Human Resources for Health Country Profiles

Lao People’s Democratic Republic WHO Library Cataloguing-in-Publication Data

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

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

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

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Acronyms v

Acknowledgements vi

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

2. Health workforce supply and trends 4

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

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

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

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

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

8. Concluding remarks 22

References 23

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

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

List of f igures

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

iv Human Resources for Health Country Profiles Acronyms

GDP gross domestic product GGE general government expenditure GGHE general government expenditure on health HRH human resources for health IMR infant mortality rate IPD Inpatient Department MA medical associate, medical assistant MDGs Millennium Development Goals MMR maternal mortality ratio MNCH maternal, neonatal and child health MOHA Ministry of Home Affairs OPD Outpatient Department PACSA Public Administration and Civil Service Authority PHC primary health care PhD Doctorate PIMS Personnel Information Management System PPP purchasing power parity PvtHE private health expenditure TB Tuberculosis THE total health expenditure UHS University of Health Science

Lao People’s Democratic Republic v Acknowledgements

The Human Resources for Health Country Profile for The Human Resources for Health Country Profiles in the Lao People’s Democratic Republic was developed the Western Pacific Region are prepared under the by Khampasong Theppanya, Asmus Hammerich and logistical and editorial support of the WHO Western Valeria De Oliveira Cruz, with assistance from Simone Pacific Regional Office Human Resources for Health Phillips in the Office of the WHO Representative in the unit and coordinated by a team composed of Gulin Lao People’s Democratic Republic and Inseok Lee, an Gedik, Rodel Nodora, Jose Aguin and Dyann Severo. intern in the Human Resources for Health team at the WHO Regional Office for the Western Pacific.

vi Human Resources for Health Country Profiles 1. Introduction

1.1 Demographic, social and political The geography is largely mountainous, with lowland background areas along the Mekong River that provide land for paddy rice cultivation and highland areas where The estimated population of the Lao People’s upland rice production and the gathering of non- Democratic Republic in 2011 was 6 385 057, timber forest products are the main sources of according to the Lao Statistics Bureau, with a livelihoods. The mountainous topography makes registered annual population growth in 2010 the construction of railway system impossible, and of 1.44%. The country has a sparse population as a result, the Mekong River is an important artery density (27 people per square kilometre), with large for transportation. Because of these geographic interprovincial variations and an average household conditions, access to hospitals and health services in size of 5.9 people. The population is young, but there the Lao People’s Democratic Republic is very difficult, are signs of changes in the demographic structure: especially for the people living in rural areas. the percentage of the population under 15 years of age decreased from 42.3% to 34.5% between 2000 1.2 Current economic situation and and 2010. The population is mainly concentrated in macroeconomic indicators rural areas, but a rural-to-urban shift is beginning to take place as the estimated percentage of the The Lao People’s Democratic Republic is on an population living in rural areas decreased from 78% increasingly sustainable growth pathway. Reforms to 67% between 2000 and 2010. The Lao population under way have reduced poverty and stimulated has a balanced sex ratio of 50% for each sex, and life growth. The real gross domestic product (GDP) growth expectancy at birth increased from 53 in 2000 to 62 rate increased from 6% in 2000 to 9% in 2010, while in 2010 (see Figure1). the registered GDP per capita in 2010 was US$ 1077 (Lao Statistics Bureau, 2012). As a result, the Lao Figure 1. Population trends People’s Democratic Republic is now a lower-middle- income economy (World Bank, 2013). The Lao People’s 100 Democratic Republic recommitted in its Seventh Five- 90 Year National Socio-Economic Development Plan 78 80 73 (2011–2015) to achieving the Millennium Development 67 70 62 Goals (MDGs) by 2015, and graduating from the group 60 53 of least-developed countries by 2020. 50 42 39 40 35 Government revenue collection has been rising slowly 30 in recent years but remains very low, estimated at 20 14.6% of GDP in 2008. Nonetheless, the budget deficit 10 N/A has declined and the the flexibility of the Government 0 to decide its spending choices has widened. In 2007, % Population % Population Life expectancy under 15 years old living in rural areas at birth (years) the collection of taxes and revenues was recentralized by a decree by the Prime Minister. However, budget 2000 2005 2010 and state audit laws still need to be fully enforced (WHO Western Pacific Regional Office, 2011). N/A, not available. Source: World Bank, 2012. The Lao People’s Democratic Republic ranked 138 out The Lao People’s Democratic Republic is a single- of 187 nations on the Human Development Index in party, socialist republic with an ethnically diverse 2011, just ahead of Cambodia. Literacy rates have population; the official language is Lao. Sixty-seven improved in the last decade, attaining 73% in the per cent of the Lao people are Theravada Buddhists, population above 15 years of age in 2005, compared and 1.5% are Christian. The remaining 31.5% follow with 60% in 1995, showing, however, a considerable non-Buddhist local religions (Encyclopaedia Britannica, gap between sexes (83% male, 63% female). School 2012). attendance has also improved for children aged 6 to 16 years: 75% of boys and 68% of girls in 2005

Lao People’s Democratic Republic 1 compared with 66% of boys and 56% of girls in 1995 are common colds, (14.6% of total OPD patients) and (United Nations Development Programme, 2011). tonsillitis and pharyngitis (10.5%), as shown in Table However, boys still have a higher attendance rate than 1. The most frequent causes for Inpatient Department girls. (IPD) cases are gynaeco-obstetrics (15.8% of total IPD patients), followed by diarrhoea (9.9%) and digestive The population below the poverty line fell from 46% system problems (9.5%) (Ministry of Health, 2012). in 1993 to 26% in 2010. Poverty is higher in remote Tuberculosis (TB) is also one of the most prevalent and highland areas and inversely correlates with road causes of health problems. In 2008, the TB prevalence or river access. Based on international purchasing rate was estimated at 260 per 100 000 people. power parity (PPP) standards, 24.8% of the population was living on less than US$ 2 a day and 33.9% on Life expectancy at birth rose from 53 years in 2000 to less than US$ 1.25 a day in 2008. Inequalities remain 67.5 years in 2011. This improvement is due mainly significant, with the share of the national economy to the decreases in maternal mortality, infant mortality of the lowest and the highest quintiles being 7.6% and under-five mortality. The maternal mortality ratio and 45%, respectively. Proxy indicators of poverty, (MMR) plummeted from 1200 maternal deaths per such as access to sanitation and electricity, also 100 000 live births in 1990 to 357 maternal deaths reflect the population’s vulnerability. The latest Lao per 100 000 live births in 2012. In addition, the infant Reproductive Health Survey found that, in 2005, mortality rate (IMR) decreased from 142 to 68 deaths 50% of households had no toilet and over 40% had per 1000 live births, and the under-five mortality no electricity. Disparities between urban and rural rate dropped from 213 to 73 per 1000 live births areas are still pronounced. For example, while 90% between 1970 and 2010 (Lao Social Indicator Survey, of urban households have electrical power, only 2011–2012 and the United Nations Inter-Agency 43% of rural households have access to electricity, for Child Mortality Estimation, 2012). Despite these and 11% of people living in rural areas have no road improvements, there are big geographical disparities access, according to the Lao Statistics Bureau (Central in these indicators. As an example, in 2005, while the Intelligence Agency, 2012). IMR was 18 per 1000 live births in Vientiane capital, Sekong province recorded an IMR of 122 per 1000 1.3 Summary of health indicators live births.

The main causes of mortality in the Lao People’s According to the Lao Reproductive Health Survey Democratic Republic are (listed by number of deaths): 2007, only 28.5% of women sought antenatal care and malaria, pneumonia, diarrhoea, heart failure and 18.5% of deliveries were being attended by trained injury (World Health Organization, 2011). The most birth attendants during the reference year. Eighty- common cause of Outpatient Department (OPD) visits four per cent of women were still delivering at home. Table 1. Leading causes of OPD and IPD patients

Top 10 causes of OPD patients Percentage Top 10 causes of IPD patients Percentage Common cold 14.6% Gynaeco-obstetricts 15.8% Tonsillitis, pharyngitis 10.5% Diarrhoea, no blood, no severe 9.9% dehydratation Digestive system 7.7% Digestive system 9.5% Nervous system, non-psychiatric 6.0% Otitis 6.4% Pneumo-bronchitis 5.4% Pneumo-bronchitis 5.3% Diarrhoea, no blood, no severe 5.4% Common cold 4.2% dehydratation Minor surgery 4.6% Road traffic injury 4.1% Road traffic injury 3.5% Urology 3.0% Gynaeco-obstetrics 2.7% Trauma, all other 2.6% Trauma, all other 2.6% Nervous system, non-psychiatric 2.1% Others 39.7% Others 37.1% Source: National Health Statistic Report, 2010–2011.

2 Human Resources for Health Country Profiles Compounding this is that only 32% of children aged 12 Department of Communicable Disease Control, Uni- to 23 months were fully immunized. This has improved versity of Health Science); compared to 2000, but there is a need to step up • Provincial level: Provincial Health Offices, efforts to resolve this issue (Somchith, 2009). regional hospitals, provincial hospitals, provincial nursing schools; 1.4 Health system • District level: District Health Offices, district hos- pitals, health centres. The main health-care delivery system of the Lao People’s Democratic Republic is a government-owned, Under the Ministry of Health, there are four central public system that operates health centres and district hospitals, four regional hospitals, 12 provincial and provincial hospitals. The Lao People’s Democratic hospitals, 130 district hospitals, 894 health centres Republic’s public health system has a strong vertical and around 5000 village drug dispensaries (see structure and is divided into three main arms: Table 2). There are around 5000 hospital beds in the • health care; country. Each health centre covers about 7000 people, • prevention, promotion and disease control; and but many centres serve fewer than 1000 (Ministry of • health management and administration. Health, 2011).

