Organisation mondiale de la santé (OMS) · Technical Documents

Investing the marginal dollar for maternal and newborn health: geographic accessibility analysis for emergency obstetric care services in Lao People's Democratic Republic

3 octobre 2016 Organisation mondiale de la santé

Le texte intégral est hébergé par l’organisation qui le publie. lawenc.com indexe les métadonnées et renvoie vers la source officielle.

Texte intégral

Investing the Marginal Dollar for Maternal and Newborn Health: Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao People's Democratic Republic

Steeve Ebener, PhD 1 and Karin Stenberg, MSc 2 1 2

Consultant, Gaia GeoSystems, The Philippines Technical Officer, Department of Health Systems Governance and Financing, World Health Organization,

Geneva, Switzerland

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

All rights reserved. Publications of the World Health Organization are available on the WHO website (http://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; email: bookorders@who.int). 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 website (http://www.who.int/about/licensing/copyright_form/index.html). 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 and dashed 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. The named authors alone are responsible for the views expressed in this publication.

WHO/HIS/HGF/GIS/2016.4

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Table of Contents Executive summary................................................................................................................... i1 1. Introduction .............................................................................................................................1 2. Reference indicators and targets .............................................................................................2 3. Assumptions and EmOC referral system ................................................................................3 4. Tool used for the different analysis: AccessMod 4.0 .............................................................6 5. Analytical approach ................................................................................................................7 5.1 Accessibility coverage analyzes ....................................................................................... 7 5.2 Geographic coverage analyzes ......................................................................................... 8 5.3 Service utilization analyzes ............................................................................................ 11 5.4 Scaling up analyzes ........................................................................................................ 13

6. Data and national norms used in the different analysis ........................................................15 6.1 Statistical data ................................................................................................................ 17 6.1.1 National level figures ........................................................................................... 17 6.1.2 Sub national level figures ..................................................................................... 18 6.1.3 Cluster level figures ............................................................................................. 20 6.1.4 Health facility level figures .................................................................................. 20 6.2 Geospatial data ............................................................................................................... 22 6.2.1 Administrative boundaries ................................................................................... 23 6.2.2 Geographic location of the EmOC facilities ........................................................ 24 6.2.3 Land cover including the extend of urban areas .................................................. 25 6.2.4 Transportation network ........................................................................................ 26 6.2.5 Hydrographic network ......................................................................................... 28 6.2.6 Digital Elevation Model ....................................................................................... 31 6.2.7 Spatial distribution of the number of births ......................................................... 31 6.3 National norms ............................................................................................................... 33

7. Results .................................................................................................................................35 7.1 Accessibility coverage analyzes ..................................................................................... 35

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

7.2 Geographic coverage analyzes ....................................................................................... 40 7.3 Service utilization analyzes ............................................................................................ 47 7.4 Scaling up analyzes ........................................................................................................ 51

8. Conclusions and recommendations.......................................................................................63 References .................................................................................................................................69 Annex 1 – Indicators and minimum acceptable levels from the 1997 UNICEF, WHO, UNFPA Guidelines for monitoring the availability and use of obstetric services ....................................................................................................................72 Annex 2 – Indicators and minimum acceptable levels from the 2009 WHO, UNFPA, UNICEF and Mailman School of Public Health handbook for monitoring emergency obstetric care ........................................................................................73 Annex 3 – Illustration of the current EmOC referral system in the Lao People's Democratic Republic ..............................................................................................74 Annex 4 –Province level demographic data used in the context of the project ........................75 Annex 5 – list of EmOC facilities identified during the National Emergency Obstetric and Newborn Care Needs Assessment conducted between 2010 and 2011 .................76 Annex 6 – Simplified classification for the global land cover distribution grid ......................77 Annex 7 – Process followed in order to create the final land cover distribution grid ..............78 Annex 8 – Protocol used to spatially distribute the number of birth in each country...............79 Annex 9 – Province level number and percentage of births where the household is located within 2 hours of travel time to a BEmOC (including CEmOC) facility for both scenarios..........................................................................................................81 Annex 10 – Travel time between each BEmOC (including CEmOC) and the nearest CEmOC ...................................................................................................................82 Annex 11 – Province level travel time statistics .......................................................................83 Annex 12 – Comparison between the estimated maximum coverage capacity obtained from Table 10 with the 2012 number of institutional deliveries for the BEmOC, including CEmOC, facilities where this information was available .......84

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 13 – Health facility level results of the geographic coverage analysis for BEmOC (including CEmOC) facilities .................................................................................85 Annex 14 – Births referred to CEmOC for complication and corresponding number of EmOC surgical teams in CEmOC facilities ............................................................86 Annex 15 – 83 facilities considered in the first scale-up scenario ............................................87 Annex 16 – Health facility level results for the first scale-up scenario ....................................89 Annex 17 – Travel time between each BEmOC and the nearest CEmOC facility in the context of the second scale-up scenario ..................................................................91 Annex 18 – Births referred to CEmOC for complication and corresponding number of EmOC surgical teams in CEmOC facilities for the second scale-up scenario .......92 Annex 19 – Health facility level results for the third scale-up scenario (first variant) .............93 Annex 20 – Births referred to CEmOC for complication and corresponding number of EmOC surgical teams in CEmOC facilities for the third scale-up scenario (first variant) ...........................................................................................................94 Annex 21 – Health facility level results for the third scale-up scenario (second variant) ........95 Annex 22 – Births referred to CEmOC for complication and corresponding number of EmOC surgical teams in CEmOC facilities for the third scale-up scenario (second variant) .......................................................................................................96 Annex 23 – Summary of scale-up scenarios presented above (with MWH: Maternity Waiting Home; SBA: Skilled birth Attendant) .......................................................97

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Acknowledgements The authors wish to express our gratitude to staff at the Ministry of Health of the Lao People's Democratic Republic for their time, inputs and the health statistics they have provided to inform the analysis presented in this report. We also would like to take this opportunity to thank Ms Eunyoung Ko and Ms Boram Koh from the WHO Country Office of the Lao People's Democratic Republic for their valuable insights and support throughout the undertaking of the study. Our gratitude also goes to Ms Noune Phommixai (National Geographic Department, NGD), Ms Siriphone Sakulku (UNFPA) and Dr Michael Epprecht (University of Bern) for the data and inputs they provided. We acknowledge the financial support provided to this project by the Government of Norway. For comments, please contact Karin Stenberg (stenbergk@who.int) or Steeve Ebener (steeve.ebener@gaia-geosystems.org).

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Executive summary Objective Progress on MDG5a to reduce maternal mortality is lagging behind in many countries and a key constraint is access to skilled care at birth including emergency obstetric care (EmOC) services. In order to expand coverage, good-quality essential services must be integrated into strong health systems. The World Health Report 2005 proposed a “close to client” approach with back up services at referral level. While the first level should be able to provide most of the Basic Emergency Obstetric Care (BEmOC) signal functions, there is also a universal need for access to comprehensive Emergency Obstetric Care (CEmOC) referral services, in case the need arises. In recognition of the key impact that EmOC services can have on maternal mortality and safe birth outcomes, the World Health Organization (WHO) is supporting the use of Geographic Information Systems (GIS) to analyse physical accessibility to facilities providing EmOC in four selected countries, namely (by alphabetical order):Burkina Faso, Cambodia, Lao People’s Democratic Republic and Malawi.1 Essentially, from a normative perspective every woman should be able to easily access a health facility that provides BEmOC. This is not currently the case in most low-income countries. Strategic decisions need to be made by policy makers and health planners with regards to what investments are feasible given limited resources and competing priorities. The broader project aims to inform policy discussions on how to optimize or target the spending of the marginal dollar for maternal health at country level; in particular to examine the infrastructure requirements for scaling up coverage of institutional delivery with skilled attendance. The research undertaken as part of this project and presented here aims to investigate the current accessibility to EmOC and potential implications for future global and national level policy recommendations and norms. Methodology The analysis first assesses accessibility coverage2. It then combines the results with data on the availability of human resources in the facilities providing the concerned health services, in order to obtain a measure combining both the population needs and service availability. This measure is referred to as geographic coverage.

This work has received financial support from the Norwegian Government as part of a work plan to operationalize the UN Secretary General’s Global Strategy for women and children's health. 2 Refers to ensuring that health services are located within reasonable reach of the people who should benefit from it (Tanahashi, 1978)

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

In the case of the Lao People's Democratic Republic, working in close collaboration with the Ministry of Health through the WHO Country Office, a freely available GIS extension developed by WHO to measure physical accessibility to health care, called AccessMod (See Chapter 4), has been used in combination with statistical data from existing sources (including household surveys, Health Information System, etc..) to perform the following analyses for the country (See Chapter 5 for more details): 1. Accessibility coverage: a. The percentage of all births where the household is located within 2 hours of travel time to a BEmOC facility; b. The travel time between each BEmOC facility and the nearest CEmOC facility. 2. Geographic coverage: a. The percentage of all births where the household is located within 2 hours of travel time to a BEmOC facility with enough capacity to cover all births under the assumption of normal delivery (i.e., with sufficient availability of skilled birth attendants); b. The percentage of births with complications requiring blood transfusion/Caesarean-section (C-section) that will reach a CEmOC facility within 2 hours of travel time from BEmOC facilities, and where the CEmOC facility has enough capacity to manage complications (through the availability of EmOC surgical teams). 3. Service utilization: Comparison between the results from the accessibility/geographic coverage analysis with data on actual service utilization (BEmOC coverage compared with the percentage of births delivered in a health facility; sub national level estimated percentage and health facility level number of births referred to CEmOC facilities for complication compared with the corresponding percentage and number of caesarean-sections observed during a recent year). 4. Scaling up: Scenarios developed to reach universal accessibility and geographic coverage through various mechanisms of expanding the EmOC facility network. The results coming out of these analyzes (Chapter 7) are presented under the form of tables, graphs and maps to be included into the analysis of maternal and new born health investments in the country. Results The analyses performed indicate that: - From an accessibility coverage perspective (Section 7.1, Table 1), the EmOC delivery network identified during 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment [15] allows for two thirds (66.9%) of all births to reach a BEmOC facility in less than 2 hours. At the same time, there is a CEmOC facility within 2 hours of reach for three of the four BEmOC facilities ii

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

(excluding CEmOC). For the last BEmOC facility, Xam Tai District Hospital, the travel time is reaching 4.2 hours; The health system in Lao People's Democratic Republic, as per the 2010-11 assessment [15], does therefore not comply with the condition set to define universal accessibility coverage as per the current framework; The availability of a motor vehicle at each BEmOC facility should nevertheless be ensured to confirm that the referral system is functioning as assumed. From a geographic coverage perspective (Section 7.2, Table 1), when taking into account current capacity and human resources to deliver the required health services, the coverage offered by the existing network of BEmOC facilities is low, 23.5% at the national level with a considerable variation at the sub national level. The health system therefore does not comply with the definition set for universal geographic coverage3 (Table 1); For CEmOC facilities, gaps in the health facility level data regarding the number of available EmOC surgical teams did not allow to confirm if the capacity in each facility would be sufficient to cover the demand would 5% of all births taking place in BEmOC facilities be referred to CEmOC facilities; From a service utilization perspective (Section 7.3), an important percentage of institutional deliveries are taking place in public Non-BEmOC facilities and this in all the Provinces except Vientiane capital where the density of EmOC facilities is sufficient to ensure that all births can take place in such a facility. These observation as well as the other results tends to indicate that both the availability of as well as the accessibility to EmOC services are barriers to service utilization. At the same time, taking the data gap issue into account, human resources might be sufficient but would have to be relocated in order to better match the demand.

Three scenarios were considered for the scale-up analysis for BEmOC (Section 7.4). The first scenario considers implementing the improvement plan proposed in the 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment [15] but without doing any changes in terms of human resources. With 49.1% in terms of geographic coverage, this scenario remains below the universal geographic coverage benchmark. The second scenario, which looked at also implementing the improvement plan but this time with an increase of the human resources the geographic coverage reaches 89.7% which is only 0.3% below the benchmark. This scenario would also allow for 9 provinces to be above the 90% benchmark but would require the recruitment or relocation of 168.7 Skilled Birth Attendants (SBAs). The potential gaps in terms of EmOC surgical team is less clear because of some data and norms gaps. The third scenario, which looks at the establishment of Maternity Waiting Homes (MWH) allows reaching 92.9% of geographic coverage at the national level. It would nevertheless require the construction and maintenance of MWH and associated facilities 3

Based on a 90% target asset by the ICPD for 2015 [4]

iii

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

(one near each of the 18 BEmOC, including CEmOC, facilities identified during the 2010-11 needs assessment), as well as the recruitment or relocation of between 480 and 504 SBAs depending on the variant being considered. At the same time, it would also require hiring or relocating EmOC surgical teams from other facilities not yet complying with CEmOC. Province code [14] LAO001 LAO002 LAO003 LAO004 LAO005 LAO006 LAO007 LAO008 LAO009 LAO010 LAO011 LAO012 LAO017 LAO021 LAO014 LAO015 LAO022 Province name [14] Attapu Bokeo Bolikhamxai Champasak Houaphan Khammouan Louang-Namtha Louangphabang Oudomxai Phongsali Salavan Savannakhet Xekong Vientiane Vientiane Capital Xaignabouli Xiangkhouang Nationwide

Accessibility coverage* 0.2% 0.0% 96.0% 85.9% 50.3% 92.9% 0.0% 13.7% 5.5% 68.3% 82.7% 91.6% 51.6% 80.3% 100.0% 0.0% 95.3% 66.9%

Geographic coverage** 0.0% 0.0% 44.5% 22.3% 9.9% 22.0% 0.0% 0.3% 0.0% 31.0% 6.9% 11.4% 0.0% 48.2% 99.2% 0.0% 31.8% 23.5%

*Percentage of births located within 2 hours of travel to a BEmOC (including CEmOC) with the combined walking + vehicle scenario **Percentage of births located within 2 hours of travel time to a BEmOC (including CEmOC) and for which there is enough capacity in the facilities with the combined walking+vehicle scenario

Table 1 – Province level results for the accessibility and geographic coverage analyzes

Key findings Despite data limitations4, the results obtained based on the assumptions made in the context of this project (Chapter 3) provide evidence that should be taken into account for any strategic analysis of maternal health investments in the country. First of all, the accessibility analysis (Section 7.1) demonstrates that any program aiming to support the transportation of pregnant women at the moment of delivery would have an important positive impact on their chance to reach an BEmOC facility within 2 hours. 4

Data limitations mainly refer to time discrepancies between datasets, to some gaps in health facility level datasets and the fact that the needs assessment has been conducted back in 2010-11 (see Chapter 6).

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

The geographic coverage analysis (Section 7.2) illustrates the potential gap that exists in terms of skilled birth attendants in BEmOC facilities in order to cover the demand of the population located within 2 hours of travel time of these facilities and the one to be referred to CEmOC facilities in case of complications during the delivery. The service utilization analysis (Section 7.3) confirms that availability and accessibility and barriers to the utilization of EmOC services. Finally, the scaling-up analysis demonstrates that the second (implementation of the improvement plan with an increase in human resources in EmOC facilities) and third (establishing waiting homes near BEmOC facilities) scenarios could be an effective approach but would nevertheless requires transferring and/or recruiting a high number of new skilled births attendants and EmOC surgical teams in these facilities as well as the establishment of Maternity Waiting Homes (MWH) for the third scenario. While this strategy needs to be further explored it is clear that an increase in the number of skilled birth attendants and EmOC surgical teams in CEmOC facilities is necessary to improve overall availability and accessibility to EmOC in the Lao People's Democratic Republic. It is important to mention here that the government has recently trained around 1,000 community midwives, however the training rate has been slowing down and it would therefore be difficult to reach the volume of SBAs suggested by some of these scenarios. Beyond this, the results obtained provide some basis for a potential revision of some of the indicators considered by the UN [2] when it comes to improving and monitoring the coverage of EmOC facilities and skilled birth attendance in countries. Looking at the National and Province level density of BEmOC and CEmOC facilities in Lao People's Democratic Republic (Table 2) we can observe that: - 18 facilities for a total population of 6’288’000 [10] corresponds to a national ratio of 1.4 BEmOC facilities per 500’000 inhabitants. This is far below the benchmark level set in the 2009 handbook [2] when it comes to the availability of EMOC facilities (indicator 1 in Annex 2). The analysis conducted here shows that the current network of BEmOC facilities is indeed insufficient to reach universal accessibility and geographic coverage at the national as per the definition used in the context of the present project (see Chapter 3); - The same observation can be made at the Province level (Table 2) as none of the sub-divisions reaches the benchmark level set in the 2009 handbook but two of them are very close to it (Vientiane Capital with 3.9 and Bolikhamxai with 3.7. This being said, universal accessibility coverage is obtained in both these Provinces as well as 3 other ones (Khammouan, Savannakhet and Xiangkhouang - The current network of CEmOC is nevertheless not sufficient to ensure for each BEmOC facilities to be within 2 hours of reach of such a facility as Xam Tai District Hospital finds itself at 4.2 hours from the nearest CEmOC facility. v

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Unfortunately, the gaps in the health facility level data regarding the number of EmOC surgical teams does not allow us to fully confirm these observations from a geographic coverage perspective. In conclusion, the analysis indicates that benchmarks that consider the density of EmOC facilities at the national or sub national level without taking accessibility and geographic coverage into account may not be appropriate. The present project could serve as the basis for justifying further work when it comes to the estimation of the maximum acceptable workload for skilled birth attendants as well as EmOC surgical teams. Number of 2011 Population (2011 estimates [13] adjusted BEmOC facilities Number of Province name [14] (including CEmOC facilities to 2011 UN country figure [10]) CEmOC facilities) Attapu Bokeo Bolikhamxai Champasak Houaphan Khammouan Louang-Namtha Louangphabang Oudomxai Phongsali Salavan Savannakhet Xekong Vientiane Vientiane Capital Xaignabouli Xiangkhouang Nationwide 0 0 2 2 2 1 0 0 0 1 1 2 0 0 6 0 1 18 0 0 2 2 0 1 0 0 0 1 0 1 0 0 6 0 1 14 128,420 167,226 268,647 651,305 320,805 377,276 165,584 448,608 302,397 175,300 369,809 908,192 99,066 486,090 771,129 376,103 272,043 6,288,000 Density of BEmOC facilities (including CEmOC facilities) per 500'000 population 0.0 0.0 3.7 1.5 3.1 1.3 0.0 0.0 0.0 2.9 1.4 1.1 0.0 0.0 3.9 0.0 1.8 1.4 Density of CEmOC facilities per 500'000 population 0.0 0.0 3.7 1.5 0.0 1.3 0.0 0.0 0.0 2.9 0.0 0.6 0.0 0.0 3.9 0.0 1.8 1.1

