&usg=AOvVaw0m3hs5rDb_lBJxR9uzj3dw https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjByKKvzY_tAhXjFFkFHZZmC6oQFjAEegQIAxAC&url=https%3A%2F%2Fwww.asean.or.jp%2Fja%2Fwp-content%2Fuploads%2Fsites%2F2%2F03_Lao_PDR_20191127.pdf&usg=AOvVaw0m3hs5rDb_lBJxR9uzj3dw

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health stakeholders, other sectors, and international development partners. Increasing coordination with Provincial Health Offices and Provincial Governors is also key. To ground strategic priorities for quality care and measure how policy changes affect health outcomes, the MOH at the central level should boost its capacities to use data for problem-solving and decision making. Moreover, the health information system is in dire need for improvement in all aspects-including, data quality, data completeness, frequency of data collection, and reporting accuracy. The MCHN Activity will support MOH’s efforts to improve accuracy and analysis of reproductive, maternal, newborn, child, adolescent health and nutrition program data collected at point of service delivery: health center and district hospitals. This Activity will support MOH’s efforts to use data for planning and budgeting at district, provincial and central level. The Activity is expected to strengthen the MCHN data flow between districts, provinces and central regions, in collaboration with other development partners who are investing in strengthening the health information system.

Provincial Health Offices (PHO) and District Health Offices (DHO)

While PHO and DHO have the responsibility to develop provincial and district budgets, allocate and manage resources, and track expenditures, their financial management skills remain weak.

Key issues include inaccurate costing of program budgets, difficulty in tracking expenses, and a lack of alignment between planning and budgeting.

Efforts to improve accountability and monitoring of health services have been structured around the Health Sector Development Plan and the Health Sector Reform Strategy. A set of 10 core indicators25 have been agreed upon by the National Assembly to track progress across the health sector at district level. The District Health Information Software (DHIS2)26 system needs to be strengthened, both in improving the quality of data collected and in building the skills of PHO and DHO members in using data to monitor quality of services, set strategic priorities, and allocate resources, financial and human resources.

● Limited Private Sector Engagement

While recently displaying slightly greater prominence, along with increasing demand for better services, the private health sector in Laos remains nascent. Public facilities are perceived as not providing the same quality of services as the private sector.27 28 Public-private partnerships and collaboration between the two sectors (public and private) remains limited and data between the

25 Underweight <5 years, stunting <5 years, infant mortality rate, under-five mortality rate, skilled birth attendant, immunization for children <1 year, population access to clean water, population access to family latrines, population coverage health insurance.

26 In 2013, the Ministry of Health decided to use the web-based, open-source software DHIS2 to replace the Excel-based report for HMIS. DHIS2 has been specifically customized into an integrated platform for data collection, sharing, validation, analysis, reporting and monitoring, tailored to the needs of the country’s health system. DHIS2 roll-out started in early 2014. By the end of 2015, the system was operational nationwide, collecting data for HMIS from all health facilities – from health centers to central hospitals.

27 The Lao People’s Democratic Republic Health System Review: Health Systems in Transition, Vol. 4 No. 1 2014

World Health Organization 2014.

28 There are an estimated 2,000 private pharmacies involved in the delivery of primary health care. It is estimated

80% of pharmaceuticals are being provided by private pharmacies, with limited application of quality standards and fair pricing. Pharmaceutical System Laos, World Health Organization, 2017.

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two sectors are rarely shared. The private sector remains largely unregulated, with varying quality of services and limited accountability to the Ministry of Health.29

While not a principal focus of this Activity, MCHN is expected to promote, where feasible, market-driven solutions to improve maternal and child health outcomes. For example, these market-driven solutions could potentially include, promoting greater private sector engagement in health insurance, or in low-cost medical technology, or in digital-based innovations, including Information, Communication, Technology, or distribution networks at community level.

C. Activity Description

1. Goal and Expected Results

The goal of the MCHN Activity is: Improved Health and Nutrition Outcomes Among Pregnant and Lactating Women, Newborns, Children and Adolescents.

Draft Results Framework

Goal: Improved Health and Nutrition Outcomes Among Pregnant and Lactating Women, Newborns, Children and Adolescents

Result 1:

Improved MOH National Capacity to Plan, Prioritize, and Guide the Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition Program

Result 2:

Improved Provincial Health Offices Capacity to Sustainably Plan, Budget, and Manage, RMNCAHN Services

Result 3:

Improved Access and Quality of RMNCAHN Services at District and Health Center Levels

Result 4:

Communities for Improved

RMNCAHN

Effective and Responsive

IR 1.1 Improved MOH’s leadership and governance capabilities

IR 2.1 Improved PHO’s management capacity

IR 3.1 Improved DHO’s management capacity

IR 4.1: Increased adoption of optimal

RMNCAHN

behaviors

IR 1.2 Improved Quality Management and Coordination

IR 2.2 Data-use for decision-making improved

IR 3.2: Increased core technical competencies of health care providers

IR 4.2 Strengthened community-led solutions for improved health and nutrition

IR 1.3 Enhanced policy environment

IR 2.3 Improved multi-sector coordination

IR 3.3: Strengthened accountability systems within facilities (health

IR 4.3 Increased community engagement for quality RMNCAHN services

29 The Lao People’s Democratic Republic health system review: Health Systems in Transition, Vol. 4 No. 1 2014

World Health Organization 2014.