The public health system is organized into three Although there are no private hospitals in the Lao administrative levels (Ministry of Health, 2007): People’s Democratic Republic, the private sector for • Central level: Ministry of Health Steering Commit- health is expanding, mainly in urban areas, with tee (Department of Hygiene and Prevention, Depart- 1993 private pharmacies, 222 private clinics and 600 ment of Finance, Department of Planning and Inter- traditional medicine practitioners (Ministry of Health, national Corporation, Department of Inspection, 2011). There are some regulations on private health Cabinet, Department of Organization and Personnel, facilities and the involvement of health personnel Department of Education and Research, Department in the private sector. However, the implementation of Curative Service, Food and Drug Department, and enforcement face typical challenges, including conflicts of interest, as most of the senior public

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

Facility Number Characteristics Public sector Village drug dispensaries 5000 Provide maternal, neonatal and child health (MCNH) package of essential services: health information, including family planning and nutrition supplements.

Provide outreach package of MCNH interventions, including immunization, deworming, vitamin A supplementation, health promotion with a focus on nutrition, and skilled delivery care. Health centres 894 Provide MNCH services, as well as community and outreach services. District hospitals 130 Provide health promotion, disease prevention, diagnosis and treatment. Provincial hospitals 12 Provide treatment and rehabilitation services. Regional hospitals 4 Provide curative health-care services at the regional level as well as health care for the entire population of the region. Central hospitals 4 Provide tertiary curative care. Special treatment centres 3 Provide dermatology, ophthalmology and rehabilitation. Private sector Clinics 222 Mainly in urban areas. There are 647 applications waiting for approval. Pharmacies 1993 Mainly in urban areas. Hospitals 0 No private hospitals. Source: Ministry of Health, 2010.

Lao People’s Democratic Republic 3 health personnel are directly or indirectly involved in leadership of the Prime Minister and with support from private health practice after official working hours. World Health Organization and other development partners, has undertaken a series of consultations Since the introduction of a market economy two to discuss how the Lao health sector needs to be decades ago, the national health sector has gradually reformed to achieve the health-related MDGs by 2015 made good progress in terms of the quantity and and universal health coverage by 2025. Following quality of service. However, the health sector still these consultations and discussions, a reform strategy has some constraints and faces great challenges that has been developed to set out short-, middle- and must be addressed. A majority of the Lao population, long-term visions, strategies and milestones for particularly in rural, remote and mountainous areas, further developing the national health sector in the lacks adequate access to basic health care. Therefore, Lao People’s Democratic Republic. it is of critical importance to solve these problems by reforming the national health system to make it In December 2012, the National Assembly approved more effective, efficient, equitable and sustainable. the National Health Sector Reform Strategy. Since early 2012, the Ministry of Health, under the 2. Health workforce supply and trends

An understanding of the local health worker are only three different types of nurses based on classification system is necessary in discussing educational background. For example, a bachelor- the health professions education system in the Lao level nurse and graduate nurse both have bachelor’s People’s Democratic Republic. Lao health workers are degrees after four years of training and therefore have separated into four major levels: postgraduate level, the same professional standing. Likewise, high-level bachelor level, high level and middle level. Table 3 nurses, associate nurses and registered nurses all have shows detailed classification of health professions in equivalent credentials and need not be distinguished the Lao People’s Democratic Republic. The fact that professionally.

Table 3. Classification of health workers

Medical Pharmacy Laboratory Nurse Midwife Dental staff Others related staff staff Postgraduate Specialist level 1*, Specialist level 2**, Master level, PhD level Medical Graduate Graduate Laboratory Physical Bachelor level Dentist Pharmacist doctor nurse midwife technician Therapist

Hygienist, Associate/ Medical Registered physical High level registered associate midwife therapist, nurse X-ray Primary Medical Technical Community Dental Pharmacist Laboratory Middle level health care assistant nurse midwife assistant assistant assistant worker * Two/three years training course after bachelor’s degree (i.e. specialist level 1 in internal medicine, in cardiology…). ** Two/three years training course after specialist level 1 degree (i.e. specialist level 2 in internal medicine, in cardiology…). Source: Department of Organization and Personnel, Ministry of Health, March 2012.

different titles are used to refer to the same profession In the Lao People’s Democratic Republic, education for creates a source of confusion in classifying health low-level workers has been discontinued. However, a professionals within the Lao system. For instance, number of low-level health workers still exist. Current seven different titles designate the role of nurse: low-level workers should upgrade their credentials bachelor-level nurse, high-level nurse, middle-level through continuing education. The Lao People’s nurse, graduate nurse, associate nurse, registered Democratic Republic suffers from a critical shortage nurse and technical nurse. However, in reality there of health workers, with 2.17 health workers per 1000

4 Human Resources for Health Country Profiles Table 4. CurrentCurrent supply of health workers at national level, March 2012

2008 2012

Health professional category/cadre Health Health Number workers/1000 Number workers/1000 population population PhD (physician) 35 0.01 35 0.01 PhD (pharmacist) - - 3 0 Master (physician) 391 0.07 381 0.06 Master (dentist) - - 31 0 Master (pharmacist) - - 46 0.01 Master (laboratory) - - 8 0 Master (nurse/midwife) - - 13 0 Master (other*) - - 8 0 Specialist 2 (physician) 9 0 20 0 Specialist 1 (physician) 206 0.03 312 0.05 Medical doctor 1169 0.2 1233 0.19 MA (Medical associate, medical assistant) 1496 0.25 1375 0.21 Bachelor/high-level nurse 113 0.02 166 0.03 Technical nurse 738 0.12 1774 0.27 Community midwife 0 0 338 0.05 Midwife 388 0.06 120 0.02 Laboratory (bachelor) 31 0.01 70 0.01 Laboratory assistant 466 0.08 490 0.07 Pharmacist (bachelor) 357 0.06 473 0.1 Pharmacist assistant 586 0.1 667 0.1 Dentist (bachelor) 171 0.03 194 0.03 Dentist assistant 109 0.02 96 0.01 Hygienist 321 0.05 482 0.07 Physiotherapist 272 0.05 284 0.04 X-ray technician 0 0 32 0 Low-level nurse and nurse-midwife 3948 0.66 3629 0.56 Middle-level primary health care worker 0 0 132 0.02 Low-level primary health care worker 244 0.04 320 0.05 Support and logistic staff 963 0.16 1434 0.22 Public health (high) N/A N/A 23 0 Total 12 013 2 14 189 2.17 * Non-health profession related masters. Source: Department of Organization and Personnel, Ministry of Health, March 2012. population density (see Table 4). Compared with 2008 Low-level nurses (auxiliary nurses) made up the data (2.00 health workers per 1000 population), there largest group of health providers from 2008 to 2012 has been a small increase in the number of health (see Table 4). Education for low-level health workers, workers in the public health sector, which serves as however, was discontinued and as a result, the number the major implementer of health services. of low-level workers has decreased. The Government of the Lao People’s Democratic Republic requests that low-level workers upgrade their level of education

Lao People’s Democratic Republic 5 Table 5. Current supply of contractual health staff, March 2012

Province Medical doctor Pharmacist (bachelor) Dentist (bachelor) Laboratory (bachelor) Nurse (high/bachelor) Medical assistant Pharmacist Pharmacist assistant Laboratory assistant Hygienist Physiotherapist Primary health care worker (low) Midwife (low) Nurse (low) Nurse-midwife (low) Specialist 2 Support and logistic staff Specialist 1 Community midwife (middle) Technical nurse (middle) Total Attapue - - 2 ------48 1 - - - 1 7 - 11 - 13 83 Bokoe - - 4 2 - - - - - 31 1 - - 3 - 2 - 1 - 50 94 Bolikhamsay - - 6 1 2 - - - - 17 13 - 1 4 2 8 - 4 - 13 71 Central level 1 1 88 35 44 3 2 2 1 257 25 - 45 31 35 - 1 4 - 294 869 Champasack - - 7 3 2 - - 2 1 134 10 - 7 3 4 24 4 76 6 63 346 Huaphan - - 4 2 - - 2 5 - 18 5 - - 10 2 - - 13 - 16 77 Khammuane - - 11 5 1 - - - - 133 6 - 4 2 1 15 - 25 36 24 263 Luangnamtha ------9 1 - 1 ------14 25 Luanprabang - - - 1 - - - - - 2 ------18 - 38 59 Oudomsay - - 1 3 1 - - 6 - 61 6 - 1 6 - - - 10 - 24 119 Phonsaly ------10 10 Saiyabury 1 - 5 8 2 - - 4 - 127 10 - 9 10 2 2 - 16 - 39 235 Salavan ------2 - - - - - 21 - 9 - 8 40 Sekong - - 1 ------19 4 - 2 - - - - 1 - 16 43 Svannakhet - - 4 5 - - - - 3 173 - 4 2 13 - 17 5 18 - 8 252 Vientiane - - 3 5 - - - - - 49 6 - 2 4 3 - - - - 32 104 Vientiane - - 14 2 4 - - 2 3 20 7 - 9 39 9 - - 3 - 24 136 capital Xiengkhuang 1 2 16 6 5 - - - 4 42 9 - 6 18 10 3 - 10 - 38 170 Total 3 3 166 78 61 3 4 21 12 1142 104 4 89 143 69 99 10 219 42 724 2996 Source: Department of Organization and Personnel, Ministry of Health, March 2012.

through continuing education. This explains the official contractual workers hired before 2003, paid decreasing trend in the number of low-level nurses hospital workers, workers paid by donor funds, and low-level midwives. and volunteers. The central, provincial and district hospitals continue to have a workforce shortage From 2004, the Ministry of Home Affairs (MOHA) problem, so they continue to hire contractual workers officially stopped hiring contractual health staff. directly. Most of the contractual staff are hoping to However, currently, there are four different kinds of become permanent staff. contractual staff in the health sector (see Table 5):

6 Human Resources for Health Country Profiles 3. Health workforce distribution

This section looks at the health workforce by gender, However, in all postgraduate categories, male health age and geographical distribution. workers make up the larger proportion (see Annex A).

3.1 Gender distribution 3.2 Age distribution

There are more women (59%) than men in the health Overall, nurses and midwives are a young workforce, workforce due to a large number of nurses and with 45% of them below 30 years of age. Dentists midwives. In these categories, women are more also represent a young group, with those aged 30–39 numerous than men (see Figure 2). Women tend to years making up almost half (46%) of the total number make up more than half of the personnel among the of dentists. The largest share of other categories low- and middle-level workers, including laboratory displayed in Figure 3 (physicians, pharmacists and specialists, pharmacists and dental assistants.