Table 2 – National and Province level density of BEmOC, including CEmOC, facilities and CEmOC facilities in Lao People's Democratic Republic Conclusion The results obtained in the context of this project can be used to inform policy discussions on how to optimize, or target, the spending of the marginal dollar for maternal health in the Lao People’s Democratic Republic. At the same time, benefits could be gained by the health sector if the methods used here are transferred to national institutions and the process as a way to improve the integration of geography and GIS in the Health Information System. This being said, the needs assessment used in the present study has been conducted back in 2010-11 and was not comprehensive. The situation depicted here might therefore not vi

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

only be incomplete at the time of the assessment but might also have changed, in terms of both the EmOC infrastructures and associated human capacities. As such, the recommendation is for WHO and the Ministry of Health to continue their collaboration in this area and to benefit further from the work that has been performed so far, by continuing the application of the methodology and using the results to strengthen planning for effective programme delivery to improve maternal health and other service delivery areas. As governments increasingly look at EmOC as a necessary vehicle to reduce maternal mortality, GIS can play an important role. A first step is to undertake an assessment of EmOC capacity at sub-national level, as described in this report. The second step will require interpretation of the results in the national policy context. A subsequent and third step entails the assessment of various strategies to improve maternity care including EmOC components. This may include expanding geographic access, improving system performance by improving the quality of care within current facilities, or addressing barriers on the demand side. The results presented in this report indicate that the strategies required may differ between provinces.

vii

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

1. Introduction Progress on MDG5 to reduce maternal mortality is lagging behind in many countries and a key constraint is access to skilled care at birth including Emergency Obstetric and Newborn Care services. Since the SBA Plan 2008-2012 and the national MNCH strategy came out in 2009, the government has tried to increase the number of SBA by promoting the one-year course of community midwives training and rapidly increased the number. As of the end of 2014, the number of graduates for the community midwives has reached a bit less than 1,000 who had started to work at health facilities such as district hospitals and health centers. However according to the recent SBA evaluation report, the rapid production caused poor quality training and therefore as a result, a poor performance of the community midwives. The government is now planning to slow down the production and focusing more on growing the capacity of teaching and developing competencybased curriculum. The World Health Report 2005 proposed a “close to client” approach with back up services at referral level. While the first level should be able to provide most of the Basic Emergency Obstetric Care (BEmOC) signal functions, there is also a universal need for access to comprehensive Emergency Obstetric Care (CEmOC) referral services, in case the need arises. Essentially, from a normative perspective every facility offering delivery at birth services should be able to provide BEmOC. This is not currently the case in most low-income countries. Strategic decisions need to be made by policy makers and health planners with regards to what investments are feasible given limited resources and competing priorities. In this regard, component 2c of the International Health Partnership (IHP+) Health System Strengthening (HSS) 2010-2011 proposal to the Norwegian Government on Activities Associated with operationalizing the UN Secretary General’s Global Strategy for women and children's health included the present project with the aim to use the capacities of Geographic Information System (GIS) to analyse physical accessibility to Emergency Obstetric Care (EmOC) in four selected countries, namely (by alphabetical order): Lao People's Democratic Republic , Cambodia, Laos and Malawi. This work has been undertaken to inform policy discussions on how to optimize or target the spending of the marginal dollar for maternal health at country level; in particular to examine the infrastructure which is assumed to be available when the marginal dollar is invested in components essential for maternal health (i.e., midwives, birthing kits), and to assess the supply side infrastructure that needs to be in place and considered in conjunction with complementary incentives for demand generation (e.g., conditional cash transfers). 1

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Once the situation analysis and identification of infrastructure constraints has been undertaken, additional analysis is carried out to examine the availability of human resources and capacity to deliver EmOC services within existing facilities. Following identification of strategies within a national policy discussion workshop, a cost analysis can subsequently be carried out to estimate the marginal investment needed to expand coverage of services. The present report first describes the analytical method, tool and data which have been used to conduct this analysis in the Lao People’s Democratic Republic before presenting the results which have been obtained through its implementation. The research findings highlight potential implications for future global and national level policy recommendations and norms regarding indicators for EmOC accessibility.

2. Reference indicators and targets Over time the UN has defined a set of indicators, and associated minimum acceptable levels (targets), to improve and monitor Emergency Obstetric Care coverage and skilled birth attendance in countries, namely: - The indicators included in the 1997 UNICEF, WHO and UNFPA Guidelines for Monitoring the Availability and Use of Obstetric Services [1] (Annex 1); - The revision of these indicators as part of the 2009 handbook for monitoring emergency obstetric care [2] (Annex 2); - MDG indicator 5.2: the proportion of births attended by skilled health personnel trained in providing life saving obstetric care [3]. - The program of Action of the International Conference on Population and Development (ICPD) and more particularly paragraph 64 of the resolution adopted by a special session of the UN General Assembly in 1999 regarding the key actions for the further implementation of the programme of action of the ICPD. This paragraph states that: “All countries should continue their efforts so that globally, by 2005, 80 per cent of all births should be assisted by skilled attendants, by 2010, 85 per cent, and by 2015, 90 per cent.” [4]. These indicators have been used as the basis for the assumptions and EmOC referral model used in the context of this project. In particular, the ICPD target that 90% of births should be assisted by a skilled attendant was used to set a benchmark for universal coverage. In the context of our analysis, we further interpreted this target to require that skilled attendance at birth should be available for 90% of births. Skilled attendance at birth is interpreted as a skilled attendant working within an enabling environment or health system that is capable of providing care for normal deliveries as well as appropriate emergency obstetric care for all women who develop complications during childbirth.5 The assumptions and methodology are presented in the next section. 5

http://web.unfpa.org/mothers/terms.htm

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

3. Assumptions and EmOC referral system The following assumptions are considered in the context of the present project: - Skilled care at birth refers to “the care provided to a woman and her newborn during pregnancy, childbirth and immediately after birth by an accredited and competent health care provider who has at her/his disposal the necessary equipment and the support of a functioning health system, including transport and referral facilities for emergency obstetric care”6. This implies having at direct disposal the capacity and capability to the Basic Emergency Obstetric Care lifesaving interventions; - A BEmOC facility is a health facility that is performing all the 7 Basic EmOC functions, namely [2]: administer parental antibiotics, administer uterotonic drugs (i.e. parental oxytocin), administer parental anticonvulsants for pre-eclampsia and eclampsia (i.e. magnesium sulphate), manually remove the placenta, remove retained products (e.g. manual vacuum extraction, dilation and curettage), perform assisted vaginal delivery (e.g. vacuum extraction, forceps delivery), perform basic neonatal resuscitation (e.g. with bag and mask); - A facility is classified as a Comprehensive Emergency Obstetric Care facility if it performs all the signal functions of a BEmOC facility plus [2]: surgery (e.g. caesarean section), and blood transfusion; - CEmOC facilities are also considered to be BEmOC facilities as they are performing the 7 Basic EmOC functions as well; - Would a complication requiring blood transfusion and/or surgery occur during the delivery in the BEmOC facility, the patient should be transferred to a CEmOC facility; - It is considered that 15% of all births are to develop complications, and among them about 30% of complications (5% of all births) would require blood transfusion and/or C-section, and therefore a transfer from the BEmOC facility to a CEmOC facility; - The maximum acceptable travel time from home to reach a BEmOC facility is 2 hours and this intends to account for: o The standard for the availability of services set to be between 2 and 3 hours in the 2009 hand book for monitoring emergency obstetric care [2] o In case of complications, especially haemorrhage, the estimated average interval between onset of a postpartum haemorrhage and death is set as being 2 hours [5] - The maximum travel time considered in case of transfer between a BEmOC facility, where all women delivering should initially seek care, to a CEmOC facility because of severe complications is again of 2 hours (same rationale: time

WHO (2004) Making Pregnancy Safer. The critical role of the skilled attendant. A joint statement by WHO, ICM and FIGO. http://whqlibdoc.who.int/publications/2004/9241591692.pdf

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

needed to address postpartum haemorrhage which is pre-managed at BEmOC facility but will require blood transfusion and/or C-section); The assumption is that women would walk or be carried from their home to the nearest road. This would take place during early labour (assuming that a birthing plan has been developed and that the woman has the support of her family to initiate care seeking as labour commences). At this stage in the delivery process a 50% reduction in walking speed is assumed. Upon reaching a road, women would then travel by motor vehicle to the nearest BEmOC facility. The analysis will include an alternative scenario where women are assumed to travel to the BEmOC facility by foot alone. This scenario is analysed to estimate the gains made by financially supporting women to be able to access road vehicle transportation; The transfer between the BEmOC facility to the CEmOC facility is done using a motor vehicle (ambulance, car, truck,…) Analyzes are performed considering transportation conditions during the dry season. While the tool used here (see Chapter 4) can account for areas and/or roads being flooded during the wet season, this particular context has not been analysed here; Based on a 90% target asset by the ICPD for 2015 [4], conditions that support universal accessibility and universal geographic coverage are assumed to be in place when: o 90% of all births in the country would be within 2 hours of travel from a BEmOC facility and that the capacity of the BEmOC facility, in terms of skilled birth attendants, is sufficient to cover the demand; o 5% of all births taking place in a BEmOC facility (considered as presenting complications) could be transferred to a CEmOC facility in less than 2 hours7 and that the capacity of the CEmOC facility, in terms of EmOC facility surgical teams, is sufficient to cover the demand.

The above assumptions translate into the EmOC referral model presented in Figure 1. It is important to note here that this model, at present: - Assumes that: o Women have enough resources to pay for the transportation on the transportation network; o A vehicle (ambulance, car, truck, etc,..) is available at each BEmOC facility for the transfer to a CEmOC facility in case of complications requiring blood transfusion and/or C-section.

We note that the assumption of a potential maximum 4 hours travel time (2 hours to skilled care and BEmOC and a further 2 hours to CEmOC) may be too long since there is a risk that in a small proportion of women with severe bleeding after a birth, blood transfusions and surgical treatment if required may be required sooner than that.

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Does not consider: o The availability of waiting homes to allow for women living in remote areas to come close to an EmOC facility before the due date and therefore increase accessibility. Does not consider the following for the situation analysis (although it may be considered for the scaling up analysis): o Demand generation activities (where demand appears to be lower than supply); o Improving transport links (e.g., improving the quality of some roads) and the expected impact on accessibility.

Figure 1 – EmOC referral model used in the context of the project

These assumptions are essential in that actual perceived accessibility may in fact be lower than theoretical accessibility, if the women do not have access to road transportation. The EmOC referral model used here may be adjusted to reflect the current country context. Attempts were made accordingly to reflect the current policy in the Lao People’s Democratic Republic (See Annex 3) and the possibility of making Maternity Waiting Homes (MWH) available was used in the scaling up analysis. However, for the first phase of analysis as presented here the pathways to home deliveries and non-EmOC facilities as well as the use of waiting homes were not utilized in the model since the objective of the research is to show the current accessibility and availability of skilled care at birth including EmOC functions, and if needed to assess 5

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

potential scale-up implications of expanding access to 90% target as set by the ICPD follow-up resolution. The analysis could therefore be expanded to show additional pathways if this is considered appropriate.

4. Tool used for the different analysis: AccessMod 4.0 All analyzes conducted in the context of this project have been possible thanks to the use of AccessMod ©. AccessMod© is a toolbox that has been developed by WHO to provide Ministries of Health, and other health partners, with the possibility to use the power of Geographic Information System (GIS) to: • Measure physical accessibility to health care, • Estimate geographical coverage (a combination of availability and accessibility coverage) of an existing health facility network, • Complement the existing network in the context of a scaling up exercise or to provide information for cost effectiveness analysis when no information about the existing network is available. AccessMod© uses the functions of Esri’s GIS technology to apply a specific set of algorithms on a series of GIS layers containing the information influencing the time taken by a patient to reach the nearest health facility depending on the mode of travel (for example, by feet, by car, etc). As GIS technology evolves, and to address needs specific to the present project, a new version of AccessMod (version 4.0) has been developed to work on a more recent version of Esri’s technology, ArcGIS 9.3.1 software. This version of AccessMod is freely accessible either through the WHO [7] or Esri ArcGIS online [8] web sites and comes with a user manual and a sample dataset to guide users on the use of AccessMod’s different modules, namely: - Module 1 to create the combined land cover distribution grid and the travelling scenario table on the basis of the land cover, road and hydrographic network layers; - Module 2 to measure the travelling time to or from for a given health facility network; - Module 3 to analyse the geographic coverage an existing health facility network through the generation of catchment areas and determination of the population covered by each of the facilities; - Module 4 to determine the locations for new health facilities, and the population they cover, to scale up an existing network or to perform different analysis when no information about the location of the existing health facility networks is available (e.g. for cost-effectiveness analysis). 6

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

5. Analytical approach The present project covers four specific analyses: 1. Accessibility coverage: a. The percentage of all births where the household is located within 2 hours of travel time of a BEmOC facility; b. The travel time between each BEmOC facility and the nearest CEmOC facility. 2. Geographic coverage: a. The percentage of all births where the household is located within 2 hours of travel time of a BEmOC facility with enough capacity to cover these births if normal delivery (i.e., with sufficient availability of skilled birth attendants); b. The percentage of births with complications requiring blood transfusion/Caesarean-section (C-section) that will reach a CEmOC facility within 2 hours of travel time from BEmOC facilities, and where the CEmOC facility has enough capacity to manage complications (through the availability of EmOC surgical teams). 3. Service utilization: Comparing results from the accessibility/geographic coverage analysis with data on actual service utilization (estimated capacity of BEmOC compared with the percentage of births delivered in a health facility; the estimated capacity of CEmOC compared with the number of caesarean-sections) 4. Scaling up: Scenarios developed to reach universal coverage through various mechanisms of expanding the EmOC facility network. The objective, method and outputs for each of these analyses are described in more details in the following sections.

5.1 Accessibility coverage analyzes Objective: Measure physical accessibility to EmOC facilities through the following data and indicators: 1.1 At the national and sub national level, the proportion of births located within 2 hours travel time from a BEmOC, including CEmOC, facility; 1.2 The travel time between each BEmOC facility and the nearest CEmOC facility; 1.3 At the health facility level: 1.3.1 The number and percentage of births reaching a BEmOC, including CEmOC, facility within 2 hours of travel time from their domicile; 1.3.2 The number and percentage of births, among those requiring blood transfusion and/or surgery during delivery (estimated as 30% of the 15% of all births delivering in a BEmOC facility (rounded to 5%) that can reach a CEmOC facility within 2 hours travel time. 7

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Method: The methodology takes into account the location of the BEmOC/CEmOC facilities, the environment that the patient will have to cross to reach the nearest care provider (including the hydrographic network as barriers), the transportation network as well as the following transportation scenarios: - walking/carried outside of the transportation network and then a motor vehicle on the transportation network; - Walking/carried only. In this first analysis, as well as all the other subsequent ones, the total number of births is spatially distributed using the approach described in Section 6.2.8. When it comes to the referral in case of complications requiring blood transfusion and/or surgery during delivery, patients are considered to be sent to the nearest CEmOC facility in terms of travel time. Outputs: 1. Maps presenting the travel time to the nearest BEmOC facility (for two scenarios: walking only, and walking + motor vehicle on the transportation network); 2. Excel file presenting, at the country and sub-national level, the total number and percentage of births within 2 hours from a BEmOC facility (for two scenarios: walking only, and walking + motor vehicle on the transportation network); 3. Map presenting, at the sub national level the percentage of births within 2 hours of a BEmOC facility (walking + motor vehicle on the transportation network); 4. Excel file presenting the travel time between each BEmOC facility and the nearest CEmOC facility (use of motor vehicle); 5. Excel file presenting the min, max and mean travel time to the nearest BEmOC facility and between BEmOC facilities and the nearest CEmOC facility (through referral) for each sub national unit (one scenario only: walking + motor vehicle on the transportation network).

5.2 Geographic coverage analyzes Objectives: Add the availability of human resources (skilled birth attendant, EmOC surgical team) and equipment (operating theatre) to the first analysis to identify potential gaps when it comes to reaching universal geographic coverage for the births where the household is located within 2 hours of travel time of the BEmOC facility (walking + motor vehicle on transportation network) and/or those transferred to a CEmOC facility in case of a complication requiring blood transfusion and/or a C-section during delivery. Method: Geographic coverage analysis combines both availability and accessibility coverage into one unique measure. The method used for this analysis therefore consists in: - For BEmOC facilities: 8

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

o Estimating the coverage capacity of each BEmOC facility by multiplying its total number of staff qualified to attend a normal delivery (skilled birth attendant) with the national, or WHO if the national one is not available (175 births per year per skilled birth attendant), workload norm; o Applying the third module of AccessMod (see Chapter 4) to define the catchment area of each BEmOC facility using the above estimated coverage capacity and 2 hours of travel time; o Verifying that more than 90% of all births are covered through this analysis to comply for universal coverage as defined in the context of this project. In the context of this project, the processing order normally used when looking at geographic accessibility to BEmOC, including CEmOC, facilities is normally as follows: o BEmOC facilities before CEmOC facilities 8 as the referral system should instruct patients to go to a BEmOC facility first, would they have a facility of each type within the same travel time, o Decreasing order of the coverage capacity of each BEmOC facility (number of skilled birth attendant multiplied by the national or WHO (175 births per staff per year) workload norm. If the staffing information is not available, then by decreasing order of the population living within the immediate vicinity (5 km) of the facility to treat the most populated areas first. This being said, the Lao People's Democratic Republic having only identified 4 facilities complying to BEmOC at the time of the National Emergency Obstetric and Newborn Care Needs Assessment conducted between 2010 and 2011 [15], these facilities being all part of the lowest level of referral and real figures regarding the number of births they covered in 2012 being available, it has finally been decided in the present case to define the processing order only on the basis of the decreasing order of their coverage capacity. For CEmOC facilities: o Using the results of the accessibility coverage analysis to identify the number of births that would be referred to each CEmOC facility considering that 5% of the births reaching a BEmOC facility would need to be transferred for blood transfusion and/or C-section; o Converting the corresponding total number of births transferred to each CEmOC facility into an expected number of EmOC surgical teams using the national workload norm or an estimated one if the national norm is not available;

Births located within two hours travel time are attached to the closest facility. Only those births located within overlapping catchment areas can find themselves attached to a different facility depending on the order of treatment. By starting with BEmOC facilities we ensure that non-complicated births are first handled by BEmOC facilites before using the capacity of the CEmOC facilities. CEmOC facilities would then in a way complement the coverage capacity of BEmOC facilities for births located further away than 2 hours of travel time from a BEmOC facility but within 2 hours of travel time of a CEmOC facility.

