Human resources for health country profiles: Lao People's Democratic Republic, World Health Organization

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Content: 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) © World Health Organization 2013 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce or translate WHO publications ­whether for sale or for non-commercial distribution­ should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/ copyright_form/en/index.html). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, fax: +632 521 1036, e-mail: [email protected] The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
Table of contents
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, 2008­2011
28
Annex F. Number of graduates by year, 2008­2011
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, 2009­2010
16
Table 10. Sources of health funds, 2009­2010
16
Table 11. Functional distribution of health care expenditure, 2009­2010
16
Table 12. Expenditure disaggregated by function, 2009­2010
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, 2013­2020
21
List of figures
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 GGE GGHE HRH IMR IPD MA MDGs MMR MNCH MOHA OPD PACSA PHC PhD PIMS PPP PvtHE TB THE UHS
gross domestic product general government expenditure general government expenditure on health human resources for health infant mortality rate Inpatient Department medical associate, medical assistant Millennium Development Goals maternal mortality ratio maternal, neonatal and child health Ministry of Home Affairs Outpatient Department Public Administration and Civil Service Authority primary health care Doctorate Personnel Information Management System purchasing power parity private health expenditure Tuberculosis total health expenditure University of Health Science
Lao People's Democratic Republic v
Acknowledgements
The Human Resources for Health Country Profile for the Lao People's Democratic Republic was developed by Khampasong Theppanya, Asmus Hammerich and Valeria de Oliveira Cruz, with assistance from Simone Phillips in the Office of the WHO Representative in the Lao People's Democratic Republic and Inseok Lee, an intern in the Human Resources for Health team at the WHO Regional Office for the Western Pacific.
The Human Resources for Health Country Profiles in the Western Pacific Region are prepared under the logistical and editorial support of the WHO Western Pacific Regional Office Human Resources for Health unit and coordinated by a team composed of Gulin Gedik, Rodel Nodora, Jose Aguin and Dyann Severo.
vi Human Resources for Health Country Profiles
1. Introduction
1.1 Demographic, social and political background
The estimated population of the Lao People's Democratic Republic in 2011 was 6 385 057, according to the Lao Statistics Bureau, with a registered annual population growth in 2010 of 1.44%. The country has a sparse population density (27 people per square kilometre), with large interprovincial variations and an average household size of 5.9 people. The population is young, but there are signs of changes in the demographic structure: the percentage of the population under 15 years of age decreased from 42.3% to 34.5% between 2000 and 2010. The population is mainly concentrated in rural areas, but a rural-to-urban shift is beginning to take place as the estimated percentage of the population living in rural areas decreased from 78% to 67% between 2000 and 2010. The Lao population has a balanced sex ratio of 50% for each sex, and life expectancy at birth increased from 53 in 2000 to 62 in 2010 (see Figure1).
Figure 1. Population trends
100
90
80
78 73
70
67
60
50 40
42 39 35
30
20
10
0 % Population
% Population
under 15 years old living in rural areas
62 53 N/A Life expectancy at birth (years)
2000
2005
2010
N/A, not available. Source: World Bank, 2012. The Lao People's Democratic Republic is a singleparty, socialist republic with an ethnically diverse population; the official language is Lao. Sixty-seven per cent of the Lao people are Theravada Buddhists, and 1.5% are Christian. The remaining 31.5% follow non-Buddhist local religions (Encyclopaedia Britannica, 2012).
The geography is largely mountainous, with lowland areas along the Mekong River that provide land for paddy rice cultivation and highland areas where upland rice production and the gathering of nontimber forest products are the main sources of livelihoods. The mountainous topography makes the construction of railway system impossible, and as a result, the Mekong River is an important artery for transportation. Because of these geographic conditions, access to hospitals and health services in the Lao People's Democratic Republic is very difficult, especially for the people living in rural areas. 1.2 Current economic situation and macroeconomic indicators The Lao People's Democratic Republic is on an increasingly sustainable growth pathway. Reforms under way have reduced poverty and stimulated growth. The real gross domestic product (GDP) growth rate increased from 6% in 2000 to 9% in 2010, while the registered GDP per capita in 2010 was US$ 1077 (Lao Statistics Bureau, 2012). As a result, the Lao People's Democratic Republic is now a lower-middleincome economy (World Bank, 2013). The Lao People's Democratic Republic recommitted in its Seventh FiveYear National Socio-economic development Plan (2011­2015) to achieving the Millennium Development Goals (MDGs) by 2015, and graduating from the group of least-developed countries by 2020. Government revenue collection has been rising slowly in recent years but remains very low, estimated at 14.6% of GDP in 2008. Nonetheless, the budget deficit has declined and the the flexibility of the Government to decide its spending choices has widened. In 2007, the collection of taxes and revenues was recentralized by a decree by the Prime Minister. However, budget and state audit laws still need to be fully enforced (WHO Western Pacific Regional Office, 2011). The Lao People's Democratic Republic ranked 138 out of 187 nations on the Human Development Index in 2011, just ahead of Cambodia. Literacy rates have improved in the last decade, attaining 73% in the population above 15 years of age in 2005, compared with 60% in 1995, showing, however, a considerable gap between sexes (83% male, 63% female). School 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 (United Nations Development Programme, 2011). However, boys still have a higher attendance rate than girls. The population below the poverty line fell from 46% in 1993 to 26% in 2010. Poverty is higher in remote and highland areas and inversely correlates with road or river access. Based on international purchasing power parity (PPP) standards, 24.8% of the population was living on less than US$ 2 a day and 33.9% on less than US$ 1.25 a day in 2008. Inequalities remain significant, with the share of the national economy of the lowest and the highest quintiles being 7.6% and 45%, respectively. Proxy indicators of poverty, such as access to sanitation and electricity, also reflect the population's vulnerability. The latest Lao reproductive health Survey found that, in 2005, 50% of households had no toilet and over 40% had no electricity. Disparities between urban and rural areas are still pronounced. For example, while 90% of urban households have electrical power, only 43% of rural households have access to electricity, and 11% of people living in rural areas have no road access, according to the Lao Statistics Bureau (Central Intelligence Agency, 2012). 1.3 Summary of health indicators
are common colds, (14.6% of total OPD patients) and tonsillitis and pharyngitis (10.5%), as shown in Table 1. The most frequent causes for Inpatient Department (IPD) cases are gynaeco-obstetrics (15.8% of total IPD patients), followed by diarrhoea (9.9%) and digestive system problems (9.5%) (Ministry of Health, 2012). Tuberculosis (TB) is also one of the most prevalent causes of health problems. In 2008, the TB prevalence rate was estimated at 260 per 100 000 people. Life expectancy at birth rose from 53 years in 2000 to 67.5 years in 2011. This improvement is due mainly to the decreases in maternal mortality, infant mortality and under-five mortality. The maternal mortality ratio (MMR) plummeted from 1200 maternal deaths per 100 000 live births in 1990 to 357 maternal deaths per 100 000 live births in 2012. In addition, the infant mortality rate (IMR) decreased from 142 to 68 deaths per 1000 live births, and the under-five mortality rate dropped from 213 to 73 per 1000 live births between 1970 and 2010 (Lao Social Indicator Survey, 2011­2012 and the United Nations Inter-Agency for Child Mortality Estimation, 2012). Despite these improvements, there are big geographical disparities in these indicators. As an example, in 2005, while the IMR was 18 per 1000 live births in Vientiane capital, Sekong province recorded an IMR of 122 per 1000 live births.
The main causes of mortality in the Lao People's Democratic Republic are (listed by number of deaths): malaria, pneumonia, diarrhoea, heart failure and injury (World Health Organization, 2011). The most common cause of Outpatient Department (OPD) visits
According to the Lao Reproductive Health Survey 2007, only 28.5% of women sought antenatal care and 18.5% of deliveries were being attended by trained birth attendants during the reference year. Eightyfour 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 Tonsillitis, pharyngitis
14.6% 10.5%
Digestive system Nervous system, non-psychiatric Pneumo-bronchitis Diarrhoea, no blood, no severe dehydratation Minor surgery Road traffic injury Gynaeco-obstetrics Trauma, all other Others Source: National Health Statistic Report, 2010­2011.
7.7% 6.0% 5.4% 5.4% 4.6% 3.5% 2.7% 2.6% 39.7%
Gynaeco-obstetricts Diarrhoea, no blood, no severe dehydratation Digestive system Otitis Pneumo-bronchitis Common cold Road traffic injury Urology Trauma, all other Nervous system, non-psychiatric Others
15.8% 9.9% 9.5% 6.4% 5.3% 4.2% 4.1% 3.0% 2.6% 2.1% 37.1%
2 Human Resources for Health Country Profiles
Compounding this is that only 32% of children aged 12 to 23 months were fully immunized. This has improved compared to 2000, but there is a need to step up efforts to resolve this issue (Somchith, 2009). 1.4 Health system The main health-care delivery system of the Lao People's Democratic Republic is a government-owned, public system that operates health centres and district and provincial hospitals. The Lao People's Democratic Republic's public health system has a strong vertical structure and is divided into three main arms: · health care; · prevention, promotion and disease control; and · health management and administration.