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

37 % Male Laboratory specialist 63 % Female 43 Physician 57 46 Dentist 54 54 Pharmacist 46 29 Nurse/midwife 29 0% 10% 20% 30% 40% 50% 60% 70% 80%

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

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

60% 54 <30 Yrs

50% 45 46 30–39 39 40% 35 40–49 31 29 29 30% 28 28 23 24 50–59 20 20% >60 13 12 10 10 10% 8 3 4 3 3 1 2 0 0% Physician Nurse/midwife Pharmacist Laboratory Dentist specialist

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

Lao People’s Democratic Republic 7 Table 6. Distribution of health workers by group/cadre and province, March 2012

Health professional group/cadre Phonsaly Luangnamtha Bokoe Luangprabang Huaphan Bolikhamsai Khammuane Saiyabury Savannakhet Salavan Sekong Capital Oudomsay Champasack Xiengkhuang Vientiane Vientiane Attapue Total PhD (physician) 33 – – – – – – – – – – – 1 – – 1 – 35 PhD (pharmacist) 3 – – – – – – – – – – – – – – – – 3 Master (physician) 214 7 5 8 4 21 6 11 20 2 12 7 32 4 5 21 2 381 Master (dentist) 28 – – – – – 1 – 1 – – – 1 – – – – 31 Master (pharmacist) 39 – – 1 – 1 – 1 1 1 – – 1 – – 1 – 46 Master (labolatory) 7 – – – – – – – – – – – – – – 1 – 8 Master (nurse/midwife) 11 – – 1 – 1 – – – – – – – – – – – 13 Master (other) 8 – – – – – – – – – – – – – – – – 8 Specialist 2 (physician) 15 – – 1 – – – – – – – – – – – 4 – 20 Specialist 1 (physician) 173 2 7 10 3 11 7 16 8 6 8 12 4 8 5 28 4 312 Medical doctor 511 19 32 41 25 34 20 53 37 100 45 55 87 40 23 71 40 1233 MA (medical associate, 151 46 27 46 24 176 57 93 23 85 50 73 207 65 32 180 40 medical assistant) 1375 Bachelor/Higher nurse 83 1 3 6 2 8 8 3 6 3 1 14 6 4 4 12 2 166 Technical nurse 413 59 56 74 66 84 69 72 73 151 59 82 170 83 65 84 114 1774 Community midwife 40 7 10 14 12 23 20 22 24 22 21 19 33 17 11 29 14 338 Midwife 26 – 6 2 – – – – 3 – 2 24 1 – 1 52 3 120 Laboratory (bachelor) 39 1 – 3 1 2 1 2 4 3 1 3 1 2 1 5 1 70 Laboratory assistant 148 8 19 14 19 16 19 23 24 34 22 30 33 18 9 38 16 490 Pharmacist (bachelor) 167 8 9 18 12 21 14 25 17 12 13 46 30 16 9 37 19 473 Pharmacist assistant 176 18 27 26 23 22 41 27 34 49 28 28 49 24 12 72 11 667 Dentist (bachelor) 71 1 8 8 6 7 7 11 8 10 8 8 20 3 4 11 3 194 Dentist assistant 23 – 1 4 2 3 1 6 4 12 4 5 15 2 1 12 1 96 Hygienist 149 16 24 19 21 16 52 25 43 21 15 14 14 12 14 9 18 482 Physiotherapist 125 6 3 5 3 13 12 8 12 11 11 13 21 13 3 21 4 284 X-ray technician 15 – 1 3 1 1 1 1 1 – – 6 1 1 – – – 32 Low-level nurse and 217 141 88 183 94 365 152 236 150 271 149 337 541 212 96 326 71 nurse-midwife 3629 Middle-level primary 1 7 12 11 1 1 12 13 15 1 3 10 2 3 15 11 14 health care worker 132 Low-level primary health – 20 43 45 34 43 30 13 24 – 2 2 17 46 – – 1 care worker 320 Support and logistic staff 623 40 36 40 24 35 49 51 58 65 51 58 82 51 39 60 72 1434 Public health (High) 5 1 2 4 1 – 4 – 1 1 3 – – – – – 1 23 Total 3514 408 419 587 378 904 583 712 591 860 508 846 1369 624 349 1086 451 14 189 Source: Department of Organization and Personnel, Ministry of Health, March 2012.

laboratory specialists) belongs to the 40–49 years age health workers in rural areas (see Annex B). In fact, group. some health workers cannot retire even if they want to.

The compulsory retirement age for civil servants in 3.3 Geographical distribution the Lao People’s Democratic Republic is 60 for males and 55 for females. However, there continues to be Geographical maldistribution of staff in the Lao a number of medical associates and low-level nurses People’s Democratic Republic is a problem (see Table 6 over 60 still employed, as it is very hard to recruit and Annex C). Only 22% of medical doctors are based

8 Human Resources for Health Country Profiles Figure 4. Geographical distribution of health workforce (% urban vs. % rural), March 2012

Low-level nurse and nurse-midwife 39 61

Technical nurse (middle) 47 53

Dentist 67 33

Medical doctor 74 26

Pharmacist 78 22

Medical specialist 91 9

Bachelor/high-level nurse 93 7

Laboratory (bachelor) 94 6

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

Source: Department of Organization and Personnel, Ministry of Health, March 2012. in rural areas. Bachelor- and high-level health workers areas have the largest share of low-level nurses and are centralized in urban areas; only 5% of bachelor/ midwives. The vast majority of medical specialists higher nurses, 4% of bachelor laboratory workers, 22% (91%) are based in urban areas, as are similar of pharmacists and 28% of dentists work in rural areas. percentages of bachelor/high-level nurses (93%) and bachelor-level laboratory workers (94%). Only 26% of 3.4 Distribution of health workers by medical doctors are working in rural areas. Overall, urban/rural area the density of medical doctors, bachelor/high-level nurses, pharmacists and dentists found in rural As seen in Figure 4, the majority of highly skilled areas is one-tenth of the density in urban areas (see workers are located in urban areas, while rural Annex D).

4. Health professions education

4.1 Structure of health education institution for the Faculty of Medical Science of the University of the Lao People’s Democratic Republic, which The Department of Training and Research of the became part of the National University of the Lao Ministry of Health is primarily responsible for People’s Democratic Republic in 1996. Since 2008, education in the health professions. This department however, the Faculty of Medical Science and the supervises all education and in-service training. College of Health Technology have been combined Therefore, all health-related educational facilities under the University of Health Science (UHS) under are under the control of this department (Ministry of the Ministry of Health. Therefore, in 2012, there were Health, 2007). two education providers for health workers: UHS and nursing schools. Until 2007, there were three education providers for health workers: the Faculty of Medical Science, the UHS produces seven training programmes: basic College of Health Technology and nursing schools. At science, dentistry, medical technology, medicine, that time, the Ministry of Education was responsible nursing, pharmacy and postgraduate studies. There

Lao People’s Democratic Republic 9 are eight provincial nursing schools located in primary health care workers, upper-secondary school Champasack, Khammuane, Luang Prabang, Oudomsay, graduates and must pass an entrance examination. Salavane, Savannakhet, Vientiane and Xien Khung. Graduates get a middle-level diploma. Nursing schools provide nursing and midwifery training programmes. Nurse: There are multiple categories of nurses in the Lao People’s Democratic Republic. Auxiliary (low- 4.2 Training of health professionals level) nurses are the largest group and may have been trained anywhere from three months to two years. Specialists (Postgraduate level) However, there have been no training courses for There are nine specialty training programmes: auxiliary (low-level) nurses since 2003. The two-year anesthesia/intensive and emergency care, cardiology, nursing schools have been upgraded to two and a family medicine, general surgery, internal medicine, half years of training and their graduates are now medical imaging and radiology, obstetrics and considered technical, or middle-level, nurses. gynaecology, ophthalmology and paediatrics. UHS in Vientiane provides educational preparation Graduate nurse (bachelor-level nurse): Graduate for professionals to enter all programmes. Entry (bachelor-level) nurses are trained at the Faculty of requirements include: a graduate degree (bachelor of Nursing at UHS in the Vientiane capital. Applicants medicine), under 45 years of age, more than three for direct entry need to be upper-secondary school years of experience, passing an entrance examination graduates and should pass the entrance examination. and a recommendation. The specialist training Training lasts for four years and graduates receive a programme lasts for three years and graduates receive bachelor’s degree. Applicants for continuing education a postgraduate degree upon completion (specialist 1 face more requirements than direct entry. They should or specialist 2). be under 45 years of age, with more than three years of experience as a registered nurse. Training for Medical related continuing education lasts for two years, including Medical doctors (bachelor level): Medical doctors are four months for a “bridge” course. All graduates get a trained at UHS in Vientiane. The training of doctors bachelor’s degree. began in 1968. Only the upper-secondary school graduates who qualify in the entrance examination Associate nurse/registered nurse (high-level nurse): can begin training. The training course lasts for six Education for associate/registered (high-level) nurses years and graduates receive a bachelor’s degree in is provided at one of four provincial nursing schools: medicine. the Faculty of Nursing at UHS in the Vientiane capital and the College of Health Science in Champasack, Medical associate (high level): The education of Luangprabang and Savannakhet provinces. All medical associates (high level) is provided at any applicants are upper-secondary school graduates and one of three institutions (Health Science College should pass the entrance examination. This course in Champasack, Luangprabang and Savannakhet lasts for three years and graduates receive a diploma. provinces) and lasts for three years for direct entry and two years for continuing education. Entry Technical nurse (middle-level nurse): Technical requirements of direct entry are upper-secondary (middle-level) nurses are trained at one of eight school diploma and passing an entrance examination, provincial nursing schools for two and half years: the and for continuing education, medical assistant level, Faculty of Nursing at UHS in Vientiane capital, College under 40 years of age and more than three years of of Health Science in Champasack, Luangprabang and experience. Graduates get a high-level diploma. Savannakhet provinces and the Public Health School in Khammuan, Oudomxay and Xiengkhuang provinces, Medical assistant (middle level): This group is and the Vientiane Nursing School). Entry requirements trained at the school of public health in Salavane call for completion of upper-secondary education and and Savannakhet provinces, and the course lasts two passing an entrance examination. years for direct entry and 18 months for continuing education. Entry requirements for direct entry are Midwife upper-secondary school diploma and passing an Graduate midwife (bachelor-level midwife): Training entrance examination. For continuing education for graduate (bachelor-level) midwives is provided at the entry enrollees can be low-level medical staff, the Faculty of Nursing at UHS in Vientiane. Training

