Background: To reduce its high maternal and neonatal mortality rate and meet Millennium Development Goals four and five, Lao PDR has adopted a national 'Strategy and Planning Framework of Implementation of Maternal, Neonatal and Child Health Services'. This paper reports on implementation constraints identified in three demonstration sites.Methods: The objectives of this paper are to analyse health worker perceptions of the implementation of the strategy and constraints faced during implementation. A qualitative design was used with interviews conducted at health facilities in three demonstration provinces. Data were collected through key interviews with provincial/district hospital providers (n = 27), health centre staff (n = 8) and village health volunteers (n = 10). Data was analysed informed by Hanson et al's health system constraint framework.Results: In each of the demonstration sites, the Maternal, Neonatal and Child Health program was generally well-understood and the different activities were being implemented. Perceived implementation constraints related mainly to a mix of supply and demand factors. Supply-side constraints related to inadequate human resources, poor remuneration, weak technical guidance, minimal supervision and limited equipment. Demand-side constraints related mainly to cost, limited access to transport, cultural practices and language. Other constraints related to broader strategic management and cross-sectoral contextual constraints. Contextual constraints included low levels of limited education, women's position in society and poor transport and communications networks. These factors influenced the implementation process and if not addressed, may reduce the effectiveness of the policy and scale-up.Conclusion: The Lao PDR has a well-defined Maternal, Neonatal and Child Health program. Analysis of the constraints experienced by service providers in implementing the program however, is essential for scaling-up the initiative. To achieve effective implementation and scale-up a number of concurrent interventions are needed to address identified constraints. More research is needed to identify the optimal combination of interventions to improve these constraints. The broader contextual characteristics require longer-term, cross-sectoral action.
Bibliographical noteFunding Information:
A demonstration initiative implemented with the assistance of the World Health Organization (WHO) started in December 2009 in two districts. In 2010 it was s scaled up into ten additional districts with a further five districts added in 2011. The initiative is on-going with financial support from Korea Foundation of International Healthcare. A demand-side health financing scheme was a voucher scheme targeting the poor, which entitled the holder to use specific health services without paying the user fee. In some districts, a separate initiative has been the district-based Health Equity Funds (HEF). These funds reimburse selected health care providers for services delivered to eligible poor.
The authors would like to express our gratitude thanks to WHO office, Lao PDR and KOFIH for the financial support of this evaluation. In addition, we would like to express our thanks to our research team from the Faculty of the Postgraduate Studies and the Xiengkhouang, Houaphanh and Salavanh provincial Health Departments and the 3 provincial hospitals, key informants at district, health center level and VHVs for their valuable time to contribute to this study. We also thank to Dr. Young-Kyung Do and the other researchers in Korea evaluation team member who joined whole mid-term evaluation project for Lao MNCH program.