Department of Communicable Disease Control, University of Health Science); · Provincial level: Provincial Health Offices, regional hospitals, provincial hospitals, provincial nursing schools; · District level: District Health Offices, district hospitals, health centres. Under the Ministry of Health, there are four central hospitals, four regional hospitals, 12 provincial hospitals, 130 district hospitals, 894 health centres and around 5000 village drug dispensaries (see Table 2). There are around 5000 hospital beds in the country. Each health centre covers about 7000 people, but many centres serve fewer than 1000 (Ministry of Health, 2011).
The public health system is organized into three administrative levels (Ministry of Health, 2007): · Central level: Ministry of Health Steering Commit- tee (Department of Hygiene and Prevention, Department of Finance, Department of Planning and International Corporation, Department of Inspection, Cabinet, Department of Organization and Personnel, Department of Education and Research, Department of Curative Service, Food and Drug Department,
Although there are no private hospitals in the Lao People's Democratic Republic, the private sector for health is expanding, mainly in urban areas, with 1993 private pharmacies, 222 private clinics and 600 traditional medicine practitioners (Ministry of Health, 2011). There are some regulations on private health facilities and the involvement of health personnel in the private sector. However, the implementation 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 Public sector Village drug dispensaries
Number
Characteristics
5000
Provide maternal, neonatal and child health (MCNH) package of essential services: health information, including family planning and nutrition supplements.
Health centres District hospitals Provincial hospitals Regional hospitals Central hospitals Special treatment centres Private sector Clinics Pharmacies Hospitals Source: Ministry of Health, 2010.
Provide outreach package of MCNH interventions, including immunization, deworming, vitamin A supplementation, health promotion with a focus on nutrition, and skilled delivery care. 894 Provide MNCH services, as well as community and outreach services. 130 Provide health promotion, disease prevention, diagnosis and treatment. 12 Provide treatment and rehabilitation services. 4 Provide curative health-care services at the regional level as well as health care for the entire population of the region. 4 Provide tertiary curative care. 3 Provide dermatology, ophthalmology and rehabilitation.
222 1993 0
Mainly in urban areas. There are 647 applications waiting for approval. Mainly in urban areas. No private hospitals.
Lao People's Democratic Republic 3
health personnel are directly or indirectly involved in private health practice after official working hours. Since the introduction of a market economy two decades ago, the national health sector has gradually made good progress in terms of the quantity and quality of service. However, the health sector still has some constraints and faces great challenges that must be addressed. A majority of the Lao population, particularly in rural, remote and mountainous areas, lacks adequate access to basic health care. Therefore, it is of critical importance to solve these problems by reforming the national health system to make it more effective, efficient, equitable and sustainable. Since early 2012, the Ministry of Health, under the
leadership of the Prime Minister and with support from World Health Organization and other development partners, has undertaken a series of consultations to discuss how the Lao health sector needs to be reformed to achieve the health-related MDGs by 2015 and universal health coverage by 2025. Following these consultations and discussions, a reform strategy has been developed to set out short-, middle- and long-term visions, strategies and milestones for further developing the national health sector in the Lao People's Democratic Republic. In December 2012, the National Assembly approved the National Health Sector Reform Strategy.
2. Health workforce supply and trends
An understanding of the local health worker classification system is necessary in discussing the health professions education system in the Lao People's Democratic Republic. Lao health workers are separated into four major levels: postgraduate level, bachelor level, high level and middle level. Table 3 shows detailed classification of health professions in the Lao People's Democratic Republic. The fact that
are only three different types of nurses based on educational background. For example, a bachelorlevel nurse and graduate nurse both have bachelor's degrees after four years of training and therefore have the same professional standing. Likewise, high-level nurses, associate nurses and registered nurses all have equivalent credentials and need not be distinguished professionally.
Table 3. Classification of health workers
Medical related
Postgraduate level
Bachelor level
Medical doctor
Nurse
Midwife
Dental staff
Pharmacy staff
Laboratory staff
Others
Specialist level 1*, Specialist level 2**, Master level, PhD
Graduate nurse
Graduate midwife
Dentist
Pharmacist
Laboratory technician
Physical Therapist
High level
Medical associate
Associate/ registered nurse
Registered midwife
Hygienist, physical therapist, X-ray
Middle level
Medical assistant
Technical nurse
Community Dental midwife assistant
Pharmacist assistant
Laboratory assistant
Primary health care 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 creates a source of confusion in classifying health professionals within the LAO system. For instance, seven different titles designate the role of nurse: bachelor-level nurse, high-level nurse, middle-level nurse, graduate nurse, associate nurse, registered nurse and technical nurse. However, in reality there
In the Lao People's Democratic Republic, education for low-level workers has been discontinued. However, a number of low-level health workers still exist. Current low-level workers should upgrade their credentials through continuing education. The Lao People's Democratic Republic suffers from a critical shortage 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
Health professional category/cadre
Number
Health workers/1000 population
PhD (physician) PhD (pharmacist) Master (physician) Master (dentist)
35
0.01
-
-
391
0.07
-
-
Master (pharmacist) Master (laboratory) Master (nurse/midwife) Master (other*) Specialist 2 (physician)
-
-
-
-
-
-
-
-
9
0
Specialist 1 (physician) Medical doctor MA (Medical associate, medical assistant) Bachelor/high-level nurse Technical nurse
206 1169 1496 113 738
0.03 0.2 0.25 0.02 0.12
Community midwife Midwife Laboratory (bachelor) Laboratory assistant Pharmacist (bachelor)
0
0
388
0.06
31
0.01
466
0.08
357
0.06
Pharmacist assistant Dentist (bachelor) Dentist assistant Hygienist
586
0.1
171
0.03
109
0.02
321
0.05
Physiotherapist X-ray technician Low-level nurse and nurse-midwife Middle-level primary health care worker Low-level primary health care worker
272 0 3948 0 244
0.05 0 0.66 0 0.04
Support and logistic staff
963
0.16
Public health (high)
N/A
N/A
Total
12 013
2
* Non-health profession related masters. Source: Department of Organization and Personnel, Ministry of Health, March 2012.
2012
Number
Health workers/1000 population
35
0.01
3
0
381
0.06
31
0
46
0.01
8
0
13
0
8
0
20
0
312
0.05
1233
0.19
1375
0.21
166
0.03
1774
0.27
338
0.05
120
0.02
70
0.01
490
0.07
473
0.1
667
0.1
194
0.03
96
0.01
482
0.07
284
0.04
32
0
3629 132
0.56 0.02
320
0.05
1434
0.22
23
0
14 189
2.17
population density (see Table 4). Compared with 2008 data (2.00 health workers per 1000 population), there has been a small increase in the number of health workers in the public health sector, which serves as the major implementer of health services.
Low-level nurses (auxiliary nurses) made up the largest group of health providers from 2008 to 2012 (see Table 4). Education for low-level health workers, however, was discontinued and as a result, the number 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
Specialist 1 Specialist 2 Medical doctor Pharmacist (bachelor) Dentist (bachelor) Laboratory (bachelor) Nurse (high/bachelor) Medical assistant Community midwife (middle) Technical nurse (middle) Pharmacist Pharmacist assistant Laboratory assistant Hygienist Physiotherapist Primary health care worker (low) Midwife (low) Nurse (low) Nurse-midwife (low) Support and logistic staff Total
Province
Attapue
- - 2- - - - - -
48 1 - - - 1 7 - 11 - 13 83
Bokoe
- - 42- - - - -
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
- - 42- - 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
- - 13 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
- - 35- - - - -
49 6 - 2 4 3 - - - - 32 104
Vientiane capital
- - 14 2 4 - - 2 3 20 7 - 9 39 9 - -
3 - 24 136
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 decreasing trend in the number of low-level nurses and low-level midwives. From 2004, the Ministry of Home Affairs (MOHA) officially stopped hiring contractual health staff. However, currently, there are four different kinds of contractual staff in the health sector (see Table 5):
official contractual workers hired before 2003, paid hospital workers, workers paid by donor funds, and volunteers. The central, provincial and district hospitals continue to have a workforce shortage problem, so they continue to hire contractual workers directly. Most of the contractual staff are hoping to become permanent staff.