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

o When the information is available, comparing the expected number of EmOC surgical teams with the real number of teams observed in each CEmOC facility to identify potential gaps. The following additional analysis can then be performed in case the total number of births delivered in each BEmOC facility and/or total number of C-sections performed in each CEmOC facility is available: - For BEmOC facilities, comparing the modelled number of births with the real one to potentially identify facilities that are being by-passed by patients; - For CEmOC facilities, comparing the modelled number of births needing C-section and/or blood transfusion with the real number of C-section to potentially identify problems in the referral system. Given that the first part of the analysis is dependent on the existence of national EmOC norms as well as on health facility level data (number of skilled birth attendant for BEmOC facilities and number of EmOC surgical teams, including functional operating theatres, for CEmOC facilities), different options have to be considered to attain these data, namely: 1. For BEmOC facilities: 1.1 When facility level data on skilled birth attendant and the national workload norm are available the full analysis as described here above can be performed directly; 1.2 When facility level data on skilled birth attendant are available but not the national workload norm, the WHO benchmark of 175 births per skilled birth attendant is used (please note that this norm might be adjusted depending on the health facility type serving as a BEmOC facility to account for the fact that nurses/midwifes might not be working 100% of their time on maternal and newborn health services. Please refer to Annex 9 of the 2009 Cambodia EmOC improvement plan as an example [6]); 1.3 When neither the national workload norm nor facility level data on skilled birth attendant are available, the maximum coverage capacity of each facility type is estimated in consultation with the Ministry of Health and WHO Country office and applied in the calculation. 2. For CEmOC facilities: 2.1 When facility level data on existing operational EmOC surgical teams and the national workload norm are available the full analysis as described here above can be performed directly; 2.2 When facility level data on existing operational EmOC surgical teams are available but there is national workload norm a benchmark is then estimated in collaboration with the WHO Country Office. 2.3 When neither the national workload norm nor facility level data on existing operational EmOC surgical teams are available a benchmark is then still estimated in collaboration with the WHO Country Office. 10

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

It is important to mention here that the present analysis could be used to inform a potential adjustment of the national, or even international, workload norms for EmOC requirements. Outputs: 1. Excel file containing separated worksheets for: a. The number of births covered by each BEmOC facility taking 2 hours of travel time and its respective coverage capacity into account. Real number of births will also be included in this worksheet if the information is available. b. At the national and sub-national level, the total number and percentage of births where the household is located within 2 hours from a BEmOC facility (walking + motor vehicle on the transportation network) and for which there is enough capacity to cover the demand. These figures are used to measure universal geographic coverage. c. The number of births referred to each CEmOC facility because of complications (5% of the births reaching the BEmOC facilities) with an estimation of the expected number of EmOC surgical teams needed to cover the demand. Real number of EmOC surgical team and real number of Csections would also be included in this worksheet if the information is available.

5.3 Service utilization analyzes Objective: Compare the actual utilization of services, with the theoretical accessibility and geographic coverage obtained in the first and second set of analyzes. Method: Data collected in the context of the most recent DHS, or equivalent household surveys, are combined with the results of the first and second analyzes at both the cluster and sub national level to obtain a map and a graph allowing for the comparison. Output: For BEmOC, including CEmOC, facilities: 1. For countries where there is no DHS, nor other equivalent survey data: no output will be possible in this case 2. For countries where a DHS, or other equivalent survey data, are available but for which the geographic location of the clusters of surveyed households are not available: 2.1 Graph that compares, at the sub national level: 2.1.1 the percentage of births that could have taken place in a BEmOC, including CEmOC, facility as within 2 hours of travel time (walking + motor vehicle on the transportation network) with the percentage of births delivered in a health facility (all levels) from the household survey (e.g., in district X 75% of births have their household located 11

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

within 2 hours access but only 45% of women had a delivery in a facility). 2.1.2 the percentage of births that could have taken place in a BEmOC, including CEmOC, facility as within 2 hours of travel time from the household (walking + motor vehicle on the transportation network) and with enough capacity to cover the demand with the percentage of births delivered in a health facility (all levels) from the household survey; 3. For countries where geocoded DHS (or other georeferenced household surveys) data are available: 3.1 Same graph as in point 2.1 here above; 3.2 Map showing the spatial distribution of cluster level un-attended home deliveries from DHS on top of the 2 hours catchment area from the accessibility coverage analysis as well as the catchment areas obtained through the geographic coverage analysis For CEmOC facilities: 4. For countries where there is no DHS, no other equivalent survey data and no EmOC level data on the number of C-sections performed for a recent year: no output will be possible in this case 5. For countries where DHS, or other equivalent survey, data are available but for which no EmOC level data on the number of C-sections performed over a recent year are available: 5.1 Comparison between the sub national percentage of births with complications referred to a CEmOC facility as per the result of the geographic coverage analysis (5% of births covered in 2 hours by a BEmOC considered as referred to a CEmOC considering only the CEMOC facilities that are within 2 hours of reach), with the percentage of births delivered by C-section as per the DHS, or any other equivalent household survey, assuming that the C-sections reported in the DHS took place in certified CEmOC facilities (e.g. 75% of women needing C-sections had geographic access based on the analysis but only 45% of these C-sections took place in a CEmOC facility as per DHS survey data). 6. For countries where DHS, or other equivalent survey, as well as EmOC level number of C-sections performed over a recent year are available: 6.1 Same comparison than the one presented in point 5.1; 6.2 Comparison between the real number of C-sections performed in CEmOC facilities for a recent year and the number of C-sections referred by the model as part of the geographic coverage analysis. In the case of the Lao People's Democratic Republic, the 2011-2012 Lao Social Indicator Survey [12] while providing the necessary sub national figures for the analysis did not use GPS devices to locate the surveyed clusters. As such, the analysis reported under point 2 here above have been performed when it comes to the utilization of EmOC services in the Lao People's Democratic Republic. 12

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

The real number of surgical teams being unfortunately not available for each facility in the country, only analysis 5.2 has been performed when it comes to the utilization of CEmOC services.

5.4 Scaling up analyzes Objective: Provide the necessary information to allow for an estimation of the cost to reach universal coverage in the country (90% of all births with geographic coverage and 5% of births delivering in BEmOC facilities to reach CEmOC facilities in less than 2 hours and having enough capacity to answer the demand). Method: The method used for this analysis depends on the results of the geographic coverage analysis, namely: 1. If the results of the geographic coverage analysis shows that 90% of all births in the country can reach a BEmOC facility within 2 hours, that the concerned BEmOC facilities have enough capacity to answer the demand, that 5% of these births can reach a CEmOC facility in less than 2 hours in case of complications and that the concerned CEmOC facilities have the necessary capacity to answer the demand, then there is no need for scaling up physical access to care as the country is theoretically reaching universal accessibility and geographic coverage as per the definition used in the context of this project; 2. If the results of geographic coverage analysis shows that 90% of all births in the country can reach a BEmOC facility within 2 hours and that the existing BEmOC facilities have enough capacity to answer the demand but that less than 5% of these births can reach a CEmOC facility within 2 hours in case of complications and/or that the concerned CEmOC facilities do not have enough capacity to answer the demand then the present analysis will look at: a. Seeing if converting some of the BEmOC facilities into CEmOC ones and/or upgrading some facilities to perform CEmOC signal functions would bridge the gap; b. using AccessMod (See Chapter 4) to model the construction of additional CEmOC facilities until covering these 5% of births if necessary (for that, national norms or, if not available, estimated number of EmOC surgical teams and operating theatres for different types of health facilities will be used during the analysis). 3. If the results of accessibility coverage analysis shows that less than 90% of all births in the country can reach a BEmOC facility within 2 hours and/or that the concerned BEmOC facilities do not have enough capacity to respond to the demand, then the analysis will be completed in two phases: a. The modelling assumes that the current BEmOC network will be expanded until reaching 90% of all births in the country by: i. Either looking at expanding the coverage capacity of existing BEmOC facilities; 13

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

ii. Or upgrading some facilities to perform all 7 BEmOC signal functions; iii. Or using the AccessMod to model the construction of new BEmOC facilities if necessary (for that, national norms or, if not available, WHO norms regarding the number of births covered by skilled birth attendant per year will be used to determine different types of facilities to be considered in the analysis) b. The geographic coverage analysis for CEmOC facilities will be conducted on the expanded BEmOC facility network obtained under point “a” to see if there is a CEmOC facility within 2 hours of travel time from each BEmOC facility and enough capacity in these CEmOC facilities to answer the demand: i. If this is the case, then these results would be used to provide the information for the cost analysis. ii. If this is not the case, then the network of CEmOC facilities will be expanded until reaching the 5% of the births covered by the network of BEmOC facilities following the steps reported in point 2 here above. The results of this analysis will then be used to estimate the cost to reach universal geographic coverage. Note: When the information is available, facilities that have been identified, through a recent EmOC assessment for example, as providing some but not all the EmOC functions will be used during the scaling up analysis and this because improving the quality of care in these existing facilities would incur a lower cost than the construction of new facilities. The analysis will thus differentiate between: 1. Number and location of facilities that would be upgraded. 2. Number and location of facilities that would be constructed Output: As mentioned here above, the outputs will depend on the results of the geographic coverage analysis: - 1st case here above: o The files obtained from the geographic coverage analysis will be used as a reference but no cost analysis would be needed as the country is estimated to reach universal accessibility and geographic coverage; - 2nd case here above: o Excel file containing the list of the new CEmOC facilities (converted BEmOC facilities and/or new facilities), including corresponding number of EmOC surgical teams and equipment that would need to be built to reach universal geographic coverage. The cost analysis would then be conducted on the basis of the results of the geographic coverage analysis as well as this new file - 3rd case here above: o Excel file containing separated worksheets for: 14

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

i. The number of births covered by each BEmOC facility taking 2 hours of travel time and its respective coverage capacity into account. Real number of births will also be included in this worksheet if the information is available. ii. The number of births referred to each CEmOC facility because of complications (5% of the births reaching the BEmOC facilities) with an estimation of the expected number of EmOC surgical teams needed to cover the demand. Real number of C-sections would also be included in this worksheet if the information is available. o Map showing the location of the new BEmOC and CEmOC facilities on top of the existing ones. These outputs will then be used to estimate the cost for scaling up the existing EmOC delivery system to reach universal geographic coverage as considered in the context of this project (Figure 1). For the 2nd and 3rd case mentioned here above, the cost analysis would include the cost of commodities and supplies required, including blood transfusion for CEmOC facilities, as coverage is expanded and additional women are seen in EmOC facilities. The outputs can also be used to evaluate the pertinence of the current UN indicators when it comes to the geographical distribution of EmOC facilities (Indicators 1 and 2 in Annex 2).

6. Data and national norms used in the different analysis Performing the different analysis considered in the context of this project requires an important volume of data that can be grouped into three main categories: Statistical data, Geospatial data, National norms, From a statistical point of view, data collected at different levels are being used, namely: 1. At the national level i. Total population and number of births; ii. Total and urban/rural Crude Birth Rate (CBR); 2. At the sub national level i. CBR or fertility rate if the CBR is not available; ii. Total population as well as breakdown by age groups and sex if using the fertility rate in (i); iii. Percentage of births delivered in all health facilities; iv. Percentage of births delivered by C-section. 3. At the cluster level (Household survey): i. Total number of non-assisted home deliveries. 15

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

4. At the health facility level: i. For BEmOC, including CEmOC, facilities: 1. Number of medical staff qualified to attend normal deliveries (skilled birth attendant); 2. If available, total number of normal deliveries over a recent year. ii. For CEmOC facilities: 3. Number of operational EmOC surgical teams (meaning including functional operating theaters); 4. If available, total number of C-sections operated over a recent year. From a geospatial perspective, the different analysis requires to have the following GIS layers at disposal: 1. Administrative boundaries matching the level of desegregation of the sub national statistical data; 2. Geographic location of all the EmOC facilities based on the most recent assessment available, 3. Transportation network; 4. Hydrographic network (major rivers and water bodies); 5. Location and extension of the cluster for the household survey data; 6. Land cover including the extend of urban areas; 7. Digital Elevation Model (DEM); 8. Spatial distribution of the number of births. In addition to these layers, a mosaic of satellite images has been used as ground reference to: - evaluate the accuracy, and to some extend level of completeness, of the different layers - insure consistency among the different source of GIS The mosaic used in the context of this project has been collected through the Landsat ETM+ program and downloaded from the Earth Science Data Interface (ESDI) at the Global Land Cover Facility [9]. When it comes to national norms, the different analysis requires having the following in hands when they exist: 1. Acceptable workload for skilled birth attendant (SBA) in BEmOC facilities (i.e. number of births per SBA per year); 2. Acceptable workload for EmOC surgical teams in CEmOC facilities (An EmOC surgical team includes one surgeon, one nurse, one anesthesiologist as well as a functional operating theater (other functions might also be required but these are the minimum essential ones); 3. Maximum travel speed expected for a motor vehicle on the different types of roads observed in the country.

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

The following sections describes more in details the sources of the data and norms used for the Lao People’s Democratic Republic as well as the potential preparation, adjustments or transformations that have been used to obtain the final dataset necessary to implement the different analysis described in Chapter 5. It is important to emphasize here the temporal discrepancies that exist between the different datasets that have been used. While from a statistical perspective the project mostly used 2011-12 Lao Social Indicator Survey (MICS/DHS) [12] and the National Emergency Obstetric and Newborn Care Needs Assessment conducted between 2010 and 2011 [15], from a geospatial perspective the representativeness of some of the layers, mainly the transportation network and land cover, are difficult to estimate as the associated metadata is not available. A temporal shift is therefore possible between the two types of data and has to be taken into account when analyzing the results presented here. In addition to that, the needs assessment used in the present study has been conducted back in 2010-11 and was not comprehensive (see section 6.1.4). The situation depicted here might therefore not only be incomplete at the time of the assessment but might also have changed, in terms of both the EmOC infrastructures and associated human capacities. Apart from that, additional data are also necessary for conducting the subsequent cost analysis but these are not detailed here as the costing is not part of the analysis being conducted so far. Such analysis would require data on costs for commodities, supplies, human resources, equipment, upgrade/maintenance and construction costs for facilities, depending on the strategies elected for the scale-up analysis.

6.1 Statistical data 6.1.1 National level figures To ensure a certain level of comparability between countries that are part of this project it has been decided to use the 2011 medium variant of the total national population produced by the United Nations, Department of Economic and Social Affairs in its 2010 revision [10]. In the case of the Lao People's Democratic Republic, this corresponds to a population of 6’288’000 inhabitants. Along the same line, the total number of births reported in the 2011 State of World's Midwifery report from UNFPA [11] has been used as a reference to crosscheck the total number of births estimated at the sub national level. For Lao People's Democratic Republic, the total number of births reported in this report for 2008 is of 170’000. When it comes to the total as well as urban/rural Crude Birth Rate (CBR) these have been obtained from the 2011-12 Lao Social Indicator Survey (MICS/DHS) [12] and shows as follow: 17

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Urban : 20 Rural: 26 Total: 25

6.1.2 Sub national level figures Sub national level CBR being not available for the Lao People's Democratic Republic, the Province level fertility rate measured in the context of the 2011-12 Lao Social Indicator Survey (MICS/DHS) [12] have been used instead. These figures are reported in Annex 4. The Province level total population as well as the breakdown by sex and specific age groups was also necessary to be able estimating the Province level number of births for 2011 These figures (Annex 4) have been obtained from the 2011 Mid-year population estimate produced by the Lao Statistics Bureau on the basis of the 2005 Population and Housing Census [13]. From there, the number of births for the year 2011 was estimated using the 2011-12 Lao Social Indicator Survey (MICS/DHS) [12] and the female population for the 15-49 years old age group using the formulas described here: http://dematerialism.net/CBR_TFR.html. Few important elements when looking at the corresponding results in Annex 4: - When applying the above mentioned formula, it has been considered that the total number of births and female in each 5 years age cohort over the 15 to 49 age group was identical. This is a very rough assumption but the only approach possible here because of the available data at the Province level; - The Province names reported in this annex are those provided by the General Department of Cadastre and Geography of Cambodia in the context of the Second Administrative Level Boundaries (SALB) dataset project [14]. The Province codes are those generated in the context of this project as well, these are therefore not official codes from the country. Finally, the CBR obtained for 2011 on the basis of the 2011 fertility rate has been applied to the 2011 population adjusted to match the UN total country figure to obtain the Province level estimated number of births in the country in 2011 (Annex 4). The last set of sub national figures concerns the Province level percent distribution of women age 15-49 who had a live birth in an health facility, public or private, in two years preceding the survey (Table 3) and percentage of births delivered by caesarean section (C-section) in a public or private facility in the two years preceding the survey (Table 4) as collected during the 2011-12 Lao Social Indicator Survey (MICS/DHS) [12].

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Province Name Percentage of births delivered in a health facility (all level) [14] Public sector Private sector Total Attapu 18.7 0.5 19.2 Bokeo 25.5 5.2 30.7 Bolikhamxai 51.7 0.5 52.2 Champasak 25.1 0.3 25.5 Houaphan 21.4 0.0 21.4 Khammouan 27.1 2.4 29.6 Louang-Namtha 42.3 0.0 42.3 Louangphabang 34.1 0.0 34.1 Oudomxai 20.5 0.3 20.8 Phongsali 18.1 0.0 18.1 Salavan 26.5 0.2 26.7 Savannakhet 37.7 1.2 38.9 Xekong 25.6 0.0 25.6 Vientiane 52.8 0.5 53.3 Vientiane Capital 81.6 2.3 83.9 Xaignabouli 33.1 0.0 33.1 Xiangkhouang 34.7 0.0 34.7 Nationwide 36.7 0.8 37.5

Table 3 - Province level percent distribution of women age 15-49 who had a live birth in an health facility in the two years preceding the survey [Extracted from 12] Percentage delivered by c-section Attapu 2.6 Bokeo 4.3 Bolikhamxai 3 Champasak 4.3 Houaphan 1.8 Khammouan 2.5 Louang-Namtha 1.2 Louangphabang 2.8 Oudomxai 1.1 Phongsali 0.4 Salavan 1.4 Savannakhet 2.3 Xekong 0.5 Vientiane 3.1 Vientiane Capital 15 Xaignabouli 4 Xiangkhouang 2.3 Province Name Total 3.7

Table 4 - Percent distribution of births delivered by caesarean section (C-section) in a public or private facility in the two years preceding the survey [Extracted from 12]

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

6.1.3 Cluster level figures GPS devices having not been used during the 2011-12 Lao Social Indicator Survey (MICS/DHS) it was not possible to geographically locate each of the surveyed clusters. As such, the analysis looking at geographically comparing the location of non-assisted home deliveries with the distribution of travel time as an estimation of service utilization (see section 5.3) was unfortunately not possible in the context of this project. 6.1.4 Health facility level figures This project considers public facilities for which the signal functions used to identify basic and comprehensive emergency obstetric care services as defined in the 2009 handbook [2] have been confirmed through either an assessment or the Ministry of Health. In the case of the Lao People's Democratic Republic, the list of EmOC facilities identified as fully functional during the National Emergency Obstetric and Newborn Care Needs Assessment conducted between 2010 and 2011 [15] has been used. This list counts 4 BEmOC facilities and 14 CEmOC facilities as presented in Annex 5. Please note that the EmOC codes reported in this Annex do not correspond to an official code but a temporary one used in the context of this project. Unfortunately, this assessment did not cover all the health facilities providing Maternal and Newborn health care in the country but a sample of 68 health facilities among the type A and B district hospitals. This sample covered all 6 central hospitals, 16 provincial health facilities, all 21 type A district hospitals, which corresponds to hospital where surgery is practice, and 25 type B district hospitals where no surgery is being practiced. the 2010-11 needs assessment was therefore not comprehenssive. It is also important to mention here that facilities that are not reporting to the Ministry of Health (private facilities for example) have not been considered in the context of the present project. As such, the accessibility and geographic coverage measured in the context of this study might be underestimated. Without a comprehensive assessment it is nevertheless not possible to estimate the amplitude of this underestimation. Concerning the different data needed at the health facility level (see beginning of Chapter 6), the following information have been obtained from the Ministry of Health for the year 2012 by the time of conducting the present study, namely the number of: - Medical workers qualified to attend normal deliveries, and therefore considered as Skilled Birth Attendants (SBA), in BEmOC, including CEmOC, facilities (Table 5); - Medical workers who followed the necessary modules (ANC, PNC, Basic emergency Obstetric and Newborn) to be considered as SBA (Table 5); 20

