DATA COLLECTION SURVEY ON HEALTH SECTOR IN LAO PEOPLE’S DEMOCRATIC REPUBLIC FINAL REPORT MARCH 2016 JAPAN INTERNATIONAL COOPERATION AGENCY (JICA) SYSTEM SCIENCE CONSULTANTS INC. LA JR 15-004 SUMMARY 1. Project Outline (1) Objectives of the project Based on the concept of Universal Health Coverage (UHC), which is advocated as the Japan’s Strategy on Global Health Diplomacy, the project aims to clarify the current situation and priorities concerning the future development of facilities and equipment as well as community intervention in the health sector of Laos and collect necessary information to study the future direction of cooperation and assistance measures. (2) Target issues of the survey This survey addresses the following three subjects as tasks: 1) Improvement of current health care service functions and making proposals for new assistance projects with respect to central hospitals 2) Improvement of current functions, creation of facility inventory list and making proposals for new assistance projects with respect to provincial hospitals in the four southern provinces 3) Making proposals for removing the barriers for acccessing health services in communities (3) Survey method With regard to 1) and 2) above, the Survey Team members traveled directly to the survey sites in Laos. The Team gathered information on the top three referral hospitals in the Vientiane capital city and the provincial hospitals/district hospitals in the southern provinces from the provincial/district health offices and health care facilities. The hospitals were analyzed on the basis of the collected primary information obtained from the responsible person at each hospital based on internal statistical data and a questionnaire, and the new projects were proposed. With regard to 3), after listing of the respective best practices through discussions with the development partners, the target villages for the survey were identified and information was gathered through interviews with village representatives in a commissioned survey. 2. Development of Central Hospitals (Setthathirath Hospital, Mahosot Hospital, Mittaphab Hospital) (1) Issues and challenges about the current situation of three central hospitals In Vientiane City, emergency care is mainly provided by Mahosot Hospital for internal medicine and Mittaphab Hospital for surgery. Involvement in emergency care has an important meaning for Setthathirath Hospital too. However, as this hospital transfers serious cases of injury to Mittaphab Hospital, it is presumed that external injuries treated by Setthathirath Hospital are mild to moderate cases, such as non- open fracture and soft tissue injury. Likewise, for emergency care in internal medicine, as this hospital is not able to carry out CT examination at present, serious cases need to be transferred to Mahosot Hospital, and as such, it is presumed that the hospital treats mild to moderate cases. i With respect to general practice, Setthathirath Hospital has more cancer outpatients and inpatients than the other two hospitals. On the other hand, Mahosot Hospital is in charge of internal medicine and abdominal surgery and Mittaphab Hospital is in charge of external injury treatment, orthopedics, neurosurgery and renal dialysis. Delivery and maternal, neonatal and child health care are mainly handled by the Mother and Child Health Hospital, but the three central hospital facilities also provide the services in these fields. With respect to existing equipment, the equipment of Mittaphab Hospital and Mahosot Hospital has been replaced as appropriate after 2010. On the other hand, Setthathirath Hospital uses the health care equipment procured in the Japanese grant aid cooperation project in the early 2000s and as such, it is of concern that the equipment may have deteriorated. Although the ultrasound unit and general X-ray unit have recently been replaced, on the whole, the equipment has not been replaced in a timely manner. The hospital has no maintenance staff dedicated to medical equipment, but if any of the equipment fails, the hospital directly contacts the medical equipment supplier in Vientiane or the supplier in Thailand, Vietnam, etc. to have it repaired. In terms of finance, while Mahosot Hospital and Mittaphab Hospital are in the black, Setthathirath Hospital is in the red or at a breakeven point. The percentage of the personnel cost to the total expenditure is larger at Setthathirath Hospital than at the other two central hospitals. This gap is mainly because of the low revenue of the hospital, which is unable to demonstrate high-quality hospital functions. Improvement in clinical infrastructure, medical record preparation and other business practices can be seen at Setthathirath Hospital as a result of JICA technical cooperation, but management problems remain. If these deficiencies are solved, it will bear a major benefit for the education and training of health care providers in Laos and the hospital will be able to perform the duties of a more advanced teaching hospital. However, deterioration of the various existing equipment, including the diagnostic apparatus, is conspicuous. Moreover, the internal structure of the hospital, which has been complicated by repeated expansions, significantly obstructs the efficiency and effectiveness of daily clinical services as well as human resources development. (2) Future prediction and projection The current division of responsibilities by the hospitals is generally in accordance with the predicted disease structure of Laos and it clearly allows each hospital to concentrate on its core competence. Considering the future direction based on the current situation, the following four points are identified as the priority issues in the development of the central hospitals. ii In regard to emergency diseases, provision of care to emergency patients of low and medium severity who make up the majority of the patients. To make progress in surgical operations, accumulation of experience in handling emergency diseases, which serves as the foundation. With respect to cancer treatment that will be needed in the future, specialization of operative treatment and chemotherapy. A central facility to handle non-communicable diseases (NCD) and other internal diseases that will rapidly increase in the future and to control Class 1 infectious diseases (3) Proposals on grant aid to Setthathirath Hospital With respect to the three central hospital facilities, it is urgently required to address the issues of Setthathirath Hospital as a top referral hospital, which are declining quality of health care services (both in terms of a need for improvement of medical technology and development of health care human resources) as a top referral hospital and a financial structure that needs to be improved. Most importantly, it is necessary to drastically improve the deteriorated hospital equipment and inefficient line of flow of patients, which are major causes of these issues. To respond to this situation, the appropriate development of the hospital facility and procurement of equipment through a grant aid project are required. 1) Direction of Improvement of hospital facilities and equipment functions Provision of initial treatment to low to medium-severity emergency patients, who are the majority of emergency patients Provision of advanced treatment in internal medicine as a center for the control of NCD, which are expected to rapidly increase in the future, as well as Class 1 infectious diseases Improvement of the environment as a venue of the practical training in clinical medicine essential for the human resource development to provide above-mentioned treatments 2) Outline of proposed assistance Improvement of the line of flow within the existing building, and installation of medical equipment Construction of new outpatient building, and installation of medical equipment Renewal of medical equipment 3) Expected financial benefits provided by proposed grant aid project Securing new patients by improved diagnostic functions Increase in the average hospitalization days and bed occupancy rate with patients of “slightly high severity” Securing annual revenue of 800 – 900 million yen as the total revenue and 500 – 600 million yen as the revolving fund (RF) revenue Securing the technology, methods and budget for the maintenance of the equipment to be newly installed iii 3. Development of Health Care Facilities and Equipment in the Southern Provinces (1) Analysis of current status 1) Characteristics of provincial and district hospitals There is a large difference in both the numbers of inpatients and outpatients between Champasak Provincial Hospital and other three provincial hospitals: Champasak Provincial Hospital puts emphasis on impatient treatment and other provincial hospitals have emphasis on outpatient treatment. When comparing these four provincial hospitals in terms of the number of inpatients per bed: The number for Salavan Provincial Hospital is small and Attapeu Provincial Hospital has a surplus. There is a large difference among district hospitals in terms of past records. A comparison of the number of inpatients per bed shows there are some district hospitals putting emphasis on outpatient treatment and other district hospitals putting emphasis on inpatient treatment. 2) Current status of referral system in the four southern provinces Patients of district hospitals are referred to Champasak Provincial Hospital by way of the provincial hospital of each province. Common reasons for referral found