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 workforce due to a large number of nurses and midwives. In these categories, women are more numerous than men (see Figure 2). Women tend to make up more than half of the personnel among the low- and middle-level workers, including laboratory specialists, pharmacists and dental assistants.
Overall, nurses and midwives are a young workforce, with 45% of them below 30 years of age. Dentists also represent a young group, with those aged 30­39 years making up almost half (46%) of the total number of dentists. The largest share of other categories displayed in Figure 3 (physicians, pharmacists and
Figure 2. Gender distribution by professional category/cadre (%), March 2012
Laboratory specialist Physician Dentist Pharmacist Nurse/midwife 0%
37 43 46
63 57 54
% Male % Female
54 46
29 29
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%
40%
39
30%
28
23
20%
10% 8 3 0% Physician
45
28 24
35 31 20 13
3 0 Nurse/midwife
1 Pharmacist
29
10
4
3
Laboratory specialist
46 29
12
10
2
Dentist
30­39 40­49 50­59 >60
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
Vientiane Capital Phonsaly Luangnamtha Oudomsay Bokoe Luangprabang Huaphan Saiyabury Xiengkhuang Vientiane Bolikhamsai Khammuane Savannakhet Salavan Sekong Champasack Attapue Total
Health professional group/cadre
PhD (physician)
33 ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ 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 ­ ­

46
Master (labolatory)
7­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­

8
Master (nurse/midwife)
11 ­ ­ 1 ­ 1 ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­
13
Master (other)
8­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­
8
Specialist 2 (physician)
15 ­ ­ 1 ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­

20
Specialist 1 (physician) 173 2 7 10 3 11 7 16 8 6 8 12 4 8 5 28 4 312
Medical doctor MA (medical associate, medical assistant) Bachelor/Higher nurse
511 19 32 41 25 34 20 53 37 100 45 55 87 40 23 71 40 1233 151 46 27 46 24 176 57 93 23 85 50 73 207 65 32 180 40 1375 83 1 3 6 2 8 8 3 6 3 1 14 6 4 4 12 2 166
Technical nurse Community midwife
413 59 56 74 66 84 69 72 73 151 59 82 170 83 65 84 114 1774 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 Low-level nurse and nurse-midwife Middle-level primary health care worker Low-level primary health care worker Support and logistic staff
15 ­ 217 141 17 ­ 20 623 40
13 88 183 12 11 43 45 36 40
1 1 1 1 1 ­ ­ 6 1 1­ 94 365 152 236 150 271 149 337 541 212 96 1 1 12 13 15 1 3 10 2 3 15 34 43 30 13 24 ­ 2 2 17 46 ­ 24 35 49 51 58 65 51 58 82 51 39
­­ 326 71
11 14
­
1
60 72
32 3629 132 320 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 40­49 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 the Lao People's Democratic Republic is 60 for males and 55 for females. However, there continues to be a number of medical associates and low-level nurses over 60 still employed, as it is very hard to recruit
3.3 Geographical distribution Geographical maldistribution of staff in the Lao People's Democratic Republic is a problem (see Table 6 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 Technical nurse (middle)
39 47
61 53
Dentist
67
33
Medical doctor
74
26
Pharmacist
78
22
Medical specialist Bachelor/high-level nurse
91
9
93
7
Laboratory (bachelor) 0%
94
6
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 are centralized in urban areas; only 5% of bachelor/ higher nurses, 4% of bachelor laboratory workers, 22% of pharmacists and 28% of dentists work in rural areas. 3.4 Distribution of health workers by urban/rural area As seen in Figure 4, the majority of highly skilled workers are located in urban areas, while rural
areas have the largest share of low-level nurses and midwives. The vast majority of medical specialists (91%) are based in urban areas, as are similar percentages of bachelor/high-level nurses (93%) and bachelor-level laboratory workers (94%). Only 26% of medical doctors are working in rural areas. Overall, the density of medical doctors, bachelor/high-level nurses, pharmacists and dentists found in rural areas is one-tenth of the density in urban areas (see Annex D).
4. Health professions education
4.1 Structure of health education institution The Department of Training and Research of the Ministry of Health is primarily responsible for education in the health professions. This department supervises all education and in-service training. Therefore, all health-related educational facilities are under the control of this department (Ministry of Health, 2007). Until 2007, there were three education providers for health workers: the Faculty of Medical Science, the College of Health Technology and nursing schools. At that time, the Ministry of Education was responsible
for the Faculty of Medical Science of the University of the Lao People's Democratic Republic, which became part of the National University of the Lao People's Democratic Republic in 1996. Since 2008, however, the Faculty of Medical Science and the College of Health Technology have been combined under the University of Health Science (UHS) under the Ministry of Health. Therefore, in 2012, there were two education providers for health workers: UHS and nursing schools. UHS produces seven training programmes: basic science, dentistry, medical technology, medicine, nursing, pharmacy and postgraduate studies. There
Lao People's Democratic Republic 9
are eight provincial nursing schools located in Champasack, Khammuane, Luang Prabang, Oudomsay, Salavane, Savannakhet, Vientiane and Xien Khung. Nursing schools provide nursing and midwifery training programmes. 4.2 Training of health professionals Specialists (Postgraduate level) There are nine specialty training programmes: anesthesia/intensive and emergency care, cardiology, family medicine, general surgery, internal medicine, medical imaging and radiology, obstetrics and gynaecology, ophthalmology and paediatrics. UHS in Vientiane provides educational preparation for professionals to enter all programmes. Entry requirements include: a graduate degree (bachelor of medicine), under 45 years of age, more than three years of experience, passing an entrance examination and a recommendation. The specialist training programme lasts for three years and graduates receive a postgraduate degree upon completion (specialist 1 or specialist 2). Medical related Medical doctors (bachelor level): Medical doctors are trained at UHS in Vientiane. The training of doctors began in 1968. Only the upper-secondary school graduates who qualify in the entrance examination can begin training. The training course lasts for six years and graduates receive a bachelor's degree in medicine. Medical associate (high level): The education of medical associates (high level) is provided at any one of three institutions (Health Science College in Champasack, Luangprabang and Savannakhet provinces) and lasts for three years for direct entry and two years for continuing education. Entry requirements of direct entry are upper-secondary school diploma and passing an entrance examination, and for continuing education, medical assistant level, under 40 years of age and more than three years of experience. Graduates get a high-level diploma. Medical assistant (middle level): This group is trained at the school of public health in Salavane and Savannakhet provinces, and the course lasts two years for direct entry and 18 months for continuing education. Entry requirements for direct entry are upper-secondary school diploma and passing an entrance examination. For continuing education the entry enrollees can be low-level medical staff,
primary health care workers, upper-secondary school graduates and must pass an entrance examination. Graduates get a middle-level diploma. Nurse: There are multiple categories of nurses in the Lao People's Democratic Republic. Auxiliary (lowlevel) nurses are the largest group and may have been trained anywhere from three months to two years. However, there have been no training courses for auxiliary (low-level) nurses since 2003. The two-year nursing schools have been upgraded to two and a half years of training and their graduates are now considered technical, or middle-level, nurses. Graduate nurse (bachelor-level nurse): Graduate (bachelor-level) nurses are trained at the Faculty of Nursing at UHS in the Vientiane capital. Applicants for direct entry need to be upper-secondary school graduates and should pass the entrance examination. Training lasts for four years and graduates receive a bachelor's degree. Applicants for continuing education face more requirements than direct entry. They should be under 45 years of age, with more than three years of experience as a registered nurse. Training for continuing education lasts for two years, including four months for a "bridge" course. All graduates get a bachelor's degree. Associate nurse/registered nurse (high-level nurse): Education for associate/registered (high-level) nurses is provided at one of four provincial nursing schools: the Faculty of Nursing at UHS in the Vientiane capital and the College of Health Science in Champasack, Luangprabang and Savannakhet provinces. All applicants are upper-secondary school graduates and should pass the entrance examination. This course lasts for three years and graduates receive a diploma. Technical nurse (middle-level nurse): Technical (middle-level) nurses are trained at one of eight provincial nursing schools for two and half years: the Faculty of Nursing at UHS in Vientiane capital, College of Health Science in Champasack, Luangprabang and Savannakhet provinces and the Public Health School in Khammuan, Oudomxay and Xiengkhuang provinces, and the Vientiane Nursing School). Entry requirements call for completion of upper-secondary education and passing an entrance examination. Midwife Graduate midwife (bachelor-level midwife): Training for graduate (bachelor-level) midwives is provided at 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 successful completion of an entrance examination. Graduates receive a bachelor's degree. Registered midwife (high-level midwife): Registered (high-level) midwives are trained at the Faculty of Nursing at UHS in Vientiane. Training for direct entry lasts for three years and continuing education for one and a half years. Entrance requirements of direct entry are upper-secondary graduation and the successful completion of an entrance examination. Technical (middle-level) nurses and community (middle-level) midwives can apply via continuing education. They should be younger than 40 years and have at least three years of experience, with a recommendation. Graduates receive a high-level diploma. Community midwife (middle-level midwife): Community (middle-level) midwives are trained at one of six provincial schools (College of Health Science in Champasack, Luangprabang and Savannakhet provinces, the Public Health School in Khammuan and Xiengkhuang provinces, and Vientiane Nursing School). Training for direct entry lasts for two years and continuing education for a year. Entry requirements of direct entry include graduation from an upper-secondary school and an entrance examination. Applicants to continuing education must be auxiliary (low-level) nurses, under the age of 40 years, with more than three years of experience and a recommendation. Dental staff Dentist (bachelor-level): Dentists are trained at the Faculty of Dentistry at UHS in Vientiane for six years after upper-secondary school and the completion of the entrance examination. Graduates receive a Bachelor of Dental Surgery degree. Pharmacy staff Pharmacist (bachelor level): Pharmacists are trained at the Faculty of Pharmacy at UHS in Vientiane for five years after upper-secondary school and completion of the entrance examination. Graduates get a bachelor's degree in pharmacy. Pharmacy assistant (middle level): The Faculty of Pharmacy at UHS in Vientiane oversees the training of pharmacy assistants. The programme provides training for three years after upper-secondary school and an entrance examination. Graduates get a middlelevel diploma.