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center and district hospitals)

IR. 3.4 Improved referrals and follow-up systems

The Activity prioritizes improving the quality of RMNCAHN services in health center and district hospitals (R3) and community engagement and responsiveness for health and nutrition (R4).

While building the Ministry of Health capacity at all levels (central, provincial, district) to manage RMNCAHN services is an essential component of health system strengthening, the majority of resources are expected to fund Results 3 and 4.

2. Theory of Change

The goal of the MCHN Activity, “To improve health and nutrition outcomes among adolescents, pregnant and lactating women, newborns, and children less than five years old”, is based on the theory of change (TOC) that:

IF the Ministry of Health leadership and governance capacity is enhanced at all levels -central, provincial and district; and, IF the quality of RMNCAHN services is improved to meet the most vulnerable segments of Lao population; and, IF community ownership and engagement for improved health and nutrition outcomes is increased;

THEN the health system will be responsive and effectively and sustainably improve the health and nutrition of pregnant, lactating women, children less than five years old and adolescent girls.

The TOC depends on the following Key Assumptions:

● Laos continues its commitment to work with development partners towards improving adolescent, maternal, newborn and child health and nutrition outcomes.

● Laos continues its commitment to the implementation of its key policy documents: Health Sector Reform, National Health Insurance Scheme, RMNCAH Strategy and others.

● Laos increasingly allocates financial resources to the health sector.

● Laos continues its commitment to the implementation of its laws and policies that ensure the equality of all its citizens, and the existing space in which civil society can reasonably operate does not narrow.

● Laos is increasingly interested in and supportive of USAID assistance and of other development partners.

3. Description of Intended Results

Result 1: Improved MOH National Capacity to Plan, Prioritize, and Guide the Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition Program

The MCHN Activity will reinforce the Lao PDR’s efforts to strengthen its governance of the health sector, including improving coordination among stakeholders, using data for strategic decision making, and improving the policy environment. This Activity is expected to build MOH’s

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capacity in planning and budgeting based on priority needs and in improving system efficiency.

This could include supporting MOH’s efforts to integrate technology within its planning/budgeting processes.

The Activity is expected to support MOH’s efforts to improve the quality of services provided by both the public sector (priority objective) as well as the private sector. This could include supporting MOH’s efforts to develop and implement regulatory frameworks, or facilitating data-sharing and learning between the two sectors.

Result 2: Improved Provincial Health Offices Capacity to Sustainably Plan, Budget, and Manage RMNCAHN Services

The MCHN Activity intends to build the capacity of the Provincial Health Office and mid-level managers and MCH/Nutrition Focal persons to analyze data, strategically plan, budget for MCHN services and monitor resources at district level, coach, and monitor the quality of services provided. Accountability systems need to be strengthened to support MoH’s efforts to ensure that allocated health resources result in improved quality and equity of RMNCAHN services. In addition, this Activity aims at strengthening PHOs’ capacity to actively participate in Provincial Government Coordinating Platforms to effectively advocate for resources based on priority needs and to increase multi-sector collaboration to address the priority needs for RMNCAHN services.

Result 3: Improved Access and Quality of RMNCAHN Services at District and Health Center Levels

This result focuses on improving equitable access and improving the quality of the maternal, newborn, child adolescent health and nutrition services, with a renewed focus on improving the health outcomes of the most underserved segments of the population. To improve quality of services, this activity will support “transformative” capacity building approaches including experiential training, on-the-job training, integration of technology to support self-directed continuing professional development, and integration of low-cost digital medicine, for example, to increase the recognition of danger signs.

This activity aims to support MOH’s efforts to strengthen accountability systems, including DHO and facility level monitoring and mentoring of facilities, in-facility quality of care (QOC) systems and performance recognition schemes. This Activity will also promote adaptations of innovative models, possibly integrating digital technology or seeking private sector engagement to improve the quality of care.

Result 4: Communities for Improved RMNCAHN Effective and Responsive

Improving the quality of RMNCAHN services and increasing equitable access to these services is not sufficient to improve health and nutrition outcomes. To improve health outcomes also requires to change the health behaviors of individuals, households and communities.

Addressing the gender, social cultural norms that hinder adoption of optimal practices is critical to promote rapid adoption of optimal health and nutrition behaviors. Changing social norms requires transformative culturally sensitive interventions that will not result in greater harm than good. It also requires work at both household and community level with community leaders, champions; women and men groups.

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This Activity is expected to support the implementation of a wide range of Social Behavior Change activities to build women’s agency, to promote male and communities’ engagement for women and children’s well-being and to promote the adoption of optimal health, nutrition, and water, hygiene and sanitation behaviors. These activities will also support building community-led solutions.

As a result of effective SBC activities, demand for health, nutrition, water/hygiene/sanitation products and services will increase. It is expected that the MCHN Activity will facilitate private sector engagement and market driven solutions to meet the increased demand for nutrition, health, and hygiene and sanitation services and supplies. This Activity is expected to build upon promising models of private sector engagement, including private/public partnerships that have resulted in increased availability of health, nutrition, and water/hygiene/sanitation services and supplies at community level.