10 Human Resources for Health Country Profiles lasts four years after upper-secondary school and the Laboratory staff successful completion of an entrance examination. Laboratory technician (bachelor level): Laboratory Graduates receive a bachelor’s degree. technicians are trained at the Faculty of Medical Technology at UHS in Vientiane for four years for Registered midwife (high-level midwife): Registered direct entry and two and a half years via continuing (high-level) midwives are trained at the Faculty of education. Entry requirements for direct entry are Nursing at UHS in Vientiane. Training for direct entry completion of upper-secondary school and an entrance lasts for three years and continuing education for one examination. Requirements for continuing education and a half years. Entrance requirements of direct entry are a high-level degree in medical laboratory studies are upper-secondary graduation and the successful for Government employees with at least five years of completion of an entrance examination. Technical experience and an entrance examination. Graduates (middle-level) nurses and community (middle-level) receive a bachelor’s degree in medical laboratory midwives can apply via continuing education. They studies. should be younger than 40 years and have at least three years of experience, with a recommendation. Laboratory assistant (middle level): Training of Graduates receive a high-level diploma. laboratory assistants takes place at the Faculty of Medical Technology at UHS in Vientiane for three Community midwife (middle-level midwife): years after upper-secondary school and an entrance Community (middle-level) midwives are trained at one examination. Graduates receive a middle-level of six provincial schools (College of Health Science diploma. in Champasack, Luangprabang and Savannakhet provinces, the Public Health School in Khammuan Others and Xiengkhuang provinces, and Vientiane Nursing Physical therapist (bachelor level): Physical therapists School). Training for direct entry lasts for two are trained via continuing education at the Faculty of years and continuing education for a year. Entry Medical Technology at UHS in Vientiane for two years. requirements of direct entry include graduation High-level physical therapists with at least five years from an upper-secondary school and an entrance of experience can enter this course. Graduates receive examination. Applicants to continuing education must a bachelor’s degree in physical therapy. be auxiliary (low-level) nurses, under the age of 40 years, with more than three years of experience and Physical therapist (high level): Training via direct entry a recommendation. is offered at the Faculty of Medical Technology at UHS in Vientiane for three years after upper-secondary Dental staff school and an entrance examination. Graduates Dentist (bachelor-level): Dentists are trained at the receive a high-level degree. Faculty of Dentistry at UHS in Vientiane for six years after upper-secondary school and the completion Primary health care workers: The training of primary of the entrance examination. Graduates receive a health care workers began in 2002 in the northern Bachelor of Dental Surgery degree. part of the country. There are five schools offering training in Champassak, Oudomxay, Khammuane, Pharmacy staff Luangprabang and Savannakhet provinces. Primary Pharmacist (bachelor level): Pharmacists are trained health care workers are lower-secondary school at the Faculty of Pharmacy at UHS in Vientiane for five graduates who train for three years. They are selected years after upper-secondary school and completion of from rural and remote locations, with the intention the entrance examination. Graduates get a bachelor’s that they will provide services in their home areas. degree in pharmacy. Saravane and Xieng Xhuan provinces also have training centres for primary health care workers. They Pharmacy assistant (middle level): The Faculty of are assigned to health centres in priority northern Pharmacy at UHS in Vientiane oversees the training provinces. Table 7 provides an overview of the public of pharmacy assistants. The programme provides health professions training institutions. There are training for three years after upper-secondary school no private health professions institutions providing and an entrance examination. Graduates get a middle- training in the Lao People’s Democratic Republic. level diploma.

Lao People’s Democratic Republic 11 Table 7. Number of training institutions by specialty 4.3 Overall cost of training/education per PhD 1 graduate Master 1 The Department of Organization and Personnel at Specialist 2 1 the Ministry of Health estimates the training cost at Specialist 1 1 UHS (medicine, dentistry, nursing, pharmacy, medical Medical doctor 1 technology, basic science and postgraduate studies) at MA (medical associate, medical Associate 3 around US$ 1500 per year. Training costs in the eight assistant) Assistant 2 provincial nursing schools (nursing and midwifery Bachelor 1 Bachelor/high-level nurse training programmes) are around $1200 per year. high-level 4 Technical nurse 8 4.4 In-service and continuing professional Community midwife 6 education Midwife (low) 0 According to the Lao People’s Democratic Republic Laboratory (bachelor) 1 Law on Health Care—Article 34, In-service Training, Laboratory assistant 1 all health-care professionals in the Lao People’s Pharmacist (bachelor) 1 Democratic Republic are required to continuously Pharmacy assistant 1 improve their knowledge and skills and take part in Dentist (bachelor) 1 training activities and evaluation of their professional Dentist assistant 0 practices in order to improve the quality of their consultations, diagnoses and care, and to keep abreast Hygienist 1 of the latest scientific progress, for the interests Physiotherapist 1 and safety of patients. Also, the Medical Profession X-ray technician 1 Council has the right and duty to assess and evaluate Low-level nurse and nurse-midwife 0 in-service training at least once every two years, in Middle-level primary health care accordance with the instructions of the Ministry of 5 worker Health. Low-level primary health care 0 worker Although the Lao People’s Democratic Republic Support and logistic staff 0 regulates continuing professional education by Public health (high) 1 law, it has not yet been implemented. However, the Government is developing guidelines and is Total 9 determined to implement continuing professional Source: Department of Organization and Personnel, Ministry of Health, March 2012. education.

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

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

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

12 Human Resources for Health Country Profiles Figure 5. Number of entrants per year in health Figure 6. Number of graduates per year in health professions education institutions, for selected professions education institutions, for selected categories (2008-2011) categories (2008-2011)

1400 1000 900 1200 1214 897 800 1000 700 600 800 646 669 693 624 761 666 500 600 638 400 364 397 464 400 370 300 203 202 318 290 200 150 160 200 275 190 169 171 192 126 100 100 124 86 114 60 63 0 59 28 40 0 0 0 0 0 0 2008 2009 2010 2011 2008 2009 2010 2011

Medical doctor Medical assistant Nurse Medical doctor Medical assistant Nurse Midwife Pharmacist Midwife Pharmacist

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

5. Human resources for health (HRH) utilization

5.1 Recruitment the system and would help to some extent solve the shortage of the staff in the health sector. There have Every April and October, an HRH quota is fixed by the been positive signs of commitment from Ministry Prime Minister’s Cabinet, the Ministry of Home Affairs of Home Affairs to increase significantly the quotas and the Ministry of Finance (see Table 8). The Division in the next few years to meet the needs of service of Personnel at Department of Organization and delivery. Personnel then requests that Ministry of Home Affairs allocate a number of health workers and non-medical All persons eligible for recruitment should meet the workers to fill needed positions. After Department following criteria (Prime Minister’s Office, 2003): of Organization and Personnel receives a number of employees as designated by the quota, Department Lao nationals or those who have acquired and of Organization and Personnel is responsible for the held Lao citizenship for three or more years; allocation of this quota at all administrative levels: are 18 to 35 years of age; comply with the central, provincial and district, as well as health law and the Decree on civil service; are good centres. citizens with no criminal record and no history of dismissal; submit an accurate description of However, currently the quotas are not sufficient to personal and family details; are physically fit address the shortage of health workers and are not and healthy as certified by state hospitals; have even enough to absorb those already trained. An qualification awarded by recognized educational increase of the quotas by the Government would allow institutions; meet all the criteria required by the the recruitment of the available health workforce into workplaces concerned.

Lao People’s Democratic Republic 13 Table 8. Approved HRH quotas, March 2012

Grand Category 2008 2009 2010 2011 Total Master 0 3 9 0 15 Specialist 1 18 15 1 4 38 Medical doctor 30 40 47 106 223 MA (medical associate, medical assistant) 12 18 9 28 67 High-level nurse 0 0 0 2 2 Technical nurse 127 152 180 408 867 Laboratory (bachelor) 0 0 1 0 1 Laboratory assistant 18 20 34 48 120 Pharmacist 27 17 31 47 122 Pharmacist assistant 29 37 38 56 160 Dentist 11 15 16 17 59 Dentist assistant 2 0 0 0 2 Hygienist 32 33 41 62 168 Physiotherapist 12 16 17 19 64 Low-level nurse 61 39 42 14 156 Low-level primary health care worker 101 72 16 0 189 Midwife (low) 0 72 15 0 87 Nurse-midwife (low) 48 0 28 54 130 Middle-level primary health care worker 0 0 0 63 63 Support and logistic staff 81 85 104 133 403 Total 612 634 629 1061 2936 Source: Department of Organization and Personnel, Ministry of Health, March 2012.