Laboratory staff Laboratory technician (bachelor level): Laboratory technicians are trained at the Faculty of Medical Technology at UHS in Vientiane for four years for direct entry and two and a half years via continuing education. Entry requirements for direct entry are completion of upper-secondary school and an entrance examination. Requirements for continuing education are a high-level degree in medical laboratory studies for Government employees with at least five years of experience and an entrance examination. Graduates receive a bachelor's degree in medical laboratory studies. Laboratory assistant (middle level): Training of laboratory assistants takes place at the Faculty of Medical Technology at UHS in Vientiane for three years after upper-secondary school and an entrance examination. Graduates receive a middle-level diploma. Others Physical therapist (bachelor level): Physical therapists are trained via continuing education at the Faculty of Medical Technology at UHS in Vientiane for two years. High-level physical therapists with at least five years of experience can enter this course. Graduates receive a bachelor's degree in physical therapy. Physical therapist (high level): Training via direct entry is offered at the Faculty of Medical Technology at UHS in Vientiane for three years after upper-secondary school and an entrance examination. Graduates receive a high-level degree. Primary health care workers: The training of primary health care workers began in 2002 in the northern part of the country. There are five schools offering training in Champassak, Oudomxay, Khammuane, Luangprabang and Savannakhet provinces. Primary health care workers are lower-secondary school graduates who train for three years. They are selected from rural and remote locations, with the intention that they will provide services in their home areas. Saravane and Xieng Xhuan provinces also have training centres for primary health care workers. They are assigned to health centres in priority northern provinces. Table 7 provides an overview of the public health professions training institutions. There are no private health professions institutions providing training in the Lao People's Democratic Republic.
Lao People's Democratic Republic 11
Table 7. Number of training institutions by specialty
PhD Master Specialist 2 Specialist 1 Medical doctor MA (medical associate, medical assistant) Bachelor/high-level nurse Technical nurse Community midwife Midwife (low) Laboratory (bachelor) Laboratory assistant Pharmacist (bachelor) Pharmacy assistant Dentist (bachelor) Dentist assistant Hygienist Physiotherapist X-ray technician Low-level nurse and nurse-midwife Middle-level primary health care worker Low-level primary health care worker Support and logistic staff Public health (high) Total
1 1 1 1 1 Associate 3 Assistant 2 Bachelor 1 high-level 4 8 6 0 1 1 1 1 1 0 1 1 1 0 5 0 0 1 9
Source: Department of Organization and Personnel, Ministry of Health, March 2012.
4.3 Overall cost of training/education per graduate The Department of Organization and Personnel at the Ministry of Health estimates the training cost at UHS (medicine, dentistry, nursing, pharmacy, medical technology, basic science and postgraduate studies) at around US$ 1500 per year. Training costs in the eight provincial nursing schools (nursing and midwifery training programmes) are around $1200 per year. 4.4 In-service and continuing professional education According to the Lao People's Democratic Republic Law on Health Care--Article 34, In-service Training, all health-care professionals in the Lao People's Democratic Republic are required to continuously improve their knowledge and skills and take part in training activities and evaluation of their professional practices in order to improve the quality of their consultations, diagnoses and care, and to keep abreast of the latest scientific progress, for the interests and safety of patients. Also, the medical profession Council has the right and duty to assess and evaluate in-service training at least once every two years, in accordance with the instructions of the Ministry of Health. Although the Lao People's Democratic Republic regulates continuing professional education by law, it has not yet been implemented. However, the Government is developing guidelines and is determined to implement continuing professional education.
The number of entrants has decreased in recent years (2008­2011) 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 (2008­2011).
Annexes E and F show the total number of entrants and graduates per category (2008­2011).
12 Human Resources for Health Country Profiles
Figure 5. Number of entrants per year in health professions education institutions, for selected categories (2008-2011)
1400 1200
1214
1000
800 693
600
397 400
318 200
86
0
0
2008
638 370 290 275 0 2009
761 464 190 114 0 2010
666 169 126 59 2011
Medical doctor Midwife
Medical assistant Pharmacist
Nurse
Figure 6. Number of graduates per year in health professions education institutions, for selected categories (2008-2011)
1000 900 800 700 600 500 400 300 200 100 0
897
624
646
669
150 100 208 2008
203 171 60 0 2009
202 192 124 40 2010
Medical doctor Midwife
Medical assistant Pharmacist
364 160 63 2011 Nurse
Note: "Nurses" comprises bachelor nurse, technical nurse and highlevel nurse. "Pharmacists" comprises pharmacists and pharmacist assistants. Source: Department of Organization and Personnel, Ministry of Health, March 2012.
Note: "Nurses" comprehends bachelor nurse, technical nurse and higher nurse. "Pharmacists" comprehends pharmacists and pharmacy assistants. Source: Department of Organization and Personnel, Ministry of Health, March 2012.
5. Human resources for health (HRH) utilization
5.1 Recruitment Every April and October, an HRH quota is fixed by the Prime Minister's Cabinet, the Ministry of Home Affairs and the Ministry of Finance (see Table 8). The Division of Personnel at Department of Organization and Personnel then requests that Ministry of Home Affairs allocate a number of health workers and non-medical workers to fill needed positions. After Department of Organization and Personnel receives a number of employees as designated by the quota, Department of Organization and Personnel is responsible for the allocation of this quota at all administrative levels: central, provincial and district, as well as health centres. However, currently the quotas are not sufficient to address the shortage of health workers and are not even enough to absorb those already trained. An increase of the quotas by the Government would allow the recruitment of the available health workforce into
the system and would help to some extent solve the shortage of the staff in the health sector. There have been positive signs of commitment from Ministry of Home Affairs to increase significantly the quotas in the next few years to meet the needs of service delivery. All persons eligible for recruitment should meet the following criteria (Prime Minister's Office, 2003): Lao nationals or those who have acquired and held Lao citizenship for three or more years; are 18 to 35 years of age; comply with the law and the Decree on civil service; are good citizens with no criminal record and no history of dismissal; submit an accurate description of personal and family details; are physically fit and healthy as certified by state hospitals; have qualification awarded by recognized educational institutions; meet all the criteria required by the workplaces concerned.
Lao People's Democratic Republic 13
Table 8. Approved HRH quotas, March 2012
Category
2008
2009
Master
0
3
Specialist 1
18
15
Medical doctor
30
40
MA (medical associate, medical assistant)
12
18
High-level nurse
0
0
Technical nurse
127
152
Laboratory (bachelor)
0
0
Laboratory assistant
18
20
Pharmacist
27
17
Pharmacist assistant
29
37
Dentist
11
15
Dentist assistant
2
0
Hygienist
32
33
Physiotherapist
12
16
Low-level nurse
61
39
Low-level primary health care worker
101
72
Midwife (low)
0
72
Nurse-midwife (low)
48
0
Middle-level primary health care worker
0
0
Support and logistic staff
81
85
Total
612
634
Source: Department of Organization and Personnel, Ministry of Health, March 2012.