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Institutional deliveries, considering that they have all been attended by a SBA (Table 5); Medical workers qualified to perform C-sections and/or anesthesia (Table 6); Operating theaters (Table 6); Births delivered by C-sections (Table 6). Number of medical workers qualified to attend normal deliveries (SBA) Number of Number of institutional SBA trainees deliveries (MOH, (MOH, 2012) 2012) 2 3 5 2 NA NA 1 5 NA 5 NA NA NA NA NA 6 NA NA 777 749 265 223 NA 4913 210 1929 2575 2081 324 1009 355 3181 1195 1268 1979 3320

EmOC code

EmOC Name

Health Facility type Midwifes Nurses Doctors 19 24 5 10 NA 58 31 147 101 10 NA 41 19 119 146 28 92 272 6 5 3 1 NA 46 10 45 88 4 NA 23 3 60 92 10 36 182

Assistant Doctors 10 6 3 4 NA 1 5 48 13 0 NA 6 6 41 23 10 16 28

Total 35 38 15 16 NA 110 46 240 237 17 NA 71 29 222 261 54 147 485

B1 B2 B3 B4 C1 C10 C11 C12 C13 C14 C2 C3 C4 C5 C6 C7 C8 C9

Adsaphangthong Khongsedone Viengthong Xam Tai 103 H MCH Hospital Phongsaly Savannakhet Setthathilat Xiengkhouang 109H Bolikhamxay Champasack (District) Champasack(Pakse) Friendship(Mittaphab) H Khamkeuth Khammouane(Thakek) Mahosot

DHA DHA DHA DHA CH CH PH PH CH PH CH PH DHA PH CH DHA PH CH

0 3 4 1 NA 5 0 0 35 3 NA 1 1 2 0 6 3 3

Table 5 - Number of medical worksers qualified to attend a normal delivery, number of SBA trainees and number of institutional deliveries in BEmOC, including CemOC, facilities for 2012 (MOH) CEmOC Code C1 C2 C3 C4 C5 C6 C7 C8 C9 C10 C11 C12 C13 C14 CEmOC Name 103 H 109H Bolikhamxay Champasack (District) Champasack(Pakse) Friendship(Mittaphab) Khamkeuth Khammouane(Thakek) Mahosot MCH Hospital Phongsaly Savannakhet Setthathilat Xiengkhouang Number of medical Health workers qualified to Facility Type perform C-sections (MOH, 2012) CH NA CH NA PH 3 DHA 0 PH 6 CH 17 DHA 1 PH 3 CH 7 CH 7 PH 2 PH 4 CH 8 PH 1 Number of medical workers qualified to perform anesthesia (MOH, 2012) NA NA 2 0 2 11 0 2 11 2 1 2 1 0 Number of Number of Coperating sections (MOH, theaters 2012) (MOH, 2012) 2 NA NA 51 1 102 1 5 4 463 13 112 1 27 2 182 13 434 2 1070 1 8 2 242 4 272 2 176

Table 6 – Number medical workers qualified to perform C-sections and/or anesthesia, number of operating theaters and number of births delivered by C-sections in 2012 (MOH) 21

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Please note that some of these figures are unfortunately missing for several health facilities (highlighted in grey in Table 5 and 6). Despite the gap in data, we can observe a big difference between the number of SBA trainees and the total number of medical workers qualified to attend normal deliveries. This difference will be addressed at the time of performing the geographic coverage analysis (see Section 7.2)

6.2 Geospatial data When it comes to projection, it has been decided to use the Universal transverse Mercator (UTM) projected coordinate system, as the data needs to be projected in a metric system when using AccessMod. In this system, the Lao People's Democratic Republic finds itself in between two zones, zone 47 and 48. As more than 85% of its surface finds itself in zone 48 it has been decided to use this one. Here are the different elements that define this particular projected coordinated system when it comes to the UTM zone in which the Lao People's Democratic Republic is located (Zone 48) as they appear in Esri’s GIS software: - Projected Coordinate System: WGS_1984_UTM_Zone_48N - Projection: Transverse_Mercator - False_Easting: 500000.00000000 - False_Northing: 0.00000000 - Central_Meridian: 105.00000000 - Scale_Factor: 0.99960000 - Latitude_Of_Origin: 0.00000000 - Linear Unit: Meter The geographic coordinate system on which the UTM system is based is the following: - Geographic Coordinate System: GCS_WGS_1984 - Datum: D_WGS_1984 - Prime Meridian: Greenwich - Angular Unit: Degree The spatial resolution of the GIS data in raster format used in this project (land cover, DEM and birth distribution) has itself been decided based on two criteria: 1. The resolution of the freely available data for the concerned layers; 2. The volume of RAM memory in the computer used for performing the different analysis as this is unfortunately one of the limiting factor when using AccessMod. In view of the above, the spatial resolution finally used is of 1 km when the data is unprojected. This corresponds to 915.8078547 meters for the Lao People's Democratic Republic once projected according to the above-mentioned projected coordinate system. 915 meters is to be considered as a low resolution that induces an important simplification of the reality when performing the different analysis in AccessMod. 22

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

As an example, a road, which in reality would seldom be wider than 10 meters, would be presenting a width of 915 meters during the different analysis. This has two major implications: 1. The traveling speed within the cells crossed by road segments would be higher than in the reality for patients on their way to the road as the model would consider the patient to be travelling by road over the all surface of these cells while he would normally still have to cross some lands by feet before reaching the road; 2. When roads are located along rivers the combination of the layers in AccessMod might result into the creation of “artificial passages” and therefore potential crossover that do not exist in the reality. While it has been possible to make some adjustments in the road and hydrographic GIS layers regarding the second point (see Section 6.2.5) nothing can unfortunately be done when it comes to the first one. Because of this, catchments areas obtained with AccesMod tend to be a little bit bigger than what they should be. This said, it is difficult to quantify this error (see AccessMod user manual for some figures), error that could finally happen to be much smaller than those generated by some of the other assumptions made in the context of this project. Taking the above into account, the following sections describe more in details the source of the GIS data used in the context of this project as well as the modifications performed on them before conducting the different analysis described in Chapter 5. 6.2.1 Administrative boundaries In order to be able to use the Province level demographic data (Annex 3) and other data collected in the context of this project (see section 6.1.2) it was necessary to have access to a GIS layer containing the boundaries of these Provinces. The layer in question has been generated on the basis of the village boundaries layer downloadable from DECIDE Info online platform developed by the Government of the Lao People's Democratic Republic [16]. The result layer contains the delimitation of the 17 Provinces observed in the country since January 2006 (Figure 2).

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Figure 2 –Province boundaries used in the different analysis 6.2.2 Geographic location of the EmOC facilities The geographic location (latitude and longitude) of the 18 EmOC facilities being not available at the time of the study this information has been generated using two different approaches: - By locating the facility on Google map when this was possible. This has been the case for 11 facilities as reported in Annex 5; - Using the boundary of the village in which the facility is located as reported in the GIS layer accessible from the DECIDE Info platform [16] and then identifying the most probable location for the facility based on both the satellite image and the road network layer (See section 6.2.4). This approach has been used for the remaining 7 facilities (information also reported in Annex 5). The location resulting from the above are reported in Figure 3.

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Figure 3 – Location of the EmOC facilities used in the different analysis The use of the second approach generates some error, error that remain difficult to estimate as it very much depends on the size of the village, the completeness and accuracy of the road network as well as the interpretation made by the GIS technician regarding the probable location of the facility. A rapid visual estimation indicates that this error could vary between 250 meters and 5 kilometers. By lack of resources, it has not been possible to further improve the accuracy of these coordinates and the analysis presented here have therefore been performed on the basis of the data reported in Figure 3. 6.2.3 Land cover including the extend of urban areas This project used the freely accessible 1 km resolution global land cover distribution grid developed in the context of the Global Mapping project by the Geospatial Information Authority of Japan, Chiba University and collaborating organizations using satellite images collected in 2003 [17].

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

In order to consider land cover classes pertinent to patient movements outside of the transportation network, the original classification has been simplified as per the table reported in Annex 6. The other change operated was to integrate the extend of urban areas from the Global Rural-Urban Mapping Project (GRUMP) [18] into the original land cover layer where this particular class is not well identified. This integration has been done following the process reported in Annex 7. Figure 4 presents the map resulting from this process.

Figure 4 – Land cover distribution layer used in the different analysis 6.2.4 Transportation network The road network layer used in the context of the project is coming from the Lao National Geographic Department (NGD). This layer generated at a scale of 1:100’000 has been updated in 2010 and contains the following road categories (CLSID code): - 2101: Paved road, - 2102: Street town, - 2103: Improved unpaved road, - 2104: Unpaved road, - 2105: Temporary road, - 2106: Footpath, - 2107: unknown. 26

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

The following changes and improvements have been implemented on the original dataset: 1. Segments classified as footpath have been removed as the model does already take into account travel by feet outside of the road network; 2. Segments classified as temporary or unknown road types were reclassified into Unpaved roads 3. Discontinuities observed in the road network have been checked on google map to see if they were real disconnects due to natural barriers (hydrographic network) or just implemented for cartographic purposes (visualization) in NGD layer. When the second applied, these discontinuities have been corrected manualy in the layer; 4. The layer resulting from step 3 has then been compared with the OpenStreetMap (OSM) road network [19] to identify segments that were not included in the original NGD file or needed to be improved as being too generalized. At the end of this process, few areas in the countries where finding themselves isolated from any road network, namely: - Nakai-Nam Theun National bio-diversity conservation area, - Xe Xap National bio-diversity conservation area, - Dong Amphan National bio-diversity conservation area, - One area in the southern part of the country. Looking at these areas in Google Map it became obvious that some population were living there and that they were most probably using the river network for traveling due to the absence of roads. It has therefore been decided to add some specific river segments to the road network in order to account for this type of transportation but only in these areas in the country. After this last step, the resulting map (Figure 5) contains the following categories for the transportation network: - Paved road - Improved unpaved road - Street town - Unpaved/temporary road - Rivers used for navigation

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Figure 5 - Transportation network layer used in the different analysis 6.2.5 Hydrographic network The hydrographic network layers (lines and polygons) used in the context of the project are also coming from the Lao National Geographic Department (NGD). The following changes have been applied on these layers: - River network (line layer): o The segments classified as secondary rivers (CLSID=5102) have been removed as not permanent water bodies; o The segments located on polygons classified as secondary rivers (CLSID=5102) in the water bodies layer have also been removed; o The segments presenting the CLSID 5111 and located on water bodies (polygon layer) have been reclassified into main rivers (CLSID=5101). These segments have not been removed from the dataset for the following reasons: by removing them the continuity between lines and polygons would have been lost and should have been corrected manually, Working at a resolution of 1 km having both a line and a polygon for some segments was not generating any errors when using AccessMod.

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

water bodies (polygon layer): o The polygons presenting CLSID of 0 have been removed because they corresponding to islands in the middle of water polygons; o Because of the resolution of work for the project (1km2) all water bodies smaller than 0.25 km2 (e.g. fish pounds) have been removed.

The hydrographic network layer resulting from the above operations is presented in Figure 6.

Figure 6 – Hydrographic network layer used in the different analysis Because of the low resolution used in the context of this project (around 915 meters) adjustments have then been made on this layer in order to ensure that once converted into raster format in AccessMod the road network was not generating any artificial passages in the dataset. This has been done by combining the land cover (Figure 4), road (Figure 5) and hydrographic network (Figure 6) layers using the first module of AccessMod and then manually correcting areas where these artificial passages where appearing.

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Figure 7 gives an example of the type of corrections that have been implemented in order to keep the consistency between roads and rivers, namely: - In Figure 7a two artificial passages (red arrows) have been created by the overlap of the road network converted into raster cells (in green) over the river network (in white) while the original vector layers (lines) clearly shows that there are no existing crossover between the left and right side of the river; - To correct this, a buffer equivalent to 1.7 time the resolution of the grid has been created around the road network (blue area on Figure 7b). The river segments located within this buffer have been manually moved outside its surface to adjust for the overlap (light blue line on Figure 7c); - Once the first module of AccessMod applied on the modified layer created under the previous step we can see on Figure 7d) that the two artificial passages are not there anymore and that the river is therefore playing its role of barrier to movement.

c) d) Figure 7 – Example of correction made on the river network layer to keep the consistency between the road and the hydrographic network

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

6.2.6 Digital Elevation Model The freely accessible 1 km Shuttle Radar Topography Mission (SRTM) dataset produced in 2000 by the NASA in collaboration with other institutions [20]. The only changes that have been applied on the original dataset were to reclassify altitude below the sea level to 0 meters and to project it according to the projected coordinate system used in the context of the project (see section 6.3). The layer resulting from these operations is reported in Figure 8.

Figure 8 – Digitial Elevation Model (DEM) used in the different analysis 6.2.7 Spatial distribution of the number of births When using AccessMod, there is a need to spatially distribute the number of births down to the resolution of the other projected GIS layers (around 916 meters in the case of the Lao People's Democratic Republic). This has been done using the Province level number of births estimated for 2011 (see section 6.1.2 and Annex 4), a population distribution grid as well as the process described in Annex 8. Through this process, no births are being placed on water bodies nor on areas that would be out of reach as per the result of the accessibility coverage analysis. 31

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

A population distribution grid is a modeled spatial distribution of the population down to a certain level of desegregation or resolution. Such model provide a picture of the probability for the population to be located in a given part of the country based on some criteria such as, but not limited to: distance to the road network, slope,…. The geographic expression of this probability is what is being used here to obtain the final spatial distribution of the number of births in the country. In the context of this project, the 2008 edition of the proprietary Landscan population distribution grid [21] has been preferred over other free datasets such as the Gridded Population of the World (GPW) [22] or WorldPop project [23]. The reason for this choice is linked to the spatial resolution of the Landscan dataset (1 km) and to the approach being used to generate this dataset as it provides more homogeneity from one country to the other than the WorldPop datasets. Figure 9 presents the resulting birth distribution grid that has been used in the different analysis conducted in the context of the present project.

Figure 9 – Spatial distribution of the number of births used in the different analysis

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

6.3 National norms Two different sets of national norms are needed to produce the outputs listed in Chapter 5, namely: - The maximum acceptable workload for: o skilled birth attendants in BEmOC facilities; o EmOC surgical teams in CEmOC facilities; - The maximum speed expected on the different road types observed in the country The absence of a national norm for the maximum acceptable workload for both SBAs in BEmOC facilities and EmOC surgical teams in CEmOC facilities required to decide on some benchmarks in consultation with the WHO Country Office in the Lao People's Democratic Republic. When it comes to the maximum workload for skilled birth attendants, and while waiting for a consensus to be reached, the proposed indicators reported in the 2008-2012 Skilled Birth Attendance Development Plan [24] have been used in the context of the present study, namely (National Average: 1SBA for 55 births): - 1 in 35 births for Health Centres, - 1 in 75 for District Hospitals, - 1 in 100 for Provincial Hospitals, - 1 in 175 for Central Hospitals. Regarding the maximum workload for EmOC medical teams, and considering that such a team needs to be composed of at least one medical worker qualified to perform C-sections; one qualified to perform anesthesia as well as an operating theater, the list of CEmOC facilities reported in Table 6 has been expended to also include other Provincial Hospital for which the information regarding the number medical workers, operating theaters and Csections performed in 2012 was available (Table 7). It is important to note here that C-sections have been taking place in health facilities for which either the medical worker qualified to perform C-sections or one qualified to perform anesthesia were not available as per the data from the MOH. At least one operating theater was nevertheless present when C-sections were reported. As listed in Table 7 only the facilities for which the three elements were present. The number of CEmOC surgical team has been estimated before obtaining the mean number of C-sections per CEmOC surgical team (also reported in Table 7). As we can see in Table 7, the mean number of C-sections per CEmOC surgical team present an important variation depending on the health facility type: - from 10 to 535 for Central Hospitals; - from 8 to 231.5 for Provincial Hospitals.

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Health facility name

Health facility type CH CH CH CH PH PH PH PH PH PH PH PH PH PH PH

Province name

Number of medical Number of medical workers qualified workers qualified to to perform Cperform anesthesia sections 7 8 7 17 6 4 4 2 3 4 3 1 8 3 2 2 1 11 11 2 2 2 1 2 1 2 1 9 2 1

Number of operating theaters 2 4 13 13 4 2 2 5 1 2 2 2 2 2 1

Estimated number of CEmOC surgical teams 2 1 7 11 2 2 2 1 1 1 2 1 2 2 1

Number of Csections (2012, Stat unit MOH) 1070 272 434 112 463 242 230 109 102 102 182 60 102 50 8

Mean number of C-sections per CEMOC surgical team 535 272 62 10 231.5 121 115 109 102 102 91 60 51 25 8

MCH Hospital Setthathilat Mahosot Friendship(Mittaphab) Champasack(Pakse) Savannakhet Luang Prabang Attapu Bolikhamxay Luang Namtha Khammouane(Thakek) Saravan Maria Teresa Oudomxay Phongsaly

Vientiane Capital Vientiane Capital Vientiane Capital Vientiane Capital Champasack Savannakhet Louangphabang Attapu Bolikhamxai Louang-Namtha Khammouan Salavan Vientiane Oudomxai Phongsali

Table 7 - Number medical workers qualified to perform C-sections and/or anesthesia, number of operating theaters, number of births delivered by C-sections as well as estimated number of CEmOC surgical teams and corresponding mean C-sections per team for 2012 (MOH) These variations might be explained by: - incomplete data both in terms of staff and/or number of C-sections, especially for the Friendship (Mittaphab) Central Hospital and Champasack Province Hospital; - important variations in overload from one hospital to the other. Taking this into account, the country specific context, the values considered for the other countries covered by the present study (145 for Cambodia and 157 for Malawi) and waiting to have a more official figure, it has been considered that the maximum acceptable workload for an EmOC surgical team was of 140 C-sections per year independently from the type of hospital.