5.2 Deployment and distribution policies (district and health-centre levels), the Ministry and mechanisms of Health and the Government have developed and endorsed a number of policies, decrees and The Lao People’s Democratic Republic has a critical regulations, starting in 2002: shortage and a maldistribution in its health workforce. • 2002: The Ministry of Health’s Health Strategy There are 0.6 qualified health workers (physicians) to the Year 2020 indicated a significant need to per 1000 population, according to 2011 Ministry of provide appropriate incentives for health workers Health data. The main challenges that contribute to in rural areas. the shortage and maldistribution of health workers • 2003: The Civil Service decree No. 82/PM stated in the Lao People’s Democratic Republic are limited that during the first five years, newly recruited posts allocated by the Government to recruit health health workers should work at least two years in workers; the preference of health workers to work rural areas. However, implementation of this decree in urban areas with better salaries; the lack of has been insufficiently enforced. professional career development opportunities; and • 2010: Financial Incentive decree No. 468/PM was graduates with inadequate preparation to work in intended to provide salary bonuses of 30%, 40% rural areas, which may be attributable to insufficient and 50% of the regular salary to civil servants training. The shortage of middle- and high-level working in rural areas, including health workers. health workers at primary and secondary health-care The implementation has not started due to delays facilities leads to a major gap in the quality of health- in defining and classification of rural areas. care services between urban and rural areas. • 2010: The Ministry of Health’s Health Personnel Development Strategy by 2020 addressed five To solve the above problems and to provide main areas for improvement: preparation of health incentives to health workers to work in rural areas personnel, utilization of health personnel, health

14 Human Resources for Health Country Profiles personnel management, equity and quality, and 5.3 Unemployment incentives for health personnel. • 2011: The Ministry of Health’s Ministerial Decree Even though the Lao People’s Democratic Republic No. 103/MOH called for newly graduated medical has a shortage of health workers, the country students to agree to three years of compulsory also faces the challenge of providing positions to service in rural health facilities. The decree also trained professionals. This is a direct result of small indicated the provision of non-financial incentives quotas for recruiting health workers due to financial such as: direct promotions for permanent staff, eli- constraints in recent years. Thus, some graduates are gibility for continuing education, and eligibility for not recruited and some of them offer their services the licensing examination. as volunteers until they get a position. This period of unemployment may last up to a few years. Except Including the latest decree, a number of policies, for those positions that the Government no longer decrees and regulations have been endorsed. However, offers training (low-level nurses and primary health enforcement, implementation, monitoring and care workers), almost all of these groups have a large evaluation of these policies using updated, accurate recruitment gap. Therefore, there are high levels of HRH databases remain weak. Also, low salaries and unemployment, especially among technical nurses, low levels of motivation decrease health system laboratory technicians and hygienists. efficiency. In rural and remote areas in particular, there is low motivation among health workers and a lack of career development opportunities (Thome and Soulivanh, 2008).

6. Financing HRH

6.1 Health expenditure 6.2 Remuneration to health workers

According to the National Health Account 2009– The salary of civil servants, including health workers, 2010, total health expenditure (THE) was 2.5% of GDP, is regulated by Prime Minister’s Decree No. 82/PM. The US$ 27.10 per capita (see Table 9). Private health starting salaries of new staff are allotted according expenditure (PvtHE) as a percentage of THE in 2009– to their educational and professional qualifications. 2010 was 59.3%, while out-of-pocket expenditure on An initial proposal for the starting level and step— health comprised the majority of health spending each level has several steps based on accumulated (46.4% of THE). The general government expenditure experience—is made by the selection board at the on health (GGEH) amounted to 40.7% of THE and 4.1% central, provincial or district level—depending on of the general government expenditure (GGE). who is recruiting. This proposal has to be approved by the Department of Organization and Personnel at As Table 10 demonstrates, about 32% of health the Ministry of Health and by the Ministry of Home expenditure in the Lao People’s Democratic Republic Affairs. There is a probation period for all new staff, derives from nongovernmental organizations and which increases with the level of posting, for instance, donors; this reflects a high dependence on foreign three months for low-level, six months for middle- aid and makes the Lao people vulnerable to shifts in level and 12 months for high-level professionals. A aid spending. final evaluation is made after this period. Based on this evaluation, a proposal for nomination is made to Table 11 shows a breakdown of THE by function and the Minister of Health by the recruitment committee indicates that almost 50% is spent on curative services. of the corresponding professional level. Fourteen per cent of this amount is spent on inpatient care. Civil servants in the Lao People’s Democratic Republic are classified by a five-level system (1, 2, 3, 4 and 5), As shown in Table 12, the expenditure for education and each level has 15 steps. Table 13 shows the entry and training of health personnel makes up only 2.6% levels classification. Table 14 shows the average of THE. monthly salary by health profession in the local currency.

Lao People’s Democratic Republic 15 Table 9. National Health Account summary results, 2009–2010 US$ per capita Kip (in US$ (in Key indicators at average % of billions) millions) exchange rate Total health expenditure (THE) 1398.95 169.87 27.1 2.5% GDP Private health expenditure (PvtHE) 829.56 100.74 16.1 59.3% THE 78.2% PvtHE Out-of-pocket expenditure on health 649.10 78.82 12.6 46.4% THE Non-profit institutions serving 21.8% PvtHE households (e.g. donors not channelled 180 459.05 21.91 3.5 through Government, nongovernmental 12.9% THE organizations) 4.1% GGE General Government Expenditure on 569.30 69.13 11.0 40.7% THE Health (GGEH) 1.0% GDP Ministry of Health expenditure 510.46 61.99 9.9 89.7% GGHE Social expenditure on health (SSHE) 39.54 4.80 0.8 6.9% GGHE 3.0% Domestic GGE Domestic government expenditure on 278.87 33.86 5.4 19.9% THE health 0.5% GDP Domestic government recurrent Domestic 244.30 29.67 4.7 4.2% expenditure on health recurrent GGE Domestic Domestic government non-wage recurrent 71.03 8.63 1.4 2.9% non-wage expenditure on health recurrent GGE External resources for health 445.56 54.11 8.6 31.9% THE Source: National Health Account 2009–2010, 2011.

Table 10. Sources of health funds, 2009–2010 Kip US$ Sources of health funds % US$ per capita (in billions) (in millions) Ministry of Finance 278.87 19.9% 33.86 5.41 Other private funds 3.84 0.3% 466.45 0.07 Households 670.58 47.9% 81.43 13.01 Nongovernmental organizations and donors 445.56 31.9% 54.11 8.64 Total 1398.85 100% 169.87 27.14 Source: National Health Account 2009–2010, 2011.

Table 11. Functional distribution of health care expenditure, 2009–2010 US$ Function Kip (in billions) % US$ per capita (in millions) Services of curative care 677.35 48.4% 82.25 13.14 Ancillary services to health care 33.50 2.4% 4.07 0.65 Medical goods dispensed to outpatients 306.80 21.9% 37.25 5.95 (including pharmaceutical products) Prevention & public health services 70.04 5.0% 8.50 1.36 Health administration & health insurance 53.68 3.8% 6.52 1.04 Health-related Functions1 257.49 18.4% 31.27 5.00 Total 1398.85 100% 169.87 27.14 Source: National Health Account 2009–2010, 2011.

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

16 Human Resources for Health Country Profiles Table 12. Expenditure disaggregated by function, 2009–2010 Kip (in US$ (in US$ per Function % billions) millions) capita Inpatient curative care 315.16 22.5% 38.27 6.11 Outpatient curative care 315.25 22.5% 38.28 6.12 Clinical laboratory 1.61 0.1% 0.19 0.03 Diagnostic imaging 0.46 0.0% 0.05 0.01 Patient transport and emergency rescue 31.43 2.2% 3.81 0.61 Traditional healers 46.94 3.4% 5.70 0.91 Medical goods dispensed to outpatients 306.79 21.9% 37.25 5.95 Maternal and child health, family planning and counselling 38.95 2.8% 4.73 0.76 School health services 10 0.7% 1.21 0.19 Prevention of communicable diseases 8.85 0.6% 1.08 0.17 Prevention of noncommunicable diseases 9.93 0.7% 1.21 0.19 All other miscellaneous public health services 2.31 0.2% 0.28 0.04 Health administration and health insurance 53.68 3.8% 6.52 1.04 Capital formation of health-care provider institutions 190.64 13.6% 23.15 3.70 Education and training of health personnel 36.25 2.6% 4.40 0.70 Research and development in health 27.52 2.0% 3.34 0.53 Food, hygiene and drinking-water control programme 2.53 0.2% 0.30 0.05 Others 0.55 0.0% 0.068 0.01 Total 1398.85 100% 169.87 27.14 Source: National Health Account 2009–2010, 2011.

Table 13. Entry level groups classification No education Level 1 Low-level education (e.g. high school) Level 2 Mid-level education certificate (minimum three-year course) Level 3 step 3 (3/3) High-level certificate (minimum three-year course) Level 4 step 1 (4/1) Bachelor’s degree certificate Level 4 step 2 (4/2) Intermediate graduate diploma Level 4 step 3 (4/3) Master’s degree or equivalent Level 4 step 5 (4/5) Higher-level graduate diploma (higher than Master’s but not PhD) Level 4 step 6 (4/6) Doctorate (PhD) Level 4 step 7 (4/7) Senior high-ranking staff (e.g. Minister) Level 5 Source: Department of Organization and Personnel, Ministry of Health, March 2012.