2010 9 1 47 9 0 180 1 34 31 38 16 0 41 17 42 16 15 28 0 104 629
2011 0 4 106 28 2 408 0 48 47 56 17 0 62 19 14 0 0 54 63 133 1061
Grand Total 15 38 223 67 2 867 1 120 122 160 59 2 168 64 156 189 87 130 63 403 2936
5.2 Deployment and distribution policies and mechanisms The Lao People's Democratic Republic has a critical shortage and a maldistribution in its health workforce. There are 0.6 qualified health workers (physicians) per 1000 population, according to 2011 Ministry of Health data. The main challenges that contribute to the shortage and maldistribution of health workers in the Lao People's Democratic Republic are limited posts allocated by the Government to recruit health workers; the preference of health workers to work in urban areas with better salaries; the lack of professional career development opportunities; and graduates with inadequate preparation to work in rural areas, which may be attributable to insufficient training. The shortage of middle- and high-level health workers at primary and secondary health-care facilities leads to a major gap in the quality of healthcare services between urban and rural areas. To solve the above problems and to provide incentives to health workers to work in rural areas
(district and health-centre levels), the Ministry of Health and the Government have developed and endorsed a number of policies, decrees and regulations, starting in 2002: · 2002: The Ministry of Health's Health Strategy to the Year 2020 indicated a significant need to provide appropriate incentives for health workers in rural areas. · 2003: The Civil Service decree No. 82/PM stated that during the first five years, newly recruited health workers should work at least two years in rural areas. However, implementation of this decree has been insufficiently enforced. · 2010: Financial Incentive decree No. 468/PM was intended to provide salary bonuses of 30%, 40% and 50% of the regular salary to civil servants working in rural areas, including health workers. The implementation has not started due to delays in defining and classification of rural areas. · 2010: The Ministry of Health's Health Personnel Development Strategy by 2020 addressed five main areas for improvement: preparation of health personnel, utilization of health personnel, health
14 Human Resources for Health Country Profiles
personnel management, equity and quality, and incentives for health personnel. · 2011: The Ministry of Health's Ministerial Decree No. 103/MOH called for newly graduated medical students to agree to three years of compulsory service in rural health facilities. The decree also indicated the provision of non-financial incentives such as: direct promotions for permanent staff, eligibility for continuing education, and eligibility for the licensing examination. Including the latest decree, a number of policies, decrees and regulations have been endorsed. However, enforcement, implementation, monitoring and evaluation of these policies using updated, accurate HRH databases remain weak. Also, low salaries and low levels of motivation decrease health system 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).
5.3 Unemployment Even though the Lao People's Democratic Republic has a shortage of health workers, the country also faces the challenge of providing positions to trained professionals. This is a direct result of small quotas for recruiting health workers due to financial constraints in recent years. Thus, some graduates are not recruited and some of them offer their services as volunteers until they get a position. This period of unemployment may last up to a few years. Except for those positions that the Government no longer offers training (low-level nurses and primary health care workers), almost all of these groups have a large recruitment gap. Therefore, there are high levels of unemployment, especially among technical nurses, laboratory technicians and hygienists.
6. Financing HRH
6.1 Health expenditure
6.2 Remuneration to health workers
According to the National Health Account 2009­ 2010, total health expenditure (THE) was 2.5% of GDP, US$ 27.10 per capita (see Table 9). Private health expenditure (PvtHE) as a percentage of THE in 2009­ 2010 was 59.3%, while out-of-pocket expenditure on health comprised the majority of health spending (46.4% of THE). The general government expenditure on health (GGEH) amounted to 40.7% of THE and 4.1% of the general government expenditure (GGE). As Table 10 demonstrates, about 32% of health expenditure in the Lao People's Democratic Republic derives from nongovernmental organizations and donors; this reflects a high dependence on foreign aid and makes the Lao people vulnerable to shifts in aid spending. Table 11 shows a breakdown of THE by function and indicates that almost 50% is spent on curative services. Fourteen per cent of this amount is spent on inpatient care. As shown in Table 12, the expenditure for education and training of health personnel makes up only 2.6% of THE.
The salary of civil servants, including health workers, is regulated by Prime Minister's Decree No. 82/PM. The starting salaries of new staff are allotted according to their educational and professional qualifications. An initial proposal for the starting level and step-- each level has several steps based on accumulated experience--is made by the selection board at the central, provincial or district level--depending on who is recruiting. This proposal has to be approved by the Department of Organization and Personnel at the Ministry of Health and by the Ministry of Home Affairs. There is a probation period for all new staff, which increases with the level of posting, for instance, three months for low-level, six months for middlelevel and 12 months for high-level professionals. A final evaluation is made after this period. Based on this evaluation, a proposal for nomination is made to the Minister of Health by the recruitment committee of the corresponding professional level. Civil servants in the Lao People's Democratic Republic are classified by a five-level system (1, 2, 3, 4 and 5), and each level has 15 steps. Table 13 shows the entry levels classification. Table 14 shows the average monthly salary by health profession in the local currency.
Lao People's Democratic Republic 15
Table 9. National Health Account summary results, 2009­2010
Key indicators Total health expenditure (THE) Private health expenditure (PvtHE) Out-of-pocket expenditure on health Non-profit institutions serving households (e.g. donors not channelled through Government, nongovernmental organizations)
Kip (in billions) 1398.95 829.56 649.10
US$ (in millions) 169.87 100.74 78.82
180 459.05
21.91
General Government Expenditure on Health (GGEH)
569.30
69.13
Ministry of Health expenditure Social expenditure on health (SSHE)
510.46 39.54
61.99 4.80
Domestic government expenditure on health
278.87
33.86
Domestic government recurrent expenditure on health Domestic government non-wage recurrent expenditure on health External resources for health Source: National Health Account 2009­2010, 2011.
244.30 71.03 445.56
29.67 8.63 54.11
US$ per capita at average Exchange Rate 27.1
% 2.5%
16.1
59.3%
12.6
78.2% 46.4%
21.8%
3.5 12.9%
of GDP THE PvtHE THE PvtHE THE
11.0 9.9 0.8 5.4 4.7 1.4 8.6
4.1% 40.7%
GGE THE
1.0%
GDP
89.7%
GGHE
6.9%
GGHE
3.0% Domestic GGE
19.9%
THE
0.5%
GDP
4.2%
Domestic recurrent GGE
Domestic 2.9% non-wage recurrent GGE
31.9%
THE
Table 10. Sources of health funds, 2009­2010
Sources of health funds Ministry of Finance Other private funds Households Nongovernmental organizations and donors Total
Kip (in billions) 278.87 3.84 670.58 445.56 1398.85
Source: National Health Account 2009­2010, 2011.
% 19.9% 0.3% 47.9% 31.9% 100%
Table 11. Functional distribution of health care expenditure, 2009­2010
Function Services of curative care Ancillary services to health care Medical goods dispensed to outpatients (including pharmaceutical products) Prevention & public health services Health administration & health insurance Health-related Functions1 Total Source: National Health Account 2009­2010, 2011.
Kip (in billions) 677.35 33.50 306.80 70.04 53.68 257.49 1398.85
% 48.4% 2.4% 21.9% 5.0% 3.8% 18.4% 100%
US$ (in millions) 33.86 466.45 81.43 54.11 169.87
US$ per capita 5.41 0.07 13.01 8.64 27.14
US$ (in millions) 82.25 4.07 37.25 8.50 6.52 31.27 169.87
US$ per capita 13.14 0.65 5.95 1.36 1.04 5.00 27.14
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, 2009­2010
Function Inpatient curative care Outpatient curative care Clinical laboratory Diagnostic imaging Patient transport and emergency rescue Traditional healers Medical goods dispensed to outpatients Maternal and child health, family planning and counselling School health services Prevention of communicable diseases Prevention of noncommunicable diseases All other miscellaneous public health services Health administration and health insurance Capital formation of health-care provider institutions Education and training of health personnel Research and development in health Food, hygiene and drinking-water control programme Others
Kip (in billions) 315.16 315.25 1.61 0.46 31.43 46.94 306.79 38.95 10 8.85 9.93 2.31 53.68 190.64 36.25 27.52 2.53 0.55
Total
1398.85
Source: National Health Account 2009­2010, 2011.
% 22.5% 22.5% 0.1% 0.0% 2.2% 3.4% 21.9% 2.8% 0.7% 0.6% 0.7% 0.2% 3.8% 13.6% 2.6% 2.0% 0.2% 0.0% 100%
US$ (in millions) 38.27 38.28 0.19 0.05 3.81 5.70 37.25 4.73 1.21 1.08 1.21 0.28 6.52 23.15 4.40 3.34 0.30 0.068 169.87
US$ per capita 6.11 6.12 0.03 0.01 0.61 0.91 5.95 0.76 0.19 0.17 0.19 0.04 1.04 3.70 0.70 0.53 0.05 0.01 27.14
Table 13. Entry level groups classification No education Low-level education (e.g. high school) Mid-level education certificate (minimum three-year course) High-level certificate (minimum three-year course) Bachelor's degree certificate Intermediate graduate diploma Master's degree or equivalent Higher-level graduate diploma (higher than Master's but not PhD) Doctorate (PhD) Senior high-ranking staff (e.g. Minister) Source: Department of Organization and Personnel, Ministry of Health, March 2012.