Regarding the second set of norms, it has unfortunately not been possible to find national norms regarding the maximum speed expected on the different road types observed in the country. Starting from the WHO 2009 global status report on road safety [25] which indicates a maximum speed of 40 km/h on urban roads and of 50 km/h on rural ones for the Lao People's Democratic Republic, and using inputs received from people living in the country, a maximum expected speed for each type of road (Figure 5) has been identified (Table 8). In addition to this, following the assumptions considered in this project (see Chapter 3), the maximum traveling speed for a pregnant woman walking in her last month of pregnancy (estimated as 50% of the speed of a woman not being pregnant, i.e. 2.5 km/h in an open area) has been attributed for each land cover class considered here (Figure 4). These speeds are also reported in Table 8.

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Land cover/ road type Bare areas Urban Low dense vegetation Medium dense vegetation Dense vegetation Primary road Secondary road Tertiary road Urban road

Maximum speed (km/h) 2.5 2.5 2 1.5 1 80 70 60 50

Transportation media Feet Feet Feet Feet Feet Vehicle Vehicle Vehicle Vehicle

Table 8 – Maximum travel speed on the different land cover and road types considered in the different analysis Please note that movements by boat have been considered only in certain part of the country in the context of this study while this transportation media is certainly being used all over the Lao People's Democratic Republic.

7. Results This Chapter presents the results obtained for each of the analysis described in Chapter 5. 7.1 Accessibility coverage analyzes This set of analyzes looks at measuring how the BEmOC, including CEmOC, facilities are accessible, in terms of travel time, to the population and how fast can a patient be transferred from a BEmOC facility to the nearest CEmOC facility in case of complications requiring a C-section and/or blood transfusion. These analyzes have been performed using the following GIS layer and associated data described in the previous Chapter: 1. Province boundaries (see Section 6.2.1) 2. Location of the EmOC facilities (see Section 6.2.2); 3. Land cover (see Section 6.2.3) 4. Transportation network (see Section 6.2.4), 5. Hydrographic network (see Section 6.2.5), 6. Digital Elevation Model (DEM) (see Section 6.2.6), 7. Births distribution (see Section (6.2.7) 8. The following travelling scenarios a. From home until the nearest BEmOC facility: i. Pregnant woman walking or being carried until reaching a road and then taking a motor vehicle ii. Pregnant woman walking or been carried only b. Between the BEmOC facility and the nearest CEmOC facility in case of complication: 35

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

i. Use of a motor vehicle 9. The maximum travelling speeds reported in Table 8. The first module of AccessMod has then been used to generate the combine land cover and scenario file and have the maximum travelling speeds reported in Table 8 integrated into it. These two files, the DEM as well as the location of the BEmOC, including CEmOC, facilities have then been used as the input data for the second module of AccessMod. The first result coming out of this module is the spatial distribution of the travel time to the nearest BEmOC, including CEmOC, facility when considering that pregnant women are walking, or being carried, until reaching the transportation network and then taking a motor vehicle/boat until the facility (Figure 10).

Figure 10 – Travel time to the nearest BEmOC facility considering that pregnant women are walking, or being carried, until reaching a road and then taking a motor vehicle until the facility The traveling scenario table has then been modified to consider that women would only be walking or being carried until the nearest BEmOC facility. In this case, the maximum speed on any road was considered to be of 2.5 km/h and navigation on rivers was not considered possible. Figure 11 presents the results when using this scenario. 36

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Figure 11 – Travel time to the nearest BEmOC facility considering that pregnant women are walking, or are being carried, until reaching the facility What we can directly see from Figure 10 and 11 is that the possibility to travel by a motor vehicle/boat once reaching the transportation network has a very important positive impact on accessibility coverage. This confirms the importance of any programs aiming to facilitate the timely transportation of pregnant women to the nearest EmOC facility at the moment of delivery. Using GIS makes it possible to extract the Province level number, and therefore indirectly the percentage of births where the household is located within 2 hours of travel time from a BEmOC facility for both considered scenarios (Annex 9). Annex 9 confirms the visual observation made here above that when women have no access to motor vehicle but are only able to reach facilities by walking or by being carried, the accessibility coverage at the national level is very low, reaching 11.3 %. When considering the combined walking/carried – motor vehicle scenario, 97,270 of births (66.9% ) would reach a BEmOC facility within 2 hours of travel time, which indicates that the Lao People's Democratic Republic does not reach universal accessibility coverage to BEmOC facilities at the national level when considering the

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

facilities identified during the 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment (Annex 5). At the Province level (Annex 9 and Figure 12), and only considering the combined walking/carried- motor vehicle scenario, we can see the country being separated into different zones: - The central part (Provinces of Bolikhamxai, Khammouan, Savannakhet, Vientiane Capital and Xiangkhouang) where accessibility coverage is above the 90% benchmark set for universal accessibility coverage; - The Northern part of the country which is subdivided into a zone composed of the Provinces of Bokeo, Louang-Namtha, Louangphabang, Oudomxai and Xaignabouli and which is presenting a very low accessibility coverage, reaching even 0% in the Provinces of Bokeo, Louang-Namtha and Xaignabouli and pockets of moderate accessibility coverage (between 50 and 90%) in the Provinces of Houaphan, Phongsali and Vientiane; - The Southern part of the country separated into a zone composed of the Provinces of and which present an accessibility coverage between 50 and 90% and the Province of Attapu which does itself present an accessibility coverage below 25%.

Figure 12 – Province level percentage of births located within 2 hours from a BEmOC, including CEmOC, facilities when considering the combined walking/carried-motor vehicle scenario 38

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

The second module of AccessMod has been used to identify the travel time between each BEmOC, including CEmOC, facility and the nearest CEmOC facility. The result of this analysis is reported in Annex 10. In this Annex facilities are listed by Province along with the travel time to the nearest CEmOC facility. Most of the BEmOC facilites identified during the 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment [15] being actually CEmOC facilites the travel time reported for them in Annex 10 is therefore equivalent to 0. For the facilities providing only BEmOC services, we can observe that the travel time is always inferior to two hours for 3 of them but largely over that benchmark for the last one, Xam Tai District Hospital, with 254 minutes (4.2 hours). In view of the above, the Lao People's Democratic Republic health system does not fully comply with the condition set to define universal accessibility coverage in the context of this project when it comes to the maximum acceptable transfer time between each BEmOC and CEmOC facilities. In addition to that, the situation observed with Xam Tai District Hospital has a direct impact on the percentage of births that could reach both a BEmOC facility in less than two hours and then a CEmOC facility within an additional two hours in case of transfer for complication. This being said, the impact is quite limited as only 687 births finds themselves within two hours of travel time of Xam Tai District Hospital. As such, 96,583 births (66.45%) are finding themselves both within two hours of travel time of a BemOC facility and then an additional two hours from the nearest CEmOC facility in case of complication. This is only 0.45% less than the result of the BEmOC accessibility coverage analysis (Annex 9). It is also important to underline once more that the public health system does not comply to universal accessibility when it comes to reaching BEmOC facilities (Annex 9) and to emphasize that the results obtained for the travel time between BEmOC and CEmOC facilities are conditional to the presence of a functioning motor vehicle on site of each BEmOC facility at the moment of the referral. The transfer time would be higher would such a motor vehicle not be available at the time of the referral.

Finally, Annex 11 provides Province level information and basic statistics, namely: - The number of BEmOC, including CEmOC, facilities, - The number of CEmOC facilities, - The indication of the BEmOC, including CEmOC, facility being the closest to the Province (identified visually based on the travel time distribution grid reported in Figure 10); - The min, max and birth weighted mean travel time, expressed in hours, to the nearest BEmOC facility from within each District. The birth weighted mean travel time has been obtained by multiplying the spatial distribution of births (Figure 9) 39

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

with combined scenario travel time distribution grid (Figure 10) before summarising the value at the Province level (Figure 2) and dividing the results by the corresponding District level total number of births (Annex 4). For reference, the national level birth weighted mean travel time is of 2.27 hours. Annex 11 allows for example to see that women living in the Province of Xekong: - have to travel between 1.2 and 39.1 hours before reaching a BEmOC facility as there are currently no BEmOC facilities available in this Province. The birth weighted mean travel time for this Province is of 2.9 hours; - would most probably go to EmOC facility number B2, Khongsedone District Hospital, if needed based on the accessibility analysis. - once arrived at the Khongsedone District Hospital, would then need to travel another 53 minutes (Annex 10) in case they would need to be transferred to a CEmOC facility because of complications during delivery. In this case, the closest CEmOC facility would be the Xiengkhouang Province Hospital (Annex 10). As such, and based on this analysis only, this Province could be among those for which further analyzes could be conducted and actions taken to improve accessibility to EmOC. 7.2 Geographic coverage analyzes This second set of analyzes look at including the availability of human resources and equipment into the accessibility coverage analysis conducted in the previous section. The geographic coverage of the existing BEmOC, including CEmOC, facilities has been measured based on the same layers and data than those used for the accessibility coverage analysis (see section 7.1). The only element that has been added is the maximum coverage capacity of each BEmOC facility to account for the availability of services. The maximum coverage capacity for each facility, expressed in terms of number of assisted deliveries covered in a year by a facility, has been obtained by multiplying the total number of potential SBAs and Number of SBA trainees in each facility with the maximum acceptable workload norms reported in section 6.3 for the EmONC facilities were this information was available (12 facilities). When comparing the both maximum coverage capacities obtained through this multiplication with the 2012 corresponding number of institutional deliveries we can observe that (Table 9): - The estimated maximum coverage capacity obtained when using the total number of potential SBA is above (up to 1,144% difference) the number of institutional deliveries for 11 of these facilities and this independently from the type of facility; - The estimated maximum coverage capacity obtained when using the number of SBA trainees is below (up to 80.7% difference) the number of institutional 40

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

deliveries for 7 of the 8 facilities for which the information was available and this once more independently from the type of facility; In conclusion: - Neither the total number of potential SBA nor the number of SBA trainees seems to reflect the number of skilled personnel indeed involved in normal deliveries in BEmOC, including CEmOC, facilities; - In addition to that, the differences observed can also be explained by the fact that: o Not all skilled attendants are necessarily practicing deliveries; o The maximum coverage capacity of several of these facilities might be under used; o The maximum acceptable workload norms that are being used in Section 6.3 are not reflecting the reality. Unfortunately, the information at disposal did not allow for verifying which one of the above mentioned reasons could apply here. Maximum Maximum coverage coverage capacity (total capacity number of (number of SBA potential SBA) trainees) Difference (%) Difference (%) between between the number the number of of institutional institutional deliveries deliveries and and maximum coverage maximum coverage capacity (total number of capacity (total potential SBAs) number of potential SBAs) 597.9% -18.3% 642.8% 1144.2% 219.4% 603.7% 237.8% 280.5% 512.7% 324.5% 438.1% 2090.5% 291.8% 1510.7% 3722.2% 2456.5% NA -76.0% NA -74.1% -64.5% NA -80.7% -70.0% NA 41.5% -32.7% -52.4% NA NA NA NA

EmOC Code

Health facility name

Health facility type

EmOC Type

Total number Number of Maximum of potential SBA acceptal SBA (MOH, trainees workload 2012) (MOH, 2012)

Number institutional deliveries (MOH, 2012)

C5 C14 C8 C12 C7 C3 B1 B2 C4 B3 B4 C11 C10

Champasack(Pakse) Xiengkhouang Khammouane(Thakek) Savannakhet Khamkeuth Bolikhamxay Adsaphangthong Khongsedone Champasack (District) Viengthong Xam Tai Phongsaly MCH Hospital

PH PH PH PH DHA PH DHA DHA DHA DHA DHA PH CH CH CH CH Total

CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC BEmOC BEmOC CEmOC BEmOC BEmOC CEmOC CEmOC CEmOC CEmOC CEmOC

222 17 147 240 54 71 35 38 29 15 16 46 110 237 261 485 2023

NA 5 NA 5 6 NA 2 3 NA 5 2 1 NA NA NA NA

100 100 100 100 75 100 75 75 75 75 75 100 175 175 175 175

22,200 1,700 14,700 24,000 4,050 7,100 2,625 2,850 2,175 1,125 1,200 4,600 19,250 41,475 45,675 84,875 279,600

NA 500 NA 500 450 NA 150 225 NA 375 150 100 NA NA NA NA

3,181 2,081 1,979 1,929 1,268 1,009 777 749 355 265 223 210 4,913 2,575 1,195 3,320 26,029

C13 Setthathilat C6 Friendship(Mittaphab) H C9 Mahosot

Table 9 – Comparison between the estimated maximum coverage capacity obtained by multiplying the maximum acceptable workload norm by the number of skilled birth attendants in each facility with the 2012 number of assisted deliveries for the BEmOC, including CEmOC, facilities when this information is available In view of the above, it has been decided to consider that the maximum acceptable workload norms reported in Section 6.3 were appropriate and to then estimate a mean maximum coverage capacity for the different health facility type based on the 2012 number of institutional deliveries. In order to expand the sample size when performing this estimation, the partially functional BEmOC and CEmOC facilities considered in the scaling up analysis (Section 7.4), for which a number of assisted deliveries was reported in 2012, have been added to 41

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

the fully functional BEmOC, including CEmOC, facilities reported in Annex 5 resulting in a total sample of 81 facilities. Table 10 present the minimum, maximum and average number of assisted deliveries by health facility type among these 81 facilities, differentiating between BEmOC and CEmOC facilities, as defined during the National Emergency Obstetric and Newborn Care Needs Assessment conducted between 2010 and 2011 [15] and the improvement plan proposed in that same assessment, as well as the corresponding number of skilled birth attendants when using the maximum acceptable workload norms defined in Section 6.39. Number of facilities in the sample 6 15 35 4 16 5 81 Minimum number of assisted deliveries 114 104 17 265 210 324 Maximum number of assisted deliveries 777 1268 604 540 3181 4913 Average number of assisted deliveries 398 570 226 392 1313 2465 Maximum acceptable workload 75 75 75 75 100 175 Corresponding number of skilled birth atttendants 5 8 3 5 13 14

EmOC Type DHA (BEmOC) DHA (CEmOC) DHB (BEmOC) DHB (CEmOC) PH (CEmOC) CH (CEmOC) Total

Table 10 – Estimated minimum, maximum and average number of skilled attended births and corresponding number of skilled birth attendants by health facility type When considering the average number of assisted deliveries as the maximum coverage capacity of each facility type (Table 10) and comparing it to the number of institutional deliveries (Annex 12), the gap between the two figures is smaller than with the previous approach (Table 9) but the number of facilities for which the estimate is below the actual number of assisted births for 2012 is increasing meaning that, for several facilities, the approach is underestimating the potential number of births that the facility has already been able to cover in 2012. To correct for this, it was decided to finally use the following approach: - When the estimated maximum coverage capacity from Table 10 was bigger than the number of institutional deliveries observed in 2012, then the estimated maximum coverage capacity from Table 10 has been used (we are assuming that the facility has been so far operating at less than the maximum capacity in terms of deliveries undertaken with available resources); - When the estimated maximum coverage capacity from Table 10 was smaller than the number of institutional deliveries observed in 2012, then the 2012 number of assisted deliveries has been considered as the maximum coverage capacity for that facility (we are assuming that the facility the number of deliveries corresponds to maximum capacity of that facility); 9

The corresponding number of skilled birth attendants for the DHA (BEmOC) is for example obtained through the following formula: 398/75 = 5.3, rounded to 5.

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

When the number of institutional deliveries was not available for 2012, the maximum coverage capacity reported in Table 10 has been used.

The resulting estimated maximum coverage capacity for the functional BEmOC, including CEmOC, facilities identified during the National Emergency Obstetric and Newborn Care Needs Assessment [15] following this approach is reported in Annex 13. It is important to note here that the theoretical national coverage capacity of all the BEmOC, including the CEmOC, facilities when it comes to normal deliveries reaches 34’159 births which is below the total number of births where the household is located within two hours of these facilities when considering the combined walking/carried – motor vehicle scenario: 97’270 births (Annex 9). As such, we can already observe here that there is an important shortage in terms of skilled birth attendant to answer the needs for this particular population. As per the methodology described under section 5.2, the maximum coverage capacity has also been used to define in which order the facilities would be processed in AccesMod. This order is also reported in Annex 13. Finally, in view of the importance played by the transportation network on accessibility only the combined walking/carried – motor vehicle travel scenario has been considered in these analyzes. Once the above data and information uploaded in ArcGIS, the third module of AccessMod has been used to produce: 1. BEmOC facility specific figures regarding the number of births covered by each facility taking both travel time (2 hour maximum) and the maximum coverage capacity into account (Annex 13); 2. The extension of the catchment area associated to each BEmOC facility (Areas in dark green in Figure 13); 3. Province level number and percentage of birth where the household is located within 2 hours of travel time to a BEmOC (including CEmOC) facility when taking both travel time and coverage capacity into account (geographic coverage (Table 11). This Table does also contain the difference, in percents, observed between accessibility and geographic coverage for that level. In view of the very low values obtained, the spatial distribution of geographic coverage has not been mapped at the Province level.