Average monthly salaries of other civil servants such of the incentive system is detailed in the Health as lawyers, teachers or police are also calculated Personnel Development Strategy by 2020. The based on their education level. Therefore, for instance, following are financial and non-financial incentives the average monthly salary for both a bachelor- that the Ministry of Health is committed to provide to level medical doctor and bachelor-level teacher is health workers. 1 165 216 kip (see Table 14). • Improve and implement remuneration of health 6.3 Health workers incentives workers in keeping with the cost of living, socioeconomic development, knowledge and skills, The Government of the Lao People’s Democratic better performance and work achievement. Republic is trying to implement both financial and • Benefits may include higher salary, health insur- non-financial incentive schemes to retain and promote ance, pension and other social benefits; gasoline health workers. The Ministry of Health’s consideration expenses, house rental fee, nursery care fee, trans-

Lao People’s Democratic Republic 17 Table 14. Average income by category cadre, March 2012 Average monthly salary Professional category (Kip) PhD* 1 293 869 Master** 1 257 312 Specialist level 2 1 293 869 Specialist level 1 1 257 312 Medical doctor 1 165 216 MA (medical associate, medical assistant) 896 568 Bachelor/high-level nurse 1 165 216 Technical nurse 896 568 Community midwife 896 568 Midwife 790 435 Laboratory (bachelor) 1 165 216 Laboratory assistant 896 568 Pharmacist (bachelor) 1 165 216 Pharmacist assistant 896 568 Dentist (bachelor) 1 165 216 Dentist assistant 896 568 Hygienist 896 568 Physiotherapist 896 568 X-ray technnician 896 568 Low-level nurse and nurse-midwife 790 435 Middle-level primary health care worker 896 568 Low-level primary health care worker 790 435 Support and logistic staff 896 568 Public health (high) 896 568 * Includes physicians and pharmacists. ** Includes physicians, dentists, pharmacists, laboratory specialists, nurses/midwives and other. US$ 1 = 8000 kip Source: Department of Organization and Personnel, Ministry of Health, March 2012.

portation fee for home visits; payment for better Health developed a Decree on Financial Incentives performance and a budget to promote professional for Rural Civil Servants. The decree defines remote, development such as scholarships, loans for educa- isolated and difficult areas; levels of each area; and tion and others. ways of measuring incentives. Tables 15 and 16 • Improve and implement appropriate non-financial explain more about the Ministry of Health’s incentive incentives for health workers, such as improve- plan for health workers working in rural areas. ment of the work environment to ensure it is clean, safe and stable, without violence including sexual Even though the Ministry of Health understands the violence; improve flexibility of work such as working importance of incentives and has developed incentive- hours and work leave plans; develop professionals related decrees, there has been minimal action. and skills of health workers such as supervision, Reasons include low levels of funding for the health teaching, accessibility to training and educational sector, low absolute rates of pay, and limited capacity leave; improve accessibility to social services such to administer and evaluate targeted incentive schemes. as health services, school, nursery school, housing, However, more positively, several other projects have and transportation; improve appropriate rewards been implemented within the Lao People’s Democratic directed to boost staff’s motivation. Republic that have incorporated the implementation of incentives for health workers. These movements The Ministry of Health prioritizes health workers will expedite implementation. working in rural and remote areas. The Ministry of

18 Human Resources for Health Country Profiles Table 15. Levels of remote, isolated and difficult areas

Level one Level two Level three 1. Geographic and natural condition • Mountainous village located • Mountainous village located • Mountainous district/village more than 50 kms from a city more than 30 km from a city located more than 20 km • Rainfall shortage/natural • Rainfall shortage from a city disaster • Rainfall shortage 2. Infrastructural condition • No road access • Poor road access/access by • Improved road access but • No post office/telephone car in only some areas or difficult to access during rainy • No electricity/water supply access only in dry season season • No market • Post office/telephone • Have post office/telephone coverage in only some areas but not convenient • No electricity/water • Have simple market

3. Education and health condition • More than 50% of children • More than 40% of children not • More than 30% of children not not enrolled in school; there enrolled in school; school is enrolled in school is no school or the school is below standard • May be able to access district substandard • Only access to health centre hospital and health centre • Limited access to health with insufficient resources with insufficient resources service; have only drug kits 4. Living and environmental condition • Majority of people rely on • Some people rely on natural • Some people rely on natural natural resources for their resources for their livelihood resources for their livelihood livelihood • Ethnic minority area, difficult • Challenging environment for • Ethnic minority area, difficult in terms of language and development and living in terms of language and communication in some areas communication • Some areas still have • Area vulnerable to disease outbreaks of infectious outbreaks; poor environment diseases, poor environment, at high risk for living and and present difficulties for working living and working

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

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

Level one Level two Level three 1. For rural civil servant • Receive a salary increase of • Receive a salary increase of • Receive a 30% salary increase 50% 40% • Be priority candidate for • Be a priority candidate for • Be a priority candidate for continued study continued study continued study • Receive appropriate • Receive appropriate • Receive appropriate recognition based on recognition based on recognition based on performance performance performance 2. For civil servants who are temporarily assigned to work in rural areas (less than 12 months) • Receive a 50% salary increase • Receive a 40% salary increase • Receive a 30% salary increase • Receive additional money for • Receive additional money for • Receive additional money for resettlement (equivalent of resettlement (equivalent of resettlement (equivalent of two months of salary) two months of salary) two months of salary) • Be a priority candidate for • Be a priority candidate for • Be a priority candidate for continued study continued study continued study • Receive appropriate • Receive appropriate • Receive appropriate admiration based on admiration based on admiration based on performance performance performance

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

Lao People’s Democratic Republic 19 7. Governance of HRH

7.1 HRH policies and plans Democratic Republic’s health system is mainly centralized, so the central Government is responsible The latest HRH-related strategy, Health Personnel for staffing, budget, planning and evaluation of Development Strategy by 2020, was developed in central, provincial, and district health centres. order to effectively and efficiently train and recruit a sufficient number of qualified health personnel 7.3 Professional regulation representing all categories of staff, mix of professions, levels of seniority, gender, ethnicity and age groups Requirements of health workers are regulated in the who could lead, manage and deliver quality health Law on Health Care No.139/PM. services in different health settings to the entire Lao population. There are five pillars of the strategy: First, health workers are required to complete at least health personnel capacity-building; utilization of a middle-level professional education and possess health personnel; equity and equality of opportunity; a diploma from a health professions education health personnel management; and health personnel institution in the Lao People’s Democratic Republic incentives. The Health Strategy to the Year 2020 or in a foreign country recognized by the Ministry also includes measures to improve HRH; it addresses of Education and the Ministry of Health of the Lao human resources under a number of different health People’s Democratic Republic. issues (University of New South Wales, 2011). Second, health workers must obtain authorization 7.2 Policy development, planning and from the Ministry of Health to practise, after managing for HRH verification and proposal from the Medical Profession Council. The Department of Organization and Personnel (see Figure 7) and the Ministry of Health develop all Third, for physicians and dentists, practitioners must policies, laws, decrees, regulations and strategies have at least five years of professional experience related to HRH. The Prime Minister’s Office, the in health care in public or private hospitals. Medical National Assembly, health-related nongovernmental assistants, dentist assistants, nurses, midwives, and organizations and development partners contribute physiotherapists and other medical technicians must feedback and provide support. The Lao People’s

Figure 7. Structure of Department of Organization and Personnel

Department of Organization and Personnel

Department of Department Training and of Health Research Personnel

Under- Graduate Organiza- Staff Adminis- graduate Research Adminis- Personnel Party Studies tion Welfare tration Studies Division tration Division Office Division Division Division Division

Source: Ministry of Health, 2012.

20 Human Resources for Health Country Profiles have at least three years of experience in public or Government. In addition, the Ministry of Health used private hospitals. PIMS to further classify health personnel according to profession, activity history and qualification for salary Fourth, health workers must be in good physical and increases (Bañez, 2011). mental health and possess a certificate indicating they are free of communicable diseases. PIMS has the ability to create reports on the following: • predetermined quota per province regarding the Fifth, health workers must show that they have never number of needed personnel been disciplined, professionally punished or punished • salary grade of civil service personnel for offences. • classification according to educational attainment • classification according to age Lastly, they must also have Lao nationality and reside • classification according to ethnicity in the Lao People’s Democratic Republic, except if • report of civil service termination otherwise provided by a separate decision. • report of additional civil service recruitment and transfer to other region Currently there is no relicensing requirement. A • report of new recruitment process is under way to introduce a national exam for • reports from the central office a license to practise. • retirement • report of civil service per province, district 7.4 HRH information • summary report.

In 2006, the Division of Personnel in the Department 7.5 Health workforce requirements of Organization and Personnel, and the Ministry of Health in coordination with the Public Administration The Lao People’s Democratic Republic also began and Civil Service Authority (PACSA) began to use an projecting HRH requirements based on the services electronic system for monitoring personnel-related that are being targeted by each different type of health information. The Personnel Information Management facility nationwide. Table 17 is the result of WHO System (PIMS) was created to standardize the gathering guidance to support planning of HRH requirements of personnel information from different sectors of the for the Lao People’s Democratic Republic.

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

Year Categories 2013 2014 2015 2016 2017 2018 2019 2020 PhD 46 50 54 57 61 65 69 72 Master 494 514 534 553 573 593 613 633 Specialist level 2 80 102 124 146 168 190 211 233 Specialist level 1 435 480 525 570 615 660 705 750 Medical doctor 1412 1490 1568 1645 1723 1801 1878 1956 Medical assistant/nurse practitioner 1376 1353 1330 1307 1284 1260 1237 1214 Bachelor/high-level nurse 188 210 233 255 278 300 323 345 Middle-level nurse 2335 2778 3222 3666 4110 4554 4998 5442 Low-level nurse 2944 2646 2347 2048 1750 1451 1153 854 Community midwife/Midwife 1017 1161 1306 1450 1594 1739 1883 2027 Laboratory (bachelor) 104 123 142 161 180 199 218 237 Laboratory assistant 469 482 496 509 523 536 550 563 Pharmacist (bachelor) 397 406 416 425 434 443 452 461 Pharmacist assistant 639 654 669 684 699 715 730 745 Dentist (bachelor) 217 227 237 248 258 268 278 288 Dentist assistant 148 165 183 200 218 235 252 270 Hygienist 417 447 478 508 538 568 599 629 Physiotherapist 342 360 378 396 414 433 451 469 X-ray technician 88 118 147 176 206 235 265 294 Primary health care worker 581 642 704 765 826 887 948 1009 Support and logistic staff 1306 1355 1404 1453 1502 1551 1599 1648 Totals 15 035 15 764 16 494 17 223 17 952 18 682 19 411 20 140 Source: Department of Organization and Personnel, Ministry of Health, March 2012.