Level 1 Level 2 Level 3 step 3 (3/3) Level 4 step 1 (4/1) Level 4 step 2 (4/2) Level 4 step 3 (4/3) Level 4 step 5 (4/5) Level 4 step 6 (4/6) Level 4 step 7 (4/7) Level 5
Average monthly salaries of other civil servants such as lawyers, teachers or police are also calculated based on their education level. Therefore, for instance, the average monthly salary for both a bachelorlevel medical doctor and bachelor-level teacher is 1 165 216 kip (see Table 14). 6.3 Health workers incentives The Government of the Lao People's Democratic Republic is trying to implement both financial and non-financial incentive schemes to retain and promote health workers. The Ministry of Health's consideration
of the incentive system is detailed in the Health Personnel Development Strategy by 2020. The following are financial and non-financial incentives that the Ministry of Health is committed to provide to health workers. · Improve and implement remuneration of health workers in keeping with the cost of living, socioeconomic development, knowledge and skills, better performance and work achievement. · Benefits may include higher salary, health insurance, pension and other social benefits; gasoline expenses, house rental fee, nursery care fee, trans-
Lao People's Democratic Republic 17
Table 14. Average income by category cadre, March 2012 Professional category PhD* Master** Specialist level 2 Specialist level 1 Medical doctor MA (medical associate, medical assistant) Bachelor/high-level nurse Technical nurse Community midwife Midwife Laboratory (bachelor) Laboratory assistant Pharmacist (bachelor) Pharmacist assistant Dentist (bachelor) Dentist assistant Hygienist Physiotherapist X-ray technnician Low-level nurse and nurse-midwife Middle-level primary health care worker Low-level primary health care worker Support and logistic staff Public health (high) * 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.
Average monthly salary (Kip) 1 293 869 1 257 312 1 293 869 1 257 312 1 165 216 896 568 1 165 216 896 568 896 568 790 435 1 165 216 896 568 1 165 216 896 568 1 165 216 896 568 896 568 896 568 896 568 790 435 896 568 790 435 896 568 896 568
portation fee for home visits; payment for better performance and a budget to promote professional development such as scholarships, loans for education and others. · Improve and implement appropriate non-financial incentives for health workers, such as improvement of the work environment to ensure it is clean, safe and stable, without violence including sexual violence; improve flexibility of work such as working hours and work leave plans; develop professionals and skills of health workers such as supervision, teaching, accessibility to training and educational leave; improve accessibility to social services such as health services, school, nursery school, housing, and transportation; improve appropriate rewards directed to boost staff's motivation. The Ministry of Health prioritizes health workers working in rural and remote areas. The Ministry of
Health developed a Decree on Financial Incentives for Rural Civil Servants. The decree defines remote, isolated and difficult areas; levels of each area; and ways of measuring incentives. Tables 15 and 16 explain more about the Ministry of Health's incentive plan for health workers working in rural areas. Even though the Ministry of Health understands the importance of incentives and has developed incentiverelated decrees, there has been minimal action. Reasons include low levels of funding for the health sector, low absolute rates of pay, and limited capacity to administer and evaluate targeted incentive schemes. However, more positively, several other projects have been implemented within the Lao People's Democratic Republic that have incorporated the implementation of incentives for health workers. These movements will expedite implementation.
18 Human Resources for Health Country Profiles
Table 15. Levels of remote, isolated and difficult areas
Level one
1. Geographic and natural condition
· Mountainous village located ·
more than 50 kms from a city
· Rainfall shortage/natural
·
disaster
Level two Mountainous village located more than 30 km from a city Rainfall shortage
Level three · Mountainous district/village located more than 20 km from a city · Rainfall shortage
2. Infrastructural condition · No road access · No post office/telephone · No electricity/water supply · No market
· Poor road access/access by car in only some areas or access only in dry season · Post office/telephone coverage in only some areas · No electricity/water · Have simple market
· Improved road access but difficult to access during rainy season · Have post office/telephone but not convenient
3. Education and health condition
· More than 50% of children
·
not enrolled in school; there
is no school or the school is
substandard
·
· Limited access to health
service; have only drug kits
More than 40% of children not ·
enrolled in school; school is
below standard
·
Only access to health centre
with insufficient resources
More than 30% of children not enrolled in school May be able to access district hospital and health centre with insufficient resources
4. Living and environmental condition
· Majority of people rely on natural resources for their livelihood · Ethnic minority area, difficult in terms of language and communication · Area vulnerable to disease outbreaks; poor environment at high risk for living and working
· Some people rely on natural · Some people rely on natural
resources for their livelihood
resources for their livelihood
· Ethnic minority area, difficult · Challenging environment for
in terms of language and
development and living
communication in some areas
· Some areas still have
outbreaks of infectious
diseases, poor environment,
and present difficulties for
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 50% · Be a priority candidate for continued study · Receive appropriate recognition based on performance
· Receive a salary increase of 40% · Be a priority candidate for continued study · Receive appropriate recognition based on performance
· Receive a 30% salary increase · Be priority candidate for continued study · Receive appropriate recognition based on 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 The latest HRH-related strategy, Health Personnel Development Strategy by 2020, was developed in order to effectively and efficiently train and recruit a sufficient number of qualified health personnel representing all categories of staff, mix of professions, levels of seniority, gender, ethnicity and age groups who could lead, manage and deliver quality health services in different health settings to the entire Lao population. There are five pillars of the strategy: health personnel capacity-building; utilization of health personnel; equity and equality of opportunity; health personnel management; and health personnel incentives. The Health Strategy to the Year 2020 also includes measures to improve HRH; it addresses human resources under a number of different health issues (University of New South Wales, 2011). 7.2 Policy development, planning and managing for HRH The Department of Organization and Personnel (see Figure 7) and the Ministry of Health develop all policies, laws, decrees, regulations and strategies related to HRH. The Prime Minister's Office, the National Assembly, health-related nongovernmental organizations and development partners contribute feedback and provide support. The Lao People's
Democratic Republic's health system is mainly centralized, so the central Government is responsible for staffing, budget, planning and evaluation of central, provincial, and district health centres. 7.3 Professional regulation Requirements of health workers are regulated in the Law on Health Care No.139/PM. First, health workers are required to complete at least a middle-level professional education and possess a diploma from a health professions education institution in the Lao People's Democratic Republic or in a foreign country recognized by the Ministry of Education and the Ministry of Health of the Lao People's Democratic Republic. Second, health workers must obtain authorization from the Ministry of Health to practise, after verification and proposal from the Medical Profession Council. Third, for physicians and dentists, practitioners must have at least five years of professional experience in health care in public or private hospitals. Medical assistants, dentist assistants, nurses, midwives, and physiotherapists and other medical technicians must
Figure 7. Structure of Department of Organization and Personnel
Department of Organization and Personnel
Department of Training and Research
Department of Health Personnel
Administration
Graduate Studies Division
Undergraduate Studies Division
Research Division
Administration
Personnel Division
Organization Division
Source: Ministry of Health, 2012. 20 Human Resources for Health Country Profiles
Party Office
Staff Welfare Division
have at least three years of experience in public or private hospitals. Fourth, health workers must be in good physical and mental health and possess a certificate indicating they are free of communicable diseases. Fifth, health workers must show that they have never been disciplined, professionally punished or punished for offences. Lastly, they must also have Lao nationality and reside in the Lao People's Democratic Republic, except if otherwise provided by a separate decision. Currently there is no relicensing requirement. A process is under way to introduce a national exam for a license to practise. 7.4 HRH information
Government. In addition, the Ministry of Health used PIMS to further classify health personnel according to profession, activity history and qualification for salary increases (Baсez, 2011). PIMS has the ability to create reports on the following: · predetermined quota per province regarding the number of needed personnel · salary grade of civil service personnel · classification according to educational attainment · classification according to age · classification according to ethnicity · report of civil service termination · report of additional civil service recruitment and transfer to other region · report of new recruitment · reports from the central office · retirement · report of civil service per province, district · summary report.