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Figure 13 – Example of comparison between the catchments areas obtained through the accessibility coverage analysis (light green) and those from the geographic coverage analysis (dark green) 2011 Estimated nbr of birth (using 2008 CBR estimated from 2010 fertility rate) Number of births located within 2 hours of travel to a BEmOC (including CEmOC) and for which there is enough capacity Percentage of births located within 2 hours of travel to a BEmOC (including CEmOC) and for which there is enough capacity Province level difference between the accessibility and geographic coverage

Province code [14]

Province name [14]

LAO001 LAO002 LAO003 LAO004 LAO005 LAO006 LAO007 LAO008 LAO009 LAO010 LAO011 LAO012 LAO017 LAO021 LAO014 LAO015 LAO022

Attapu Bokeo Bolikhamxai Champasak Houaphan Khammouan Louang-Namtha Louangphabang Oudomxai Phongsali Salavan Savannakhet Xekong Vientiane Vientiane Capital Xaignabouli Xiangkhouang Country total/percentage: Color legend:

3,271 4,276 5,344 16,834 7,735 10,092 3,140 9,514 7,365 4,238 10,903 23,694 2,972 9,520 13,681 6,213 6,537 145,329

0 0 2,378 3,751 769 2,219 0 27 0 1,313 749 2,706 0 4,584 13,577 0 2,081 34,155 Values obtained with AccessMod Calculated variables

0.0% 0.0% 44.5% 22.3% 9.9% 22.0% 0.0% 0.3% 0.0% 31.0% 6.9% 11.4% 0.0% 48.2% 99.2% 0.0% 31.8% 23.5%

-0.2% 0.0% -51.5% -63.6% -40.3% -70.9% 0.0% -13.4% -5.5% -37.3% -75.8% -80.2% -51.6% -32.2% -0.7% 0.0% -63.5% -43.4%

Table 11 - Province level number and percentage of births where the household is located within 2 hours of travel time to a BEmOC (including CEmOC) when taking both travel time and coverage capacity into account 44

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Then from Annex 13 and Table 11 as well as Figure 13 we can observe that: - The coverage capacity estimated for all the BEmOC facilities has been used in the analysis; - Taking into account the assumptions considered for this analysis (see Chapter 3), national geographic coverage reaches 23.5%. The Lao People's Democratic Republic does therefore not meet the universal geographic coverage benchmark set for BEmOC. Geographic coverage is actually also low at the Provincial level; - 34’155 (Table 11) of all the 97,270 births located within two hours of travel time of a BEmOC facility (Annex 9) can expect to find enough skilled birth attendants to cover the demand in the concerned facilities; - Only one Province, Vientiane capital, finds itself above the 90% universal coverage benchmark; - Several Provinces are presenting a geographic coverage equal to 0, these are (by alphabetical order): Attapu, Bokeo, Louang-Namtha, Oudomxai, Xekong and Xaignabouli; - The Provinces presenting the highest difference between the accessibility and geographic coverage (Table 11) are: Savannakhet (80.2 % difference) Salavan (75.8%) Khammouan (70.9%) - The Provinces presenting a difference higher than 70% are also located in the Southern part of the country. The second part of this analysis looks at estimating the geographic coverage offered by CEmOC for deliveries with complications. As universal accessibility coverage is not reached at the BEmOC level, this analysis is not complete but already serves as an indication of a potential gap in human resource capacity among the CEmOC reported in the 2010 National Emergency Obstetric and Newborn Care Needs Assessment. The nearest CEmOC facility to each BEmOC facility identified during the accessibility coverage analyzes (Annex 10) has been used to refer these 5% of the normal deliveries (Annex 10) to the corresponding CEmOC facility except for Xam Tai District hospital as the travel time is above 2 hours. The result of this operation is reported in Annex 14. Most of the EmOC facilities in the Lao People's Democratic Republic being CEmOC facilities the number of patients with complications being referred from a BEmOC facility is very limited. First, important variations can be observed when comparing the total number of births delivered by C-section in 2012 provided by the MOH for 13 of the CEmOC facilities with the expected number of births to be referred to these same CEmOC, because of the geographic coverage analysis. More precisely (Annex 14): - For 5 CemOC (109H CH, Phongasly PH, Khamkeuth DHA, Champasak (District) DHA and Friendship (Mittaphab) CH) the number of births referred by the model is higher than the real number of births delivered by C-section in 2012. This 45

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

difference seems to be explained by the fact that the percentage of births delivered by C-section in these facilities is actually lower than 5 % as the model did not refer births from other facilities (Annex 10); For the other 8 CemOC, the number of birth referred by the model is lower than the real number of births delivered by C-section in 2012. In this case, the difference might be explained by the fact that a number of deliveries with complication are also referred from non-BEmOC facilities, which makes sense as both the accessibility and geographic coverage analysis have demonstrated that the number of BEmOC facilities at disposal is not enough to cover the demand for normal deliveries.

Among them, the MCH Central Hospital, located in the capital city, is the CEmOC facility for which the difference between the modeled referred number of births with complications and the real data is the highest. Both the model referred number of births and real number of births delivered by Csections have then been used to estimate the corresponding expected number of EmOC surgical teams that would be needed in order to cover the demand and compare these values with the estimated number of EmOC surgical teams derived from the 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment [15]. This comparison is also reported in Annex 14. In both cases, the expected number of EmOC surgical teams has been obtained by dividing the number of births (referred or real) by 140, this being the maximum acceptable workload in terms of number of C-sections per year per EmOC surgical team as defined in Section 6.3. As we can see from the last two columns on the right in Annex 14: - There would be enough EmOC surgical teams in 8 CEmOC facilities when considering the number of births referred for complication by the model (negative values). For the remaining 5 facilities, the gap is inferior to 1; - There is a gap in terms of number of estimated EmOC surgical teams required in 5 of the 12 CEmOC facilities for which there is data when considering the real number of births delivered by C-sections. The most important gap in this case is observed in the MCH Central Hospital for which an additional 5.6 teams would be required to cover the demand10. Two issues would first need to be addressed before using these results to take any decision aiming at modifying the current number of EmOC surgical teams in these facilities:

This finding suggests that the workload indicator of 140 C-section per EmOC surgical team per year might not match the reality for this facility since obviously the MCH Central Hospital is performing a much higher number of C-sections without having such resources available.

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

1. The data regarding the number of medical workers qualified to perform Csections, the number of medical workers qualified to perform anesthesia and the number of operating theaters in EmOC facilities should be completed and confirmed by the MOH; 2. The maximum acceptable workload of 140 C-section per EmOC surgical team per year might need to be revisited in view of the figures reported in Annex 14. Regarding the second point here above, if the maximum acceptable workload should remain equal to 140 C-sections per EmOC surgical team per year, then facilities such as the MCH Central Hospital pr Champsack (Pakse) Provincial Hospital are understaffed to cover the demand. 7.3 Service utilization analyzes The analysis covered by this section looks at comparing different set of real and modeled data on service utilization with the results of the accessibility (Section 7.1) and geographic (Section 7.2) coverage analysis to identify potential barriers to the utilization of EmOC services. The data used to perform these analyzes are therefore the results from the above two mentioned analyzes, sub national level data collected in the context of the 2011-12 Lao Social Indicator Survey (MICS/DHS) [12] and health facility level data provided by the MOH. This being said, the geographic location of the surveyed clusters having not been collected during the Lao Social Indicator Survey and the 2010-11 needs assessment been not comprehensive, it has only been possible to conduct a limited number of the original analysis listed in Section 5.3. First, the province level percentage of births covered through the accessibility and geographic coverage analyzes have been put in relation to the percent distribution of women age 15-49 who had a live birth in an health facility, public or private, in two years preceding the 2011-12 Lao Social Indicator Survey (MICS/DHS) [12] (see Section 6.1.2). The result of this comparison is reported in Figure 14. The following can be observed from Figure 14 taking into account that only public EmOC facilities have been considered when conducting the accessibility and geographic coverage analysis and that the 2010 needs assessment was not comprehensive: - Vientiane Capial is the only province that sees both accessibility and geographic coverage being above 90% as well as a percentage of women age 15-49 who had a live birth in an health facility close to that benchmark as well. This could be an indication indicate that most births in this province might be taking place in an EmOC facility and that neither availability nor accessibility could be main barriers to BEmOC service utilization; - Phongsali is then the only province presenting a percentage of women age 15-49 who had a live birth in an health facility which is lower than the result of the both 47

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

the accessibility and geographic coverage analysis giving a clear indication that neither availability nor accessibility are the main barriers to service utilization; Six provinces, namely Attapu, Bokeo, Louang-Namtha, Louangphabang, Oudomxai and Xaignabouli are presenting an accessibility and a geographic coverage smaller to the percentage of women age 15-49 who had a live birth in an health facility. This is explained by the fact that the 2010-11 needs assessment did not identify any functional EmOC facilities in these provinces. If the lack of EmOC facilities would be confirmed, availability would then be the most important barrier to service utilization; The proximity of Vientiane Capital, and the EmOC facilities located there, is at the origin of the accessibility and geographic coverage observed for Vientiane while no functional EmoC facilities were identified in this province during the needs assessment. In this case, availability is the main barrier; For the remaining 8 provinces (Bolikhamxai, Champasak, Houaphan, Khammouan, Salavan, Savannakhet, Xekong and Xiangkhouang) the main barrier is also availability of services.

Figure 14 - Province level percentage of births covered by BEmOC facilities as determined through the accessibility and geographic coverage analysis plotted against percent distribution of women age 15-49 who had a live birth in an health facility, public or private, in two years preceding the 2011-12 Lao Social Indicator Survey (MICS/DHS) [12]11 When it comes to CEmOC facilities, the availability of both health facility level data from the MOH as well as sub national level data from the 2011-12 Lao Social Indicator Survey (MICS/DHS) [12] allowed performing both comparisons listed under point 6 in section 5.3. 11

The region level figures used for creating this graph can be found in Table 1 and 3

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

For the sub national level, the fact that Xam Tai District Hospital was finding itself further away than 2 hours from a CEmOC facility (Annex 10), first required to run once more the 3rd module of AccessMod to measure geographic coverage in each province without taking this facility into account. Once this done, the province level percentage of births with complication as referred to a CEmOC facility through the geographic coverage analysis, without taking Xam Tai district hospital into account, has been compared to the percentage of births delivered by C-section in the two years before the 2011 Lao Social Indicator Survey (MICS/DHS) [12]. The former has been calculated for each district by taking 5% of the births located within two hours of travel time to a BEmOC (including CEmOC) facility and for which there is enough capacity in the facility (accessibility coverage) and dividing this value by the total number of births in that same district. Doing so allows comparing the results of the model with the Lao Social Indicator Survey data (Table 12). Percentage of all births that Percentage delivered by C- can reach a CEmOC within 2 Section (DHS, 2010) hours in case of complications

Province code

Province name

LAO001 LAO002 LAO003 LAO004 LAO005 LAO006 LAO007 LAO008 LAO009 LAO010 LAO011 LAO012 LAO017 LAO021 LAO014 LAO015 LAO022

Attapu Bokeo Bolikhamxai Champasak Houaphan Khammouan Louang-Namtha Louangphabang Oudomxai Phongsali Salavan Savannakhet Xekong Vientiane Vientiane Capital Xaignabouli Xiangkhouang Nation wide

2.6% 4.3% 3.0% 4.3% 1.8% 2.5% 1.2% 2.8% 1.1% 0.4% 1.4% 2.3% 0.5% 3.1% 15.0% 4.0% 2.3% 3.7%

0.0% 0.0% 2.2% 1.1% 0.2% 1.1% 0.0% 0.0% 0.0% 1.5% 0.3% 0.6% 0.0% 2.4% 5.0% 0.0% 1.6% 1.2%

Table 12 - Province level comparison between the percentage of births delivered by Csection in the two years before the 2011 Lao Social Indicator Survey (MICS/DHS) [12] and the percentage of births referred to the nearest CEmOC facility through the geographic coverage analysis 49

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

In Table 12, the percentage obtained through the model is always lower than the one reported in the LSIS except for the province of Phongsali. The lower percentage can be explained as follow: - non-EmOC facilities, including facilities from the private sectors, are most probably also referring births with complications to CEmOC facilities; - an important percentage of C-sections are taking place in the private sector; - a certain number of C-sections taking place in CemOC facilities are not referred during delivery but planned in advanced - more than 5% of all birth are actually referred for complications from BEmOC facilities. For Phongsali, an explanation could be found among the contrary assumptions. The second analysis consists in comparing the number of births with complications to be covered at the CEmOC level according to the model during the geographic coverage analysis (Annex 14) with the real number of C-sections performed in CEmOC facilities for which the information was available for 2012 (Table 6, Annex 14). The result of this comparison is reported in Figure 15.

Figure 15 - Comparison between the health facility level expected number of births referred for complication to a CEmOC facility from the geographic coverage analysis with the number of births delivered by C-section in 201212 In Figure 15 (please refer to the observations reported for Table 12 for a possible explanation): - 5 CEmOC facilities (109H, Phongsaly, Khamkeuth, Champasack (District) and Friendship (Mittaphab)) are presenting a modelled number of births referred to The x axis does not take into account the capacity and availability of EmOC surgical teams. The values used corresponds only to 5% of the births handled at the BEmOC level as per the results of the geographic coverage analysis 12

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

the nearest CEmOC facility which is higher than the real number of c-sections observed in these same facilities in 2012; The opposite observation can be made for the other 8 CEmOC facilities.

In addition to the above analysis, and using 2012 MOH data for all the facilities considered in the improvement plan included into the 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment [15], at least 1,276 C-sections have been reported to the MOH as performed in 20 non-CEmOC facilities in 2012 resulting in an estimated 0.8 % of births delivered by C-section in 2012 and therefore in 4.6% of Csections having been performed in a non-CEmOC facility during that same year. The limitations in terms of maximum coverage capacity of EmOC surgical team in CEmOC facilities (see section 7.2) does not allow to tell if the important percentage of Csections taking place in non-CEmOC facilities is due to a shortage in capacity (human resources and/or equipment) in these CEmOC facilities. It is also important to remember here that the number of CEmOC facilities might have increased between the 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment and 2012. 7.4 Scaling up analyzes The accessibility coverage analyzes performed to date (Section 7.1) indicates that the BEmOC, including CEmOC, facilities identified during the 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment [15] are not sufficient to reach universal accessibility coverage nor geographic coverage (Section 7.1 and 7.2). The same analysis also indicated that universal accessibility coverage is not reached when it comes to the travel time between each BEmOC facilities and the nearest CEmOC facility in case of referral for complications during delivery. The geographic coverage analysis nevertheless demonstrated that there would be enough EmOC surgical teams in 8 of the 13 EmOC facilities to cover the demand in terms of Csection would 5 % of the birth being delivered in BEmOC facilities have been referred to them. For the remaining 5 facilities, the gap remains inferior to 1 team and could therefore be completed would the resources be available. In view of the above, the last two modules of AccessMod have been used to look at scaling up the BEmOC network identified during the 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment [15] in order to reach universal geographic coverage at the BEmOC level and analyze the impact this would have at the CEmOC level. In the case of the Lao People's Democratic Republic, extending the coverage capacity of the 18 BEmOC, including CEmOC, facilities identified during 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment [15] to cover all births where 51

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

the household is located within 2 hours of travel time of these facilities, as per the results of the accessibility analysis (Annex 9), would not be sufficient as geographic coverage would then only reach 66.9 % (97,270 births). Additional BEmOC facilities therefore need to be added to those identified as fully EmOC in 2010-11. First scale-up scenario The first scale-up scenario entails at analyzing the coverage reached when implementing the improvement plan proposed in the 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment [15]. In this plan, the original list of 18 EmOC facilities (Annex 5) has been expanded to reach 83 facilities distributed as follow (Annex 15): • Two of the BEmOC from the original list (Adsaphangthong DHA and Viengthong DHA, code in green in Annex 15) to which 38 new BEmOC facilities have been added; • the 14 CEmOC facilities from the original list (code in light blue) with two of the previously BEmOC facilities (Khongsedone DHA and Xam Tai DHA) that have been upgraded to CEmOC (code in dark blue) and to which 27 new facilities have been added. Table 13 provides the distribution by Province of these BEmOC and CEmOC facilities. Province name Attapu Bokeo Bolikhamxai Champasak Houaphan Khammouan Louang-Namtha Louangphabang Oudomxai Phongsali Salavan Savannakhet Vientiane Vientiane Capital Xaignabouli Xekong Xiangkhouang Total Number of BEmOC Number of CEmOC facilities facilities 2 1 1 2 3 2 6 4 2 2 0 2 1 2 1 2 2 2 3 2 5 3 5 4 0 4 0 6 3 2 2 1 4 2 40 43

Table 13 - Province level distribution of the BEmOC and CEmOC facilities as per the 2010-11 improvement plan [15] 52

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

The geographic coordinates for these additional facilities have been obtained from the same sources than the original list. The coordinates in question, in both decimal degrees and in the metric system (UTM, zone 48 N), as well as the source in question are also reported in Annex 15 and the location of these facilities can be visualized in Figure 16.

Figure 16 - Location of the BEmOC and CEmOC facilities considered in the first scaling up scenario as per the 2010-11 improvement plan [15] The maximum coverage capacity for the additional 65 facilities has been estimated using the same approach than the one described in Section 7.2 and the number of institutional deliveries reported in Annex 15, meaning that: - When the estimated maximum coverage capacity reported in Table 10 was bigger than the number of institutional deliveries observed in 2012, then the estimated maximum coverage capacity from Table 10 has been used; - When the estimated maximum coverage capacity from Table 10 was smaller than the number of institutional deliveries observed in 2012, then the 2012 number of assisted deliveries has been considered as the maximum coverage capacity for that facility; - When the number of institutional deliveries was not available for 2012, the maximum coverage capacity reported in Table 10 has been used. Doing so, the total maximum coverage capacity for the 83 considered facilities reaches 71,345 births (Annex 15) which corresponds to only 49.1% of all births estimated as taking place in the country in 2011 (Annex 9). In conclusion, while the increase in 53

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

coverage would correspond to 25.6%, this approach would nevertheless not allow reaching universal geographic coverage without associating it with an increase in human resources. This is what is being demonstrated through the implementation of the second scale-up scenario. Second scale-up scenario In the second scale-up scenario the maximum travel time remains constrained to 2 hours but the coverage capacity of the 83 facilities reported in Annex 15 is extended in order to cover all births where the household is located within these 2 hours of travel time. This scenario uses the same data as those used for the geographic coverage analysis (Section 7.2) and the third module of AccessMod, with the only exceptions that, in this case: - the coverage capacity of each BEmOC, including CEmOC, facility has been set to be unlimited. Doing so allows for ensuring that all births where the household is located within 2 hours of travel time of each facility are attached to these facilities in the simulation; - the 83 facilities have been processed according to the following order: o Health facility type starting from the highest-level structure down, namely: Central Hospital, Provincial Hospital, Type A district hospitals (DHA) and type B district hospitals (DHB) to account for the capacity to absorb the demand. - by decreasing order for the maximum coverage capacity within each health facility as estimated for the first scale-up scenario (Annex 15). That way, the capacity of the facilities having the potential to cover a higher number of births is being used first (resulting order reported in Annex 16). In view of the importance played by the transportation network on accessibility only the combined walking/carried – motor vehicle travel scenario has been considered here. The BEmOC, including CEmOC, facility level results when applying this scenario are then presented in Annex 16. In Annex 16: - The equivalent number of skilled birth attendants needed to cover the demand has been obtained by dividing the modeled number of births covered by the second scenario by the maximum workload considered for each type of facilities as reported in Section 6.3; - The gap in skilled birth attendant for each facility has then been obtained by subtracting the number of potential skilled birth attendants provided by the MOH for 2012 from the equivalent number of skilled birth attendants needed to cover the demand as per the result of the model.