Lao People’s Democratic Republic 21 8. Concluding remarks

The shortage and maldistribution of the health existing health workers at health centres should be workforce in the Lao People’s Democratic Republic, improved and upgraded through accelerated in-service together with the inadequate skills of the health staff, training and ‘bridge’ courses. In addition, more middle- pose serious challenges to achieving the health-related and high-level professionals are needed to serve rural Millennium Development Goals (MDGs). In response to communities. In response, the Health Strategy to these challenges, Health Strategy to the Year 2020 the Year 2020 prioritizes staffing of health centres gives priority to improving employment capacity, with middle-level/community midwives. Short-term increasing deployment of skilled health workers to solutions include enhancing service delivery through rural and remote areas, and enhancing the capacity of outreach activities at the community level. For remote health professionals through improved education and villages where the regular outreach from health training in order to achieve the MDGs by 2015. centres is difficult, posting village health workers is a method piloted to provide health promotion and Recent years have witnessed an increase of graduates preventive health services. in health professions who have not been fully absorbed by the health system and have remained The urgent need to scale up the health workforce unemployed or working voluntarily. Improving calls for a more rigorous education system for health employment capacity is one of the key ways to professionals in the Lao People’s Democratic Republic. strengthen the health workforce. On a biannual To achieve this, issues related to educational capacity basis, the Prime Minister’s Cabinet, the Ministry of for training health professionals, such as training Home Affairs and the Ministry of Finance fix a quota approaches and methods, faculty development, for new placements of civil servants, including the infrastructure, and teaching resources and materials number of health workers. The Division of Personnel must be addressed. The Education Development Centre in the Department of Organization and Personnel for Health Professionals, which has been established then receives a number of employees as designated in some provinces, provides an excellent opportunity by the quota. The Department is responsible for the to update educational approaches and build and allocation of this quota at all administrative levels: strengthen faculty capacity. Besides addressing these central, provincial and district, as well as health key issues related to the development of the health centres. workforce in the country, HRH governance capacities are critically important to the implementation of HRH The quota, however, rarely meets the actual need for strategies, including strengthening the capacities of health workers, and as a result there is a shortage relevant departments in the Ministry of Health. of employed health workers around the country. In addition, there remains qualified but unemployed In addition, financial limitations remain a major health workers who do not receive positions under obstacle to increasing the quantity and quality of the the current quota system. Increasing quotas in order health workforce. Domestic government expenditure to recruit the available health workforce into the accounts for only 19.9% of total health expenditure, system will help, to some extent, solve the shortage while out-of-pocket spending makes up 46.4% of of health staff. But until quotas are increased, the the total. The heavy reliance on international aid most promising way to increase the health workforce makes long-term planning and employment of health is to develop innovative ways to recruit existing workers tenuous. Moreover, the generally low level of health workers into the system. compensation, especially in rural areas, may explain part of the difficulty of attracting and retaining The tendency for health workers to prefer urban competent health workers. The correlation is clear: over rural settings poses a significant challenge to low levels of overall financial investment in health ensure that the health workforce is evenly distributed directly translate to inadequate human resources for according to needs and population levels across the health. An increased financial commitment will serve country. Likewise, over half of the existing health to improve the competency, reliability and quantity of workers in rural health centres are low-level health the health workforce. workers. To remedy this problem, the capacity of

22 Human Resources for Health Country Profiles References

Bañez R (2011). Improvement of the Personnel Ministry of Health (2010). Health Personnel Information Management System. City, Publisher. Development Strategy by 2020. Vientiane Capital, Lao People’s Democratic Republic. Central Intelligence Agency (2012). The World Factbook. Washington, DC (https://www.cia.gov/ Ministry of Health (2007). Human Resources for library/publications/the-world-factbook/, accessed Health: Analysis of the situation in the Lao People’s on 15 April 2012) Democratic Republic. Vientiane Capital, Lao People’s Democratic Republic. Prime Minister’s Office (2003). Decree on Civil Service of the Lao People’s Democratic Republic. [Civil Service Somchith A (2009). Infant Mortality and Maternal Decree No. 82/PM]. Vientiane Capital, Lao People’s Mortality in the Lao People’s Democratic Republic Democratic Republic. [lecture]. Vientiane Capital, Department of Hygiene and Prevention, Ministry of Health, Lao People’s Prime Minister’s Office (2010). Decree on Financial Democratic Republic. Incentive for Rural Civil Servants [Financial Incentive decree No. 468/PM]. Vientiane Capital, Lao People’s Thome J-M and Soulivanh P (2008). Lao People’s Democratic Republic. Democratic Republic: Health Financing Reform and Challenges in Expanding the Current Social Protection Department of Organization and Personnel (March Schemes. In: UNESCAP, eds. Promoting Sustainable 2012). Data on Health Workers Stock and Distribution. Strategies to Improve Access to Health Care in the Vientiane Capital, Ministry of Health, Lao People’s Asian and Pacific Region. Bangkok, United Nations Democratic Republic. Economic and Social Commission for Asia and the Pacific. Encyclopaedia Britannica (2013). Laos. City, Publisher (http://global.britannica.com/EBchecked/ United Nations Inter-Agency for Child Mortality topic/330219/Laos, accessed on January 2013). Estimation (2012). Child Mortality Estimates. (www. childmortality.org, accessed on 15 January 2012). City. Lao Statistics Bureau (2012). GDP per capita. Vientiane Capital, Lao People’s Democratic Republic (http:// University of New South Wales (2011). HRH profile of www.nsc.gov.la/, accessed on 15 January 2012). the Lao People’s Democratic Republic. Sydney, UNSW HRH Knowledge Hub. Lao Statistics Bureau (2012). Lao Social Indicator Survey (LSIS) 2011–2012. Vientiane Capital, Lao WHO Western Pacific Regional Office (2011). Western People’s Democratic Republic. Pacific Country Health Information Profiles: Lao People’s Democratic Republic, 2011 revision. Manila. Ministry of Health (2012). National Health Statistic Report, 2010–2011. Vientiane Capital, Lao People’s World Bank (2012). Data: Lao PDR. Washington, DC Democratic Republic. (www.databank.worldbank.org, accessed on 14 February 2013). Ministry of Health (2011). National Health Account 2009–2010. Vientiane Capital, Lao People’s Democratic Republic.

Lao People’s Democratic Republic 23 Annexes

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

Professional category/cadre Total Female % Female PhD (physician) 35 10 28.57% PhD (pharmacist) 3 1 33.33% Master (physician) 381 133 34.91% Master (dentist) 31 5 16.13% Master (pharmacist) 46 13 28.26% Master (laboratory) 8 2 25.00% Master (nurse/midwife) 13 9 69.23% Master (other) 8 3 37.50% Specialist 2 (physician) 20 2 10.00% Specialist 1 (physician) 312 112 35.90% Medical doctor 1233 600 48.66% MA (medical associate, medical assistant) 1375 813 59.13% Bachelor/high-level nurse 166 139 83.73% Technical nurse 1774 1302 73.39% Community midwife 338 285 84.32% Midwife 120 103 85.83% Laboratory (bachelor) 70 30 42.86% Laboratory assistant 490 290 59.18% Pharmacist (bachelor) 473 254 53.70% Pharmacist assistant 667 394 59.07% Dentist (bachelor) 194 89 45.88% Dentist assistant 96 53 52.21% Hygienist 482 254 52.70% Physiotherapist 284 176 61.97% X-ray technician 32 6 18.75% Low-level nurse and nurse-midwife 3629 2450 67.51% Middle-level primary health care worker 132 45 34.09% Low-level primary health care worker 320 116 36.25% Support and logistic staff 1434 694 48.40% Public health (high) 23 3 13.04% TOTAL 14 189 8385 59.10% Source: Department of Organization and Personnel, Ministry of Health, March 2012.

24 Human Resources for Health Country Profiles Annex B. Health workers by age group and cadre, March 2012

Professional category/cadre <30 30–39 40–49 50–59 >60 Total PhD (physician) 0 3 10 18 4 35 PhD (pharmacist) 0 1 0 1 1 3 Master (physician) 3 65 143 161 9 381 Master (dentist) 0 11 10 8 2 31 Master (pharmaciat) 1 13 20 11 1 46 Master (laboratory) 0 2 2 3 1 8 Master (nurse/midwife) 0 2 8 2 1 13 Master (other) 0 1 4 3 0 8 Specialist 2 (physician) 0 0 2 13 5 20 Specialist 1 (physician) 7 98 111 77 19 312 Medical doctor 146 288 497 281 21 1233 MA (medical associate, medical assistant) 94 156 766 321 38 1375 Bachelor/high-level nurse 9 51 94 11 1 166 Technical nurse 979 425 321 46 3 1774 Community midwife 42 171 120 5 0 338 Midwife 13 65 34 8 0 120 Laboratory (bachelor) 3 21 40 5 1 70 Laboratory assistant 117 143 178 48 4 490 Pharmacist (bachelor) 102 148 163 56 4 473 Pharmacist assistant 174 199 224 66 4 667 Dentist (bachelor) 28 94 55 15 3 195 Dentist assistant 1 5 63 25 1 95 Hygienist 178 175 111 17 1 482 Physiotherapist 53 73 134 22 2 284 X-ray technician 8 19 2 3 32 Low-level nurse and nurse-midwife 212 1041 1735 590 51 3629 Middle-level primary health care worker 87 43 2 0 0 132 Low-level primary health care worker 216 99 5 0 0 320 Support and logistic staff 334 471 388 208 33 1434 Public health (high) 0 3 16 4 0 23 TOTAL 2799 3875 5275 2027 213 14 189 Source: Department of Organization and Personnel, Ministry of Health, March 2012.