In 2006, the Division of Personnel in the Department of Organization and Personnel, and the Ministry of Health in coordination with the Public Administration and Civil Service Authority (PACSA) began to use an electronic system for monitoring personnel-related information. The Personnel Information Management System (PIMS) was created to standardize the gathering of personnel information from different sectors of the
7.5 Health workforce requirements The Lao People's Democratic Republic also began projecting HRH requirements based on the services that are being targeted by each different type of health facility nationwide. Table 17 is the result of WHO guidance to support planning of HRH requirements for the Lao People's Democratic Republic.
Table 17. Projections for health workforce requirements, 2013­2020
Categories PhD Master Specialist level 2 Specialist level 1 Medical doctor Medical assistant/nurse practitioner Bachelor/high-level nurse Middle-level nurse Low-level nurse Community midwife/Midwife Laboratory (bachelor) Laboratory assistant Pharmacist (bachelor) Pharmacist assistant Dentist (bachelor) Dentist assistant Hygienist Physiotherapist X-ray technician Primary health care worker Support and logistic staff Totals
2013 46 494 80 435 1412 1376 188 2335 2944 1017 104 469 397 639 217 148 417 342 88 581 1306 15 035
2014 50 514 102 480 1490 1353 210 2778 2646 1161 123 482 406 654 227 165 447 360 118 642 1355 15 764
2015 54 534 124 525 1568 1330 233 3222 2347 1306 142 496 416 669 237 183 478 378 147 704 1404 16 494
Year
2016
2017
57
61
553
573
146
168
570
615
1645 1723
1307 255 3666 2048 1450 161 509 425 684 248 200 508 396 176 765 1453 17 223
1284 278 4110 1750 1594 180 523 434 699 258 218 538 414 206 826 1502 17 952
Source: Department of Organization and Personnel, Ministry of Health, March 2012.
2018 65 593 190 660 1801 1260 300 4554 1451 1739 199 536 443 715 268 235 568 433 235 887 1551 18 682
2019 69 613 211 705 1878 1237 323 4998 1153 1883 218 550 452 730 278 252 599 451 265 948 1599 19 411
2020 72 633 233 750 1956 1214 345 5442 854 2027 237 563 461 745 288 270 629 469 294 1009 1648 20 140
Lao People's Democratic Republic 21
8. Concluding remarks
The shortage and maldistribution of the health workforce in the Lao People's Democratic Republic, together with the inadequate skills of the health staff, pose serious challenges to achieving the health-related Millennium Development Goals (MDGs). In response to these challenges, Health Strategy to the Year 2020 gives priority to improving employment capacity, increasing deployment of skilled health workers to rural and remote areas, and enhancing the capacity of health professionals through improved education and training in order to achieve the MDGs by 2015. Recent years have witnessed an increase of graduates in health professions who have not been fully absorbed by the health system and have remained unemployed or working voluntarily. Improving employment capacity is one of the key ways to strengthen the health workforce. On a biannual basis, the Prime Minister's Cabinet, the Ministry of Home Affairs and the Ministry of Finance fix a quota for new placements of civil servants, including the number of health workers. The Division of Personnel in the Department of Organization and Personnel then receives a number of employees as designated by the quota. The Department is responsible for the allocation of this quota at all administrative levels: central, provincial and district, as well as health centres. The quota, however, rarely meets the actual need for health workers, and as a result there is a shortage of employed health workers around the country. In addition, there remains qualified but unemployed health workers who do not receive positions under the current quota system. Increasing quotas in order to recruit the available health workforce into the system will help, to some extent, solve the shortage of health staff. But until quotas are increased, the most promising way to increase the health workforce is to develop innovative ways to recruit existing health workers into the system. The tendency for health workers to prefer urban over rural settings poses a significant challenge to ensure that the health workforce is evenly distributed according to needs and population levels across the country. Likewise, over half of the existing health workers in rural health centres are low-level health workers. To remedy this problem, the capacity of
existing health workers at health centres should be improved and upgraded through accelerated in-service training and `bridge' courses. In addition, more middleand high-level professionals are needed to serve rural communities. In response, the Health Strategy to the Year 2020 prioritizes staffing of health centres with middle-level/community midwives. Short-term solutions include enhancing service delivery through outreach activities at the community level. For remote villages where the regular outreach from health centres is difficult, posting village health workers is a method piloted to provide health promotion and preventive health services. The urgent need to scale up the health workforce calls for a more rigorous education system for health professionals in the Lao People's Democratic Republic. To achieve this, issues related to educational capacity for training health professionals, such as training approaches and methods, faculty development, infrastructure, and teaching resources and materials must be addressed. The Education Development Centre for Health Professionals, which has been established in some provinces, provides an excellent opportunity to update educational approaches and build and strengthen faculty capacity. Besides addressing these key issues related to the development of the health workforce in the country, HRH governance capacities are critically important to the implementation of HRH strategies, including strengthening the capacities of relevant departments in the Ministry of Health. In addition, financial limitations remain a major obstacle to increasing the quantity and quality of the health workforce. Domestic government expenditure accounts for only 19.9% of total health expenditure, while out-of-pocket spending makes up 46.4% of the total. The heavy reliance on international aid makes long-term planning and employment of health workers tenuous. Moreover, the generally low level of compensation, especially in rural areas, may explain part of the difficulty of attracting and retaining competent health workers. The correlation is clear: low levels of overall financial investment in health directly translate to inadequate human resources for health. An increased financial commitment will serve to improve the competency, reliability and quantity of the health workforce.
22 Human Resources for Health Country Profiles
References
Baсez R (2011). Improvement of the Personnel Information Management System. City, Publisher. Central Intelligence Agency (2012). The World Factbook. Washington, DC (https://www.cia.gov/ library/publications/the-world-factbook/, accessed on 15 April 2012) Prime Minister's Office (2003). Decree on Civil Service of the Lao People's Democratic Republic. [Civil Service Decree No. 82/PM]. Vientiane Capital, Lao People's Democratic Republic. Prime Minister's Office (2010). Decree on Financial Incentive for Rural Civil Servants [Financial Incentive decree No. 468/PM]. Vientiane Capital, Lao People's Democratic Republic. Department of Organization and Personnel (March 2012). Data on Health Workers Stock and Distribution. Vientiane Capital, Ministry of Health, Lao People's Democratic Republic. Encyclopaedia Britannica (2013). Laos. City, Publisher (http://global.britannica.com/EBchecked/ topic/330219/Laos, accessed on January 2013). Lao Statistics Bureau (2012). GDP per capita. Vientiane Capital, Lao People's Democratic Republic (http:// www.nsc.gov.la/, accessed on 15 January 2012). Lao Statistics Bureau (2012). Lao Social Indicator Survey (LSIS) 2011­2012. Vientiane Capital, Lao People's Democratic Republic. Ministry of Health (2012). National Health Statistic Report, 2010­2011. Vientiane Capital, Lao People's Democratic Republic. Ministry of Health (2011). National Health Account 2009­2010. Vientiane Capital, Lao People's Democratic Republic.
Ministry of Health (2010). Health Personnel Development Strategy by 2020. Vientiane Capital, Lao People's Democratic Republic. Ministry of Health (2007). Human Resources for Health: Analysis of the situation in the Lao People's Democratic Republic. Vientiane Capital, Lao People's Democratic Republic. Somchith A (2009). Infant Mortality and Maternal Mortality in the Lao People's Democratic Republic [lecture]. Vientiane Capital, Department of Hygiene and Prevention, Ministry of Health, Lao People's Democratic Republic. Thome J-M and Soulivanh P (2008). Lao People's Democratic Republic: Health Financing Reform and Challenges in Expanding the Current Social Protection Schemes. In: UNESCAP, eds. Promoting Sustainable Strategies to Improve Access to Health Care in the Asian and Pacific Region. Bangkok, United Nations Economic and Social Commission for Asia and the Pacific. United Nations Inter-Agency for Child Mortality Estimation (2012). Child Mortality Estimates. (www. childmortality.org, accessed on 15 January 2012). City. University of New South Wales (2011). HRH profile of the Lao People's Democratic Republic. Sydney, UNSW HRH Knowledge Hub. WHO Western Pacific Regional Office (2011). Western Pacific Country Health Information Profiles: Lao People's Democratic Republic, 2011 revision. Manila. World Bank (2012). Data: Lao PDR. Washington, DC (www.databank.worldbank.org, accessed on 14 February 2013).
Lao People's Democratic Republic 23
Annexes
Annex A. Gender distribution by professional category/cadre (%), March 2012
Professional category/cadre PhD (physician) PhD (pharmacist) Master (physician) Master (dentist) Master (pharmacist) Master (laboratory) Master (nurse/midwife) Master (other) Specialist 2 (physician) Specialist 1 (physician) Medical doctor MA (medical associate, medical assistant) Bachelor/high-level nurse Technical nurse Community midwife Midwife Laboratory (bachelor) Laboratory assistant Pharmacist (bachelor) Pharmacist assistant Dentist (bachelor) Dentist assistant Hygienist Physiotherapist X-ray technician Low-level nurse and nurse-midwife Middle-level primary health care worker Low-level primary health care worker Support and logistic staff Public health (high) TOTAL Source: Department of Organization and Personnel, Ministry of Health, March 2012.