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Implementing this scenario allows for the BEmOC, including CEmOC, facilities listed in Annex 15 to cover 130,470 births where the household is located within 2 hours of travel time, corresponding to a geographic coverage of 89.8% at the national level. We are therefore at only 0.2% of reaching the universal geographic coverage benchmark with this scenario which a very small margin taking into account the different factors that do influence this result, starting with the population distribution grid. In addition to that, and as per the information already available in terms of potential number of Skilled Birth Attendants (SBAs) for 2012, the overall capacity needed to cover the demand would be sufficient (and this despite the fact that the number of SBAs for the 103 and 109 Central Hospital as well as Vapy District Hospital are missing). However, six facilities demonstrate a gap which sums to 168.7 SBAs (value obtained by adding the gaps indicated by cell in white in the last column on the right in Annex 16). This scenario would therefore require the recruitment or relocation of these 168.7 SBAs. It is also important to mention here that high density of hospitals in Vientiane Capital, and therefore overlap between catchment areas, result in the number of births covered by the second scenario to be equal to zero for several of these facilities. This modeled number, and therefore equivalent number of skilled birth attendants, could end up being redistributed among the different facilities based on their respective capacity. Several other facilities do also present a very low, sometime even equal to zero, modeled number of births being covered. In these cases, the result of the analysis could be used to reduce the numbers of new sites and/or select new ones that would not only result in the same coverage but also group human resources in a more cost-effective way. Taking the above into account, Table 14 shows the Province level number and percentage of births covered by the implementation of the second scenario as well as the difference with the result of the geographic analysis (Table 11). As we can see in Table 14, the implementation of this second scenario does not only allow being very close to universal coverage at the national level but is also resulting in making 9 Province finding themselves above that same benchmark, 8 more than when performing the geographic coverage analysis (Section 7.2). Finally, the travel time between each of the 40 BEmOC facilities and the nearest CEmOC facility from the improvement plan has been calculated in order to see if each of these facilities would be within 2 hours of reach of a CEmOC facility in case of delivery with complication considering that a motor vehicle would be available on site of the BEmOC facility. The result of this analysis is presented in Annex 17 and shows that only Dakchung DHB would find itself further away than 2 hours of reach of a CEmOC facility. Using the information reported in Annex 17, 5% of the births reaching the BEmOC, including CEmOC, facilities have been referred to the nearest CEmOC facility to 55

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

simulate the volume of births with complications that would require C-sections (Annex 18). 2011 Estimated nbr of birth (using 2008 CBR estimated from 2010 fertility rate) Number of births covered by the implementation of the second scaling up scenario Percentage of births covered through he implementation of the second scaling up scenario Province level difference between the geographic coverage analysis and the scaling up scenario

Province code [14]

Province name [14]

LAO001 LAO002 LAO003 LAO004 LAO005 LAO006 LAO007 LAO008 LAO009 LAO010 LAO011 LAO012 LAO017 LAO021 LAO014 LAO015 LAO022

3,271 4,276 5,344 16,834 7,735 10,092 3,140 9,514 7,365 4,238 10,903 23,694 2,972 9,520 13,681 6,213 6,537 145,329

2,649 3,405 5,173 16,098 5,454 9,897 2,159 7,268 4,341 3,231 10,482 23,116 2,607 8,941 13,679 5,626 6,345 130,470 Values obtained with AccessMod Calculated variables

81.0% 79.6% 96.8% 95.6% 70.5% 98.1% 68.8% 76.4% 58.9% 76.2% 96.1% 97.6% 87.7% 93.9% 100.0% 90.6% 97.1% 89.8%

81.0% 79.6% 52.3% 73.3% 60.6% 76.1% 68.8% 76.1% 58.9% 45.2% 89.3% 86.1% 87.7% 45.8% 0.7% 90.6% 65.2% 66.3%

Table 14 - Number and percentage of births covered through the implementation of the second scale-up scenario and difference with the results of the geographic coverage analysis Annex 18 also includes the real number of C-sections performed in these facilities in 2012 (MOH), the expected number of EmOC surgical teams for both the modeled and real number of C-sections and the overload benchmark defined in section 6.3 as well as the comparison, and therefore gap, with the estimated number of EmOC surgical teams derived from the 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment [15]. The following can be observed from Annex 18: - The number of births with complication referred by the model is much higher than the real number of C-sections observed for 2012 in these facilities; - As mentioned earlier, C-sections have been performed in non-CEmOC facilities in 2012; - While the existing data gap for several facilities does not allow confirming this fully the comparison between the current estimated and modeled number of EmOC surgical teams tends to indicate that the capacity to cover both the modeled and current demand for C-sections would be sufficient but teams would have to be transferred among some facilities. The implementation of the above measures would of course have a cost to be absorbed as part of the implementation of the improvement plan. 56

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

It is therefore interesting to also look at other alternatives, such as the establishment of Maternity Waiting Homes (MWH) near the already fully BEmOC facilities. This option would allow for all pregnant women living further away than 2 hours of travel time from a BEmOC facility to access these waiting homes and is being tested in the context of the third scenario presented here below. Third scale-up scenario The third scale-up scenario considers the use of Maternal Waiting Homes (MWH). MWH are residential facilities, located near a qualified medical facility, where women defined as "high risk" can await their delivery and be transferred to a nearby medical facility shortly before delivery, or earlier should complications arise [26]. In this particular scenario, it has also been considered that women living further away than 2 hours of travel time, and therefore not necessarily at "high risk" would also be given access to these MWH and that one MWH would be located near each of the existing 18 BEmOC, including CEmOC, facilities identified during the 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment [15] (Annex 5). When it comes to the maximum travel time considered in the analysis, tests have been performed using the travelling time grid generated during the accessibility coverage analysis (see Section 7.1) to see after how many hours of travel time from these MWH we would be reaching the 90% benchmark in terms of accessibility coverage. In the case of the Lao People's Democratic Republic, we found that geographic coverage would reach over 90% with the 18 existing EmOC facilities if all pregnant women living between 2 and 6 hours of travel time came to the MWH and resources made available to ensure their stay. In reality, the national policy would not restrict access to maternity MWH based on travel time. Moreover, in many settings, the MWH may be primarily meant for women at high obstetric risk, and not for all pregnant women. The criteria for high risk pregnancies must be defined locally and will depend on the available resources and local risk factors [26]. For the purpose of the analysis presented here however, we have not considered the proportion at risk since the general assumption is that 90% of women should have access to EmOC. This analysis has been conducted in two steps, namely: 1. The maximum coverage capacity of the existing BEmOC, including CEmOC, facilities has been extended to cover all the births where the household is located within 2 hours of travel time; 2. The spatial distribution of the births not covered by the existing BEmOC facilities during step 1 has then been used as input data to attribute the births where the household is located between 2 and 6 hours of travel time to one of the 25 MWH to be established. 57

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Two variants can be considered when attributing the births where the household is located between 2 and 6 hours of travel time to one of the MWH, namely: 2a. It is considered that the health system is well established and is able to identify to which MWH each pregnant women should be sent based on the available capacity in each BemOC; 2b. Pregnant women are being sent to the nearest waiting home, in terms of travel time, from their respective household. Both variants have been tested here as they do have different implications in terms of cost, both on the patient and health service delivery side. First variant When considering the first variant (2a here above), the processing order followed in both steps of the analysis is the same as the one followed during the geographic coverage analysis (Annex 13), meaning that priority will be given to facilities having the highest coverage capacity. The BEmOC, including CEmOC, facility level results when applying this scenario are then presented in Annex 19. In Annex 19, the number of skilled birth attendants needed to cover the demand as well as the gap in skilled birth attendant for each facility have been calculated in the same way than for Annex 16. Implementing this first variant of the third scenario allows for the 18 BEmOC, including CEmOC, facilities identified during 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment [15] to cover 135,127 births (97,270 where the household is located within 2 hours of travel time and 37,857 that would travel from further away before the due date and stay in MWH), corresponding to a geographic coverage of 92.9% at the national level. We would therefore reach the universal geographic coverage benchmark for BEmOC facilities in this case. This being said, implementing this scenario indicates that in 6 EmOC facilities there would be insufficient numbers of SBAs, totaling an amount of 480 (sum of the cells in white in the last column on the right in Annex 19). This number would have to be adjusted once the values for Central Hospitals number “103” and “109” are available and also taking into account that the load in Vientiane Capital could be distributed among all facilities. This gap could partially be filled by relocating SBAs from facilities where there is no estimated gap (cells in pink in the last column on the right in Annex 19). Furthermore, the scenario would require the construction and maintenance of MWH and associated facilities.

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

We can also observe that, like for the second scenario, several EmOC facilities located in Vientiane Capital would not cover any births as per this scenario and this because of the overlap of their catchment area with the other facilities also located in this Province. This being said, the load could always be redistributed among all the facilities in function of their respective current human resources. At the same time, the number of births that would reach the waiting home is very low for several facilities. Keeping therefore a waiting home for only to the following CEmOC facilities would still allow to remain above the 90% universal geographic coverage benchmark (92.2%): MCH Hospital Central Hospital as well as Champasack (Pakse), Xiengkhouang and Phongsaly Provincial Hospitals. The travel time between each BEmOC facility and the nearest CEmOC facility would remain the same than for the geographic coverage analysis (Annex 10) but the expected number of birth to be referred to these same CEmOC would naturally increase as reported in Annex 20. In this case, the gap in terms of EmOC surgical teams would be more important. The analysis indicates a gap of 25.8 teams when considering the modeled number of referred births and the 140 C-sections benchmark set in Section 6.3. While considering the number of births delivered by C sections reported by the MOH for 2012, and taking into account that data is missing for the 103 and 109 Central Hospitals, the gap disappear, the available capacity being enough, but there would be a need to relocate teams between existing facilities. Please refer to the end of Section 7.2 for additional comments regarding the difference observed here between these two estimations. Based on the result of the model, implementing this first variant of the 3rd scenario would therefore also require hiring or relocating EmOC surgical teams from other facilities not yet complying with CEmOC. When looking at the geographic coverage obtained with this scenario (considering all the MWH reported in Annex 19) at the Province level (Table 15) we can see that 10 of the 17 provinces are now above 90% and that 2 other ones are very close to this benchmark (Attapu and Phongsali). This scenario would therefore not only allow reaching universal coverage at the national level but would also improve province level equity.

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Province code [14]

Province name [14]

Percentage of births covered 2011 Estimated nbr of birth (using Number of births covered by the through he implementation of the 2008 CBR estimated from 2010 implementation of the third scaling third scaling up scenario, first fertility rate) up scenario, first variant variant

Province level difference between the geographic coverage analysis and the scaling up scenario

LAO001 LAO002 LAO003 LAO004 LAO005 LAO006 LAO007 LAO008 LAO009 LAO010 LAO011 LAO012 LAO017 LAO021 LAO014 LAO015 LAO022

3,271 4,276 5,344 16,834 7,735 10,092 3,140 9,514 7,365 4,238 10,903 23,694 2,972 9,520 13,681 6,213 6,537 145,329

2,863 2,397 5,278 16,590 6,093 10,064 2,337 7,945 5,298 3,795 10,853 23,595 2,796 9,381 13,679 5,715 6,449 135,127 Values obtained with AccessMod Calculated variables

87.5% 56.0% 98.8% 98.5% 78.8% 99.7% 74.4% 83.5% 71.9% 89.5% 99.5% 99.6% 94.1% 98.5% 100.0% 92.0% 98.7% 92.9%

87.5% 56.0% 54.3% 76.3% 68.8% 77.7% 74.4% 83.2% 71.9% 58.6% 92.7% 88.2% 94.1% 50.4% 0.7% 92.0% 66.8% 69.4%

Table 15 - Number and percentage of births covered through the implementation of the third scale-up scenario (first variant) and difference with the results of the geographic coverage analysis Second variant For the second variant (2b here above), the same approach than for the first variant has been applied when it comes to the births where the household is located within 2 hours of travel time of a BEmOC, including CemOC facility. The results for this particular part of the birth population remains therefore the same in Annex 21. When it comes to the attribution of the births located between 2 and 6 hours of travel time to a waiting home, the travel time distribution grid generated during the accessibility analysis for the combined walking/carried and vehicle scenario (Figure 10) has been used to identify which waiting home is the nearest in terms of travel time for any given location in the country. This is done by using the Path Distance Allocation tool in ArcGIS. The result is itself presented in Figure 17. Using the grid reported between 2 and 6 hours operation is reported in skilled birth attendants attendants. in Figure 17, it is then possible to attribute the births located of travel time to the nearest waiting home. The result of this Annex 21 at the same time than the corresponding number of needed to cover the demand and the gap in skilled birth

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Figure 17 - Extension of the nearest travel time catchment area for each waiting home

Implementing this second variant of the second scenario allows covering the same number of births than for the first variant, 135,127 births as well as reaching the same geographic coverage at the national level, 92.9%. The same observations made for the first variant when it comes to the overlap of catchment areas for EmOC facilities located in Vientiane, the low number of births in some of the MWH do apply here as well. This being said, the impact on the number of Skilled Birth Attendants is different, as this variant indicates that nine facilities would require 504 additional SBAs to provide EmOC services (sum of the cells in white in the last column on the right in Annex 21). This is a little higher than for the first variant (480) and explained by the fact that the maximum acceptable workload for SBAs is related to the health facility type (See Section 6.3). There is potential scope for relocating some of the 1,232 SBAs that are estimated to be in surplus among the remaining facilities (sum of the cells highlighted in pink in the last column on the right in Annex 21). The need to construct and maintain the MWH as well as associated facilities would also remain. The main reason for this difference compare to the first variant is the fact that the maximum workload benchmark set in the context of this project differs according to the type of health facility (See Section 6.3). By attributing births to the nearest waiting home, and therefore directly nearest BEmOC facility, more births are attached to facilities in which skilled birth attendants are spending time on other activities than giving birth, therefore requiring a higher number of them to cover the demand. 61

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

This difference in redistribution of the births among BEmOC facilities does of course result in a different distribution of the referral of the births with complications among CEmOC facilities but not in an increase in terms of EmOC surgical team as, in this case, the maximum acceptable workload is the same for any health facility type (Annex 22). The Province level distribution of geographic coverage remains the same as both variants are actually covering the same births. The figures reported in Table 15 do therefore also apply to this variant. Policy implications of the above scale up scenarios The above three scenarios first indicate that upgrading the functional EmOC facilities identified during the 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment would not be sufficient to reach universal geographic coverage and that looking for alternative solutions such as the expansion of the existing network, as proposed in the 2011 improvement plan, or the establishment of MWH near already existing EmOC facilities could have a much important impact on geographic coverage. Annex 23 summarizes the three scale-up scenarios that have been presented in the previous sections of this report. In terms of the maternity waiting home (MWH) scenarios, one could for example take the modelling further and assume that women living within 2-6 hours of distance would be referred to a MWH based on the existing capacity (as per scenario 3 variant 1 below), whereas women living further away than 6 hours could be referred simply to the nearest waiting home, to minimize the travel time for them and their families. We have not modelled the outcomes for the population living more than 6 hours away in the scenarios presented here, since the results here are mainly for illustration, to indicate the resources needed to reach a 90% geographic coverage target. The overall purpose is to indicate the kind of analysis and results that can be done for a scale-up analysis, and that the Ministry of Health of the Lao People's Democratic Republic may wish to consider for national purposes related to maternal health planning. This being said, the following will have to be addressed before using the results of the second scenario to do any cost analysis: - Several of the input parameters, such as the maximum acceptable workload for skilled birth attendants and EmOC surgical teams, will require further discussion and validation; - The health facility level data would have to be completed, in particular the real number of assisted births and number of C-sections; - The list of facilities considered in the scenario would require further discussion and agreement in order to account for the fact that the coverage capacity of some facilities has not been used and that geographic coverage is estimated to be below the 90% benchmark for two Provinces is; 62

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Assumptions regarding the modelling of policies related to maternity waiting homes would need to be discussed, and the population in need identified, whether this include a subpopulation of women identified as high risk. Furthermore, the approach to be used within the modelling to attribute women to maternity waiting homes would require further discussion, i.e., whether this would entail a specific referral system which would be based on EmOC facility characteristics or be based on the shortest travel time.

8. Conclusions and recommendations The results obtained in the context of this project have the objective to inform policy discussions on how to optimize, or target, the spending of the marginal dollar for maternal health in countries. The analysis of the accessibility and geographic coverage of the currently existing network of EmOC facilities on the basis of the referral model presented in Figure 1 was carried out to see if: - 90% of all births would be within 2 hours of travel from a BEmOC facility and there would be enough capacity in these facilities to answer the demand; - Deliveries with complications requiring C-section and/or blood transfusion (estimated as 5%) taking place in a BEmOC facility could be transferred to the nearest CEmOC facility in less than 2 hours and the capacity in these facilities would be sufficient to cover the demand. In the case of the Lao People's Democratic Republic, considering the above mentioned model and taking into account the data limitations described in Chapter 6 (mainly time discrepancies between datasets and exclusion of EmOC facilities that are not reporting to the Ministry of Health), the analyses performed in the context of this project demonstrated that: - From an accessibility coverage perspective (see Section 7.1 and Table 1): o The EmOC delivery network identified during the 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment [15] allows for 66.9% of all births to reach a BEmOC facility in less than 2 hours. Universal accessibility coverage is therefore not reached for BEmOC facilities at the national level; o At the sub national level, universal accessibility coverage is reached in five Provinces (Table 1); o There is a CEmOC facility within 2 hours of reach for three of the four BEmOC facilities (excluding CEmOC) identified during the 2010-11 assessment. For the last BEmOC facility, Xam Tai District Hospital, the travel time is reaching 4.2 hours. As such, the health system in the Lao People's Democratic Republic would not fully comply with the condition set to define universal accessibility coverage as per the current framework. Please note that the observation for the other 3 facilities remains 63

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

conditional on the presence of a functioning motor vehicle on site of each BEmOC facility at the moment of the referral; When looking at geographic coverage (Section 7.2 and Table 1): o The coverage offered by the existing network of BEmOC facilities is very low, 23.5% at the national level (Table 11), the health system therefore not complying with the definition set for universal geographic coverage. At the sub national level; o Only Vientiane Capital reaches universal geographic coverage at the Province level; o For CEmOC facilities, gaps in the available data regarding the number of EmOC surgical teams as well as difficulties to estimate the maximum aceptable workload for these teams did not allow to fully assess if the capacity in each facility would be sufficient to cover the demand would 5% of all births taking place in BEmOC facilities be referred to CEmOC facilities. More complete data would therefore be necessary before being able drawing any conclusion on this issue.