Lao People’s Democratic Republic 25 Annex C. Density of health workers by category and province (per 1000 population)

Professional category/ cadre Phonsaly Luangnamtha Bokoe Luangprabang Huaphan Bolikhamsai Khammuane Saiyabury Savannakhet Salavan Sekong Xiengkhuang Oudomsay Champasack Vientiane Capital Vientiane Attapue Total

1 PhD (physician) 0.04 ------0.00 - - 0.00 - 0.01 2 PhD (pharmacist) 0.00 ------0.00 3 Master (physician) 0.25 0.04 0.03 0.03 0.02 0.05 0.02 0.03 0.08 0.00 0.04 0.02 0.03 0.01 0.05 0.03 0.01 0.06 4 Master (dentist) 0.03 - - - - - 0.00 - 0.00 - - - 0.00 - - - - 0.00 5 Master (pharmaciat) 0.05 - - 0.00 - 0.00 - 0.00 0.00 0.00 - - 0.00 - - 0.00 - 0.01 6 Master (labolatory) 0.01 ------0.00 - 0.00 Master (nurse/ 7 0.01 - - 0.00 - 0.00 ------0.00 midwife) 8 Master (other) 0.01 ------0.00 Specialist 2 9 0.02 - - 0.00 ------0.01 - 0.00 (physician) Specialist 1 10 0.20 0.01 0.04 0.03 0.02 0.02 0.02 0.04 0.03 0.01 0.03 0.03 0.00 0.02 0.05 0.04 0.03 0.05 (physician) 11 Medical Doctor 0.60 0.11 0.19 0.13 0.14 0.08 0.06 0.14 0.14 0.21 0.16 0.14 0.09 0.10 0.21 0.10 0.29 0.19 MA (medical associate, 12 0.18 0.26 0.16 0.15 0.14 0.40 0.18 0.25 0.09 0.17 0.18 0.19 0.22 0.17 0.30 0.26 0.29 0.21 medical assistant) Bachelor/high-level 13 0.10 0.01 0.02 0.02 0.01 0.02 0.03 0.01 0.02 0.01 0.00 0.04 0.01 0.01 0.04 0.02 0.01 0.03 nurse 14 Technical nurse 0.49 0.33 0.32 0.24 0.38 0.19 0.22 0.19 0.27 0.31 0.21 0.21 0.18 0.22 0.61 0.12 0.84 0.27 15 Community midwife 0.05 0.04 0.06 0.04 0.07 0.05 0.06 0.06 0.09 0.05 0.08 0.05 0.03 0.04 0.10 0.04 0.10 0.05 16 Midwife 0.03 - 0.03 0.01 - - - - 0.01 - 0.01 0.06 0.00 - 0.01 0.07 0.02 0.02 17 Laboratory (bachelor) 0.05 0.01 - 0.01 0.01 0.00 0.00 0.01 0.02 0.01 0.00 0.01 0.00 0.01 0.01 0.01 0.01 0.01 18 Laboratory assistant 0.17 0.05 0.11 0.04 0.11 0.04 0.06 0.06 0.09 0.07 0.08 0.08 0.03 0.05 0.08 0.05 0.12 0.08 19 Pharmacist (bachelor) 0.20 0.05 0.05 0.06 0.07 0.05 0.05 0.07 0.06 0.02 0.05 0.12 0.03 0.04 0.08 0.05 0.14 0.07 20 Pharmacist assistant 0.21 0.10 0.16 0.08 0.13 0.05 0.13 0.07 0.13 0.10 0.10 0.07 0.05 0.06 0.11 0.10 0.08 0.10 21 Dentist (bachelor) 0.08 0.01 0.05 0.03 0.03 0.02 0.02 0.03 0.03 0.02 0.03 0.02 0.02 0.01 0.04 0.02 0.02 0.03 22 Dentist assistant 0.03 - 0.01 0.01 0.01 0.01 0.00 0.02 0.02 0.02 0.01 0.01 0.02 0.01 0.01 0.02 0.01 0.01 23 Hygienist 0.18 0.09 0.14 0.06 0.12 0.04 0.17 0.07 0.16 0.04 0.05 0.04 0.01 0.03 0.13 0.01 0.13 0.07 24 Physiotherapist 0.15 0.03 0.02 0.02 0.02 0.03 0.04 0.02 0.05 0.02 0.04 0.03 0.02 0.03 0.03 0.03 0.03 0.04 25 X-ray technician 0.02 - 0.01 0.01 0.01 0.00 0.00 0.00 0.00 - - 0.02 0.00 0.00 - - - 0.00 Low-level nurse and 26 0.26 0.79 0.51 0.58 0.54 0.82 0.49 0.63 0.56 0.56 0.54 0.86 0.56 0.55 0.89 0.47 0.52 0.56 nurse-midwife Middle-level PHC 27 0.00 0.04 0.07 0.04 0.01 0.00 0.04 0.03 0.06 0.00 0.01 0.03 0.00 0.01 0.14 0.02 0.10 0.02 workers Low-level PHC 28 - 0.11 0.25 0.14 0.20 0.10 0.10 0.03 0.09 - 0.01 0.01 0.02 0.12 - - 0.01 0.05 workers Support and logistic 29 0.74 0.23 0.21 0.13 0.14 0.08 0.16 0.14 0.22 0.13 0.18 0.15 0.09 0.13 0.36 0.09 0.53 0.22 staff 30 Public health (high) 0.01 0.01 0.01 0.01 0.01 - 0.01 - 0.00 0.00 0.01 - - - - - 0.01 0.00 Total 4.150 2.300 2.431 1.871 2.181 2.041 1.878 1.887 2.221 1.763 1.830 2.148 1.424 1.623 3.252 1.554 3.316 2.17 Source: Department of Organization and Personnel, Ministry of Health, March 2012.

26 Human Resources for Health Country Profiles Annex D. Distribution of health workers by urban/rural area

Health Health workers/ workers/ Total Professional category/cadre % Urban % Rural 1000 Popu- 1000 Popu- number lation in lation in urban areas rural areas PhD (physician) 35 100.00% 0.00% 0.02 0.00 PhD (pharmacist) 3 100.00% 0.00% 0.00 0.00 Master (physician) 487 92.81% 7.19% 0.28 0.01 Master (dentist) 381 91.34% 8.66% 0.22 0.01 Master (pharmacist) 31 96.77% 3.23% 0.02 0.00 Master (laboratory) 46 97.83% 2.17% 0.03 0.00 Master (nurse/midwife) 8 100.00% 0.00% 0.00 0.00 Master (other) 13 100.00% 0.00% 0.01 0.00 Specialist 2 (physician) 8 100.00% 0.00% 0.00 0.00 Specialist 1 (physician) 312 90.71% 9.29% 0.18 0.01 Medical doctor 1233 74.05% 25.95% 0.57 0.06 MA (medical associate, medical assistant) 1375 54.33% 45.67% 0.47 0.12 Bachelor/high-level nurse 166 93.37% 6.63% 0.10 0.00 Technical nurse 1774 46.73% 53.27% 0.52 0.18 Community midwife 338 16.86% 83.14% 0.04 0.05 Midwife 120 25.83% 74.17% 0.02 0.02 Laboratory (bachelor) 70 94.29% 5.71% 0.04 0.00 Laboratory assistant 490 54.69% 45.31% 0.17 0.04 Pharmacist (bachelor) 473 77.59% 22.41% 0.23 0.02 Pharmacist assistant 667 51.42% 45.58% 0.21 0.06 Dentist (bachelor) 194 67.01% 32.99% 0.08 0.01 Dentist assistant 96 51.04% 48.96% 0.03 0.01 Hygienist 482 52.28% 47.72% 0.16 0.04 Physiotherapist 284 73.94% 26.06% 0.13 0.01 X-ray technician 32 90.63% 9.38% 0.02 0.00 Low-level nurse and nurse-midwife 3629 39.27% 60.73% 0.89 0.42 Middle-level primary health care workers 132 13.64% 86.36% 0.01 0.02 Low-level primary health care workers 320 14.69% 85.31% 0.03 0.05 Support and logistic staff 1434 76.36% 23.64% 0.68 0.06 Public health (high) 23 56.52% 43.48% 0.01 0.00 TOTAL 14 189 55.23% 44.77% 4.88 1.22 Note: ‘Urban’ includes the capital of each district. ‘Rural’ includes all the places that are not considered urban under that definition. Population: Estimated population from Population Census 2005. Source: Department of Organization and Personnel, Ministry of Health, March 2012.

Lao People’s Democratic Republic 27 Annex E. Number of entrants by year, 2008–2011

Number of entrants Professional category/cadre 2008 2009 2010 2011 PhD 10 3 0 2 Master 22 19 37 41 Specialist 2 0 0 0 0 Specialist 1 167 156 162 171 Medical doctor 397 290 114 169 MA (medical associate, medical assistant) 86 370 464 666 Bachelor nurse 24 32 35 130 High-level nurse 117 115 284 321 Technical nurse 552 491 442 763 Low-level nurse 0 0 0 0 Community midwife 24 92 101 247 Midwife 0 0 0 59 Laboratory technician 22 23 21 16 Laboratory assistant 141 137 145 130 Pharmacist 185 140 64 78 Pharmacist assistant 133 135 126 48 Dentist 124 126 72 53 Dentist assistant 0 0 0 0 Hygienist 143 132 168 159 Physiotherapist 98 35 76 188 X-ray technician 18 14 0 27 Primary health care worker (low and middle level) 29 (low) 118 125 164 Primary health care worker (high level) 0 352 339 502 Support and logistic staff 0 0 0 0 Total 2263 2780 2775 3934 Source: Department of Organization and Personnel, Ministry of Health, March 2012.

28 Human Resources for Health Country Profiles Annex F. Number of graduates by year, 2008–2011

Number of graduates Professional category/cadre 2008 2009 2010 2011 PhD 3 0 0 0 Master 22 19 18 24 Specialist 2 0 0 0 0 Specialist 1 55 52 53 66 Medical doctor 100 171 202 160 MA (medical associates, medical assistant) 28 60 124 160 Bachelor nurse 24 32 35 130 High-level nurse 0 0 0 30 Technical nurse 600 614 634 737 Low-level nurse 0 0 0 0 Community midwife 0 0 140 167 Midwife 0 0 40 63 Laboratory technician 19 21 26 24 Laboratory assistant 124 140 137 144 Pharmacist 29 77 52 237 Pharmacist assistant 121 126 130 127 Dentist 45 15 56 37 Dentist assistant 0 0 0 0 Hygienist 141 127 124 226 Physiotherapist 81 34 67 76 X-ray technician 0 18 14 27 Primary health care worker (low level) 156 29 0 0 Primary health care worker (middle level) 0 29 180 154 Support and logistic staff 0 0 0 0 Total 1548 1564 2032 2589 Source: Department of Organization and Personnel, Ministry of Health, March 2012.

Lao People’s Democratic Republic 29

This publication is available on the Internet at: http://www.wpro.who.int/hrh/ documents/publications/hrh_buffet_country_profiles/en/index.html

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