Total 35 3 381 31 46 8 13 8 20 312 1233 1375 166 1774 338 120 70 490 473 667 194 96 482 284 32 3629 132 320 1434 23 14 189
Female 10 1 133 5 13 2 9 3 2 112 600 813 139 1302 285 103 30 290 254 394 89 53 254 176 6 2450 45 116 694 3 8385
% Female 28.57% 33.33% 34.91% 16.13% 28.26% 25.00% 69.23% 37.50% 10.00% 35.90% 48.66% 59.13% 83.73% 73.39% 84.32% 85.83% 42.86% 59.18% 53.70% 59.07% 45.88% 52.21% 52.70% 61.97% 18.75% 67.51% 34.09% 36.25% 48.40% 13.04% 59.10%
24 Human Resources for Health Country Profiles
Annex B. Health workers by age group and cadre, March 2012
Professional category/cadre
<30 30­39
PhD (physician) PhD (pharmacist) Master (physician) Master (dentist) Master (pharmaciat) Master (laboratory) Master (nurse/midwife) Master (other) Specialist 2 (physician) Specialist 1 (physician) Medical doctor MA (medical associate, medical assistant) Bachelor/high-level nurse Technical nurse Community midwife Midwife Laboratory (bachelor) Laboratory assistant Pharmacist (bachelor) Pharmacist assistant Dentist (bachelor) Dentist assistant Hygienist Physiotherapist X-ray technician Low-level nurse and nurse-midwife Middle-level primary health care worker Low-level primary health care worker Support and logistic staff Public health (high) TOTAL
0 0 3 0 1 0 0 0 0 7 146 94 9 979 42 13 3 117 102 174 28 1 178 53 212 87 216 334 0 2799
3 1 65 11 13 2 2 1 0 98 288 156 51 425 171 65 21 143 148 199 94 5 175 73 8 1041 43 99 471 3 3875
Source: Department of Organization and Personnel, Ministry of Health, March 2012.
40­49 10 0 143 10 20 2 8 4 2 111 497 766 94 321 120 34 40 178 163 224 55 63 111 134 19 1735 2 5 388 16 5275
50­59 18 1 161 8 11 3 2 3 13 77 281 321 11 46 5 8 5 48 56 66 15 25 17 22 2 590 0 0 208 4 2027
>60 4 1 9 2 1 1 1 0 5 19 21 38 1 3 0 0 1 4 4 4 3 1 1 2 3 51 0 0 33 0 213
Total 35 3 381 31 46 8 13 8 20 312 1233 1375 166 1774 338 120 70 490 473 667 195 95 482 284 32 3629 132 320 1434 23 14 189
Lao People's Democratic Republic 25
Annex C. Density of health workers by category and province (per 1000 population)
Vientiane Capital Phonsaly Luangnamtha Oudomsay Bokoe Luangprabang Huaphan Saiyabury Xiengkhuang Vientiane Bolikhamsai Khammuane Savannakhet Salavan Sekong Champasack Attapue Total
Professional category/ cadre
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
7
Master (nurse/ midwife)
0.01 - - 0.00 - 0.00 - - - - - - - - - - - 0.00
8 Master (other)
0.01 - - - - - - - - - - - - - - - - 0.00
9
Specialist 2 (physician)
0.02 - - 0.00 - - - - - - - - - - - 0.01 - 0.00
10
Specialist 1 (physician)
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
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
12
MA (medical associate, medical assistant)
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
13
Bachelor/high-level nurse
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
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
26
Low-level nurse and nurse-midwife
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
27
Middle-level PHC workers
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
28
Low-level PHC workers
- 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
29
Support and logistic staff
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
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
Professional category/cadre
Total number
% Urban
% Rural
Health
Health
workers/ workers/
1000 Popu- 1000 Popu-
lation in
lation in
urban areas rural areas
PhD (physician)
35 100.00%
0.00%
0.02
0.00
PhD (pharmacist) Master (physician) Master (dentist)
3 100.00%
487
92.81%
381
91.34%
0.00% 7.19% 8.66%
0.00 0.28 0.22
0.00 0.01 0.01
Master (pharmacist) Master (laboratory)
31
96.77%
46
97.83%
3.23% 2.17%
0.02 0.03
0.00 0.00
Master (nurse/midwife) Master (other)
8 100.00% 13 100.00%
0.00% 0.00%
0.00 0.01
0.00 0.00
Specialist 2 (physician) Specialist 1 (physician)
8 100.00%
312
90.71%
0.00% 9.29%
0.00 0.18
0.00 0.01
Medical doctor
1233
74.05%
25.95%
0.57
0.06
MA (medical associate, medical assistant) Bachelor/high-level nurse
1375 166
54.33% 93.37%
45.67% 6.63%
0.47 0.10
0.12 0.00
Technical nurse Community midwife
1774 338
46.73% 16.86%
53.27% 83.14%
0.52 0.04
0.18 0.05
Midwife Laboratory (bachelor)
120
25.83%
74.17%
70
94.29%
5.71%
0.02 0.04
0.02 0.00
Laboratory assistant Pharmacist (bachelor)
490
54.69%
45.31%
473
77.59%
22.41%
0.17 0.23
0.04 0.02
Pharmacist assistant Dentist (bachelor)
667
51.42%
45.58%
194
67.01%
32.99%
0.21 0.08
0.06 0.01
Dentist assistant
96
51.04%
48.96%
0.03
0.01
Hygienist Physiotherapist
482
52.28%
47.72%
284
73.94%
26.06%
0.16 0.13
0.04 0.01
X-ray technician Low-level nurse and nurse-midwife
32 3629
90.63% 39.27%
9.38% 60.73%
0.02 0.89
0.00 0.42
Middle-level primary health care workers Low-level primary health care workers
132
13.64%
86.36%
320
14.69%
85.31%
0.01 0.03
0.02 0.05
Support and logistic staff Public health (high)
1434 23
76.36% 56.52%
23.64% 43.48%
0.68 0.01
0.06 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, 2008­2011
Professional category/cadre
2008
PhD
10
Master
22
Specialist 2
0
Specialist 1
167
Medical doctor
397
MA (medical associate, medical assistant)
86
Bachelor nurse
24
High-level nurse
117
Technical nurse
552
Low-level nurse
0
Community midwife
24
Midwife
0
Laboratory technician
22
Laboratory assistant
141
Pharmacist
185
Pharmacist assistant
133
Dentist
124
Dentist assistant
0
Hygienist
143
Physiotherapist
98
X-ray technician
18
Primary health care worker (low and middle level) Primary health care worker (high level)
29 (low) 0
Support and logistic staff Total
0 2263
Source: Department of Organization and Personnel, Ministry of Health, March 2012.
Number of entrants
2009
2010
3 19 0 156 290 370 32 115 491 0 92 0 23 137 140 135 126 0 132 35 14 118 352 0 2780
0 37 0 162 114 464 35 284 442 0 101 0 21 145 64 126 72 0 168 76 0 125 339 0 2775
2011 2 41 0 171 169 666 130 321 763 0 247 59 16 130 78 48 53 0 159 188 27 164 502 0 3934
28 Human Resources for Health Country Profiles
Annex F. Number of graduates by year, 2008­2011
Professional category/cadre
2008
PhD
3
Master
22
Specialist 2
0
Specialist 1
55
Medical doctor
100
MA (medical associates, medical assistant)
28
Bachelor nurse
24
High-level nurse
0
Technical nurse
600
Low-level nurse
0
Community midwife
0
Midwife
0
Laboratory technician
19
Laboratory assistant
124
Pharmacist
29
Pharmacist assistant
121
Dentist
45
Dentist assistant
0
Hygienist
141
Physiotherapist
81
X-ray technician
0
Primary health care worker (low level)
156
Primary health care worker (middle level)
0
Support and logistic staff Total
0 1548
Source: Department of Organization and Personnel, Ministry of Health, March 2012.
Number of graduates
2009
2010
0 19 0 52 171 60 32 0 614 0 0 0 21 140 77 126 15 0 127 34 18 29 29 0 1564
0 18 0 53 202 124 35 0 634 0 140 40 26 137 52 130 56 0 124 67 14 0 180 0 2032
2011 0 24 0 66 160 160 130 30 737 0 167 63 24 144 237 127 37 0 226 76 27 0 154 0 2589
Lao People's Democratic Republic 29
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