Comparing these results with the first and second indicator of the 2009 WHO, UNFPA, UNICEF and Malman School of Public Health handbook for monitoring emergency obstetric care (Annex 2 [2]) as well as the density of EmOC facilities (BEmOC including CEmOC facilities) and CEmOC facilities at the Province level (Table 2) we can note that, in the case of the Lao People's Democratic Republic : - When it comes to BEmOC, including CEmOC, facilities: o 18 facilities for a total population of 6’288’000 [10] corresponds to a national ratio of 1.4 BEmOC facilities per 500’000 inhabitants. This is far below the benchmark level set in the 2009 handbook [2] when it comes to the availability of EMOC facilities (indicator 1 in Annex 2). The analysis conducted here shows that the current network of BEmOC facilities is indeed insufficient to reach universal accessibility and geographic coverage at the national as per the definition used in the context of the present project (see Chapter 3); o The same observation can be made at the Province level (Table 2) as none of the sub-divisions reaches the benchmark level set in the 2009 handbook but two of them are very close to it (Vientiane Capital with 3.9 and Bolikhamxai with 3.7. This being said, universal accessibility coverage is obtained in both these Provinces as well as 3 other ones (Khammouan, Savannakhet and Xiangkhouang - When it comes to CEmOC facilities (Table 2): o 14 facilities correspond to a national ratio of 1.1 CEmOC facility for 500’000 population which is above benchmark level set in the 2009 handbook [2]. o At sub national level, 6 Provinces (35.2%) are above the benchmark level set in the handbook for geographic distribution of CEmOC facilities. o The current network of CEmOC is nevertheless not sufficient to ensure for each BEmOC facilities to be within 2 hours of reach of such a facility as 64

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Xam Tai District Hospital finds itself at 4.2 hours from the nearest CEmOC facility. Unfortunately, the gaps in the health facility level data regarding the number of EmOC surgical teams does not allow us to fully confirm these observations from a geographic coverage perspective. These results, together with the results of the implementation of the same approach in the other three countries (Burkina Faso, Cambodia and Malawi) could serve as the basis for revising the indicators considered in the 2009 handbook [2] as they clearly demonstrate the limitations that exist when only considering the density of facilities at the national or sub national level without taking into account: - environmental factors influencing the distribution and the mobility of the population such as natural barriers like mountain or the hydrographic network; - the fact that patients might seek care in a different Province than the one in which they are living. The service utilization analyzes (see Section 7.3) illustrates that an important percentage of institutional deliveries are taking place in public Non-BEmOC facilities and this in all the Provinces except Vientiane capital where the density of EmOC facilities is sufficient to ensure that all births can take place in such a facility. At the same time, these analyses confirmed that the maximum coverage capacity of the existing BEmOC is reached very quickly, leading to a large number of assisted deliveries to take place in non-EmOC facilities outside of Vientiane Capital. While this analysis do not allow to clearly identify the main barriers in utilizing EmOC services in the country, the above two observations as well as the results of the other analysis tends to indicate that: - both the availability of and accessibility to EmOC services are indeed limiting such an utilization; - the human resources could be sufficient but might need to be relocated in order to better match the demand. In view of the above, a scaling up analysis has been performed using three different scenarios: - Scenario 1: Implementing the improvement plan proposed in the 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment [15] but without doing any changes in terms of human resources; - Scenario 2: Implementing the improvement plan proposed in the 2010-11 National Emergency Obstetric and Newborn Care Needs Assessment [15] together with an increase of the human resources to be able covering all the births where the household is located within 2 hours of travel time to these facilities; - Scenario 3: Considering establishing a Maternity Waiting Home (MWH) near each of the 18 BEmOC, including CEmOC, facilities identified during the 201011 National Emergency Obstetric and Newborn Care Needs Assessment [15] for pregnant women having to travel more than two hours to reach a BEmOC facility. 65

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

When implementing the first scenario, the geographic coverage for the 83 BEmOC, including CEmOC, facilities in the plan reaches 49.1% at the national level which remains below the universal geographic coverage benchmark. The second scenario does itself allow covering 130,470 births where the household is located within 2 hours of travel time, corresponding to a geographic coverage of 89.7% at the national level. Very close to universal geographic coverage benchmark set for the present study, this scenario would nevertheless require the recruitment or relocation of 168.7 Skilled Birth Attendants (SBAs) but would result in having 9 Provinces above the 90% benchmark. In terms of EmOC surgical teams the comparison between the current estimated and modeled number of EmOC surgical teams tends to indicate that the capacity to cover both the modeled and current demand for C-sections would be sufficient but teams would have to be transferred among some facilities. Two different variants have then been considered for the third scenario, namely: 2a. It is considered that the health system is well established and is able to identify to which MWH each pregnant women should be sent based on the available capacity in each BEmOC; 2b. Pregnant women are being sent to the nearest waiting home, in terms of travel time, from their respective household. The implementation of the first variant results in the BemOC facilities covering of 135,127 births (97,270 where the household is located within 2 hours of travel time and 37,857 that would travel from further away before the due date and stay in MWH ), corresponding to a geographic coverage of 92.9% at the national level which is above the universal geographic coverage benchmark foor This variant would nevertheless require an additional 480 SBAs to be hired or potentially relocated from facilities where there is no estimated gap as well as the construction and maintenance of MWH and associated facilities. At the same time, it would also require hiring or relocating EmOC surgical teams from other facilities not yet complying with CEmOC. Finally, this variant would allow for 10 of the 17 Provinces to be above the 90% benchmark and 2 other ones to be very close to it (Attapu and Phongsali). The second variant would allows covering the same number of births than for the first variant, 135,127 births as well as reaching the same geographic coverage at the national level, 92.9%, as well as the Province level. The only difference would be in the gap in terms of SBAs which in this case would reach 504 and therefore be a little bit higher than for the first variant. The need to relocate EmOC surgical team would present a different distribution in this case but the number of teams to be relocated would remain the same. 66

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

The second and both variants of the third scenario therefore provides options to reach universal accessibility and geographic coverage for both BEmOC and CEmOC as well as improve equity in access at the sub national level but this would incur significant cost that will have to be estimated. Several issues pertaining to input parameters, health facility level data and norms will also first have to be addressed before reaching this stage in order to ensure more precise results. In addition to that, the government has recently trained around 1,000 community midwives, however the training rate has been slowing down and it would therefore be difficult to reach the volume of SBAs suggested by some of these scenarios. While all results presented in this report are subject to the availability, quality, accuracy and level of completeness of data (see Chapter 6), and taking the above mentioned limitations into account, the findings to date allows for the identification of potential areas in which the government might want to perform more in-depth analyses. The importance of quality data also underlines the need for the Ministry of Health to have a strong Health Information System (HIS) in which the geographic and time dimensions are well integrated. The Ministry of Health could take advantage of the present project work to improve this integration. At the same time, and to fully benefit from the results that this type of analyzes can provide, it would be important to ensure that knowledge on the applied methods are transferred to the Ministry of Health of the Lao People's Democratic Republic and other relevant institutions. This concerns GIS in general and physical accessibility analysis in particular. In view of the above, it is proposed that the Ministry of Health and WHO collaborate on the assessment of geographic access and to use the work presented here as a driver to strengthen the integration of geography and time in the HIS as well as the GIS capacity of the Ministry. The following recommendations are therefore proposed for consideration: For WHO to support the Ministry of Health and other relevant institutions when it comes to the: - strengthening of GIS capacity in general and the ability to conduct analyzes such as the ones presented here; - transfer of knowledge behind the methods and tools used in the present study; - updating of the analysis to take into account the fact that the 2010-11 needs assessment was not comprehensive and that the situation has changed since then in terms of both the number of EmOC infrastructures and associated human capacities. For the Ministry of Health to: 67

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Provide feedback on the results obtained through the different analyzes presented here; Consider this project as an opportunity to strengthen its GIS capacity as well as to better integrate geography and time in the HIS; Consider the implementation of a follow up project in which: o the input data, norms and parameters would be validated/adjusted/revised in order to produce more precise results for decision making; o New scenarios could be tested in order to come up with the most cost effective scaling up option for extending emergency obstetric care services in the Lao People's Democratic Republic .

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

References [1] UNICEF, WHO, UNFPA (1997): Guidelines for Monitoring the Availability and Use of Obstetric Services: http://www.childinfo.org/files/maternal_mortality_finalgui.pdf [Accessed February 26, 2014] WHO, UNFPA, UNICEF and Mailman School of Public Health. Averting Maternal Death and Disability (AMDD) (2009): Monitoring emergency obstetric care: A Handbook http://apps.who.int/iris/bitstream/10665/44121/1/9789241547734_eng.pdf [Accessed February 26, 2014] Indicators for monitoring the Millennium Development Goals web site (page for indicator 5.2 Proportion of births attended by skilled health personnel: http://mdgs.un.org/unsd/mi/wiki/5-2-Proportion-of-births-attended-by-skilledhealth-personnel.ashx [Accessed February 26, 2014] United Nations (1999): Resolution adopted by the General Assembly during its Twenty-first special session, document A/RES/S-21/2, 8 November 1999: http://www.unfpa.org/webdav/site/global/shared/documents/publications/1999/key_ actions_en.pdf [Accessed February 26, 2014]

[2]

[3]

[4]

[5] Maine D. (1987): Prevention of Maternal Deaths in Developing countries: Program options and practical considerations. In International Safe Motherhood Conference, 1987. Unpublished data [6] Ministry of Health of Cambodia (2009): Cambodia EmOC Improvement Plan (For Implementation January 2010 – December 2015): http://www.unfpa.org/sowmy/resources/docs/library/R124_MOHCambodia_2009_ Final_EmONC_Improvement_Plan_March2010.pdf [Accessed February 26, 2014] AccessMod page on WHO web site: http://www.who.int/kms/initiatives/accessmod/en/index.html [Accessed February 26, 2014] AccessMod version 4.0 web page on ArcGIS online: http://www.arcgis.com/home/item.html?id=f64ccd70c3e045eb8ba6811033c9def6 [Accessed February 26, 2014] Earth Science Data Interface (ESDI) at the Global Land Cover Facility http://glcfapp.glcf.umd.edu:8080/esdi/index.jsp [Accessed February 26, 2014]

[7]

[8]

[9]

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

[10] United Nations, Department of Economic and Social Affairs, Population Division (2011). World Population Prospects: The 2010 Revision, Volume I: Comprehensive Tables. ST/ESA/SER.A/313 [11] UNFPA (2011): The State of World's Midwifery 2011: Delivering Health, Saving Lives, UNFPA (2011): http://www.unfpa.org/sowmy/report/home.html [Accessed February 26, 2014] [12] 2011-12 Lao Social Indicator Survey (MICS/DHS) web site: http://www.measuredhs.com/what-we-do/survey/survey-display-351.cfm [Accessed February 26, 2014] [13] Lao Statistic Bureau: Area and average mid-year population by provinces in 20052012: http://www.nsc.gov.la/index.php?option=com_content&view=article&id=37:popul ation&catid=6:year-book&Itemid=160 [Accessed February 26, 2014] [14] Second Administrative Level Boundaries (SALB) dataset web site: www.unsalb.org [Accessed August 20, 2013] [15] University of Health Sciences, Faculty of Post-Graduate Studies (2012): Lao People’s Democratic Republic National Emergency Obstetric and Newborn Care Needs Assessment. [16] DECIDE Info online platform: http://www.decide.la/ [Accessed February 26, 2014] [17] Global Mapping project web page: http://www.iscgm.org/gm/index.html [Accessed January 23, 2015] [18] Center for International Earth Science Information Network (CIESIN)/Columbia University, International Food Policy Research Institute (IFPRI), The World Bank, and Centro Internacional de Agricultura Tropical (CIAT). 2011. Global RuralUrban Mapping Project, Version 1 (GRUMPv1): Urban Extents Grid. Palisades, NY: NASA Socioeconomic Data and Applications Center (SEDAC). [19] CloudMade web site: http://downloads.cloudmade.com/ [Accessed February 26, 2014] [20] Shuttle Radar Topography Mission (SRTM) data products web page: http://www2.jpl.nasa.gov/srtm/cbanddataproducts.html [Accessed February 26, 2014] [21] Landscan population distribution grid web site: http://www.ornl.gov/sci/landscan/ [Accessed February 26, 2014]

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

[22] Gridded Population of the World (GPW) web site: http://sedac.ciesin.columbia.edu/data/collection/gpw-v3 [Accessed February 26, 2014] [23] WorldPop project web site: http://www.worldpop.org.uk/ [Accessed January 12, 2014] [24] Lao People's Democratic Republic Ministry of Health (2009): Skilled Birth Attendance Development plan Lao PDR 2008-2012: http://www.moh.gov.kh/files/mch/EmONC%20Improvement%20Plan%20English. pdf [Accessed September 13, 2014] [25] WHO (2009): Global status report on road safety: time for action: www.who.int/violence_injury_prevention/road_safety_status/2009 [Accessed February 26, 2014] [26] WHO (1996): Maternity waiting homes: a review of experiences. WHO/RHT/MSM/96.21 http://whqlibdoc.who.int/hq/1996/WHO_RHT_MSM_96.21.pdf?ua=1 [Accessed February 26, 2014]

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 1 – Indicators and minimum acceptable levels from the 1997 UNICEF, WHO, UNFPA Guidelines for monitoring the availability and use of obstetric services [1]

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 2 – Indicators and minimum acceptable levels from the 2009 WHO, UNFPA, UNICEF and Mailman School of Public Health handbook for monitoring emergency obstetric care [2]

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 3 – Illustration of the current EmOC referral system in the Lao People's Democratic Republic

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 4 –Province level demographic data used in the context of the project Male / age group 2011 [13] Female / age group 2011 [13] Total 0 - 14 years 15 - 49 years 50 and above Total 2011 total fertility rate [12]

Province code [14]

Province name [14]

Population 2011 [13]

0 - 14 years

15 - 49 years

50 and above

2011 Number of Births (calculated from 2011 fertility rate)

2011 Crude birth rate (calculated from 2011 fertility rate)

2011 2011 Estimated Population nbr of birth (2011 estimates (using CBR from [13] adjusted to 2011 fertility 2011 UN rate) country figure

LAO001 LAO002 LAO003 LAO004 LAO005 LAO006 LAO007 LAO008 LAO009 LAO010 LAO011 LAO012 LAO017 LAO021 LAO014 LAO015 LAO022

130'402 169'807 272'794 661'358 325'757 383'099 168'140 455'532 307'065 178'006 375'517 922'210 100'595 493'593 783'032 381'908 276'242

27'306 32'844 54'613 121'500 71'995 75'937 31'754 93'107 65'954 35'942 78'159 172'132 22'567 89'515 109'068 66'177 58'938

30'351 41'996 69'122 167'300 74'756 92'105 43'017 109'122 72'331 42'682 87'202 234'205 22'547 132'422 233'444 101'629 66'008

6'478 9'777 14'216 39'713 17'611 20'795 8'683 25'991 15'335 10'851 19'527 49'834 4'774 28'900 48'873 25'035 14'525

64'135 84'617 137'951 328'513 164'362 188'837 83'454 228'220 153'620 89'475 184'888 456'171 49'888 250'837 391'385 192'841 139'471

26'399 32'005 52'790 118'443 70'193 74'755 31'163 91'175 64'612 34'721 76'929 169'572 22'003 86'579 104'944 63'976 56'947

32'202 42'434 67'815 167'741 72'878 96'326 42'804 108'922 72'353 41'117 90'803 238'104 23'625 127'656 239'024 100'083 64'801

7'666 10'751 14'238 46'661 18'324 23'181 10'719 27'215 16'480 12'693 22'897 58'363 5'079 28'521 47'679 25'008 15'023

66'267 85'190 134'843 332'845 161'395 194'262 84'686 227'312 153'445 88'531 190'629 466'039 50'707 242'756 391'647 189'067 136'771

3.6 3.6 2.8 3.6 3.8 3.7 2.6 3.1 3.6 3.7 4.3 3.5 4.5 2.7 2.0 2.2 3.6 3.2

3'322 4'343 5'427 17'094 7'855 10'248 3'189 9'661 7'480 4'304 11'071 24'060 3'018 9'668 13'892 6'310 6'639 147'581

25.5 25.6 19.9 25.8 24.1 26.7 19.0 21.2 24.4 24.2 29.5 26.1 30.0 19.6 17.7 16.5 24.0 23.1

128'420 167'226 268'647 651'305 320'805 377'276 165'584 448'608 302'397 175'300 369'809 908'192 99'066 486'090 771'129 376'103 272'043 6'288'000

3'271 4'276 5'344 16'834 7'735 10'092 3'140 9'514 7'365 4'238 10'903 23'694 2'972 9'520 13'681 6'213 6'537 145'329

6'385'057 1'207'508 1'620'239

360'918 3'188'665 1'177'206 1'628'688

390'498 3'196'392

Collected statistical data Calculated variables

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 5 – list of EmOC facilities identified during the National Emergency Obstetric and Newborn Care Needs Assessment conducted between 2010 and 2011 [15] EmOC Code B1 B2 B3 B4 C1 C10 C11 C12 C13 C14 C2 C3 C4 C5 C6 C7 C8 C9 EmOC Type BEmOC BEmOC BEmOC BEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC Province Name Province Code Savannakhet LAO012 Salavan LAO011 Houaphan LAO005 Houaphan LAO005 Vientiane Capital LAO014 Vientiane Capital LAO014 Phongsali LAO010 Savannakhet LAO012 Vientiane Capital LAO014 Xiangkhouang LAO022 Vientiane Capital LAO014 Bolikhamxai LAO003 Champasak LAO004 Champasak LAO004 Vientiane Capital LAO014 Bolikhamxai LAO003 Khammouan LAO006 Vientiane Capital LAO014 Village Name B. Donghen-Tai B. Khong-Khoum 5 B. Nathouan B. Xam Tai B. Phonpapao B. Kaoyod B. Vatkeo B. Thahae B. Donkoi B. Phonsa-At-Neua B. Phaxay B. Pakxan-Tai B. Dontalat B. Lakmeuang B. Phonsavang B. Chengsavang B. Laophoxay B. Kaoyod Health Facility Name Adsaphangthong Khongsedone Viengthong Xam Tai 103 H MCH Hospital Phongsaly Savannakhet Setthathilat Xiengkhouang 109H Bolikhamxay Champasack (District) Champasack(Pakse) Friendship(Mittaphab) Khamkeuth Khammouane(Thakek) Mahosot Health Facility Type DHA DHA DHA DHA CH CH PH PH CH PH CH PH DHA PH CH DHA PH CH Latitude Longitude 16.70318 105.28111 15.58933 105.80511 20.08326 103.37099 19.99331 104.63368 17.94950 102.63359 17.95969 102.61325 21.68306 102.10916 16.55039 104.74653 17.93429 102.64848 19.44669 103.20312 17.95524 102.62091 18.37246 103.66507 14.78819 105.81101 15.11819 105.79953 18.00486 102.62552 18.18305 104.98930 17.39016 104.80682 17.96006 102.61184 Northing 1846741.2 1723673.4 2221526.0 2210782.9 1986194.7 1987350.0 2400536.7 1829834.8 1984489.7 2151239.4 1986846.9 2031911.4 1635056.2 1671554.5 1992333.8 2010438.1 1922728.0 1987393.1 Easting 529969.5 586315.8 329668.8 461679.2 249356.4 247215.3 200853.7 472956.6 250913.0 311364.7 248020.7 358970.4 587277.2 585910.6 248579.9 498868.6 479480.7 247066.3 Source coordinate NGD village dataset NGD village dataset NGD village dataset NGD village dataset Google Map Google Map NGD village dataset Google Map Google Map Google Map Google Map Google Map NGD village dataset Google Map Google Map NGD village dataset Google Map Google Map

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 6 – Simplified classification for the global land cover distribution grid [17] Original_class original_class_name _code 1 Broadleaf Evergreen Forest 2 Broadleaf Deciduous Forest 3 Needleleaf Evergreen Forest 4 Needleleaf Deciduous Forest 5 Mixed Forest 6 Tree Open 7 Shrub 8 Herbaceous 9 Herbaceous with Sparse Tree/Shrub 10 Sparse vegetation 11 Cropland 12 Paddy field 13 Cropland / Other Vegetation Mosaic 14 Mangrove 15 Wetland 16 Bare area,consolidated(gravel,rock) 17 Bare area,unconsolidated (sand) 18 Urban 20 Water bodies Simplified_class_code 5 5 5 5 5 4 5 3 3 4 4 5 4 6 6 1 1 2 6 Simplified_class_name Dense vegetation Dense vegetation Dense vegetation Dense vegetation Dense vegetation Medium dense vegetation Dense vegetation Low dense vegetation Low dense vegetation Medium dense vegetation Medium dense vegetation Dense vegetation Medium dense vegetation Water Water Bare areas Bare areas Urban Water

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 7 – Process followed in order to create the final land cover distribution grid This annex describes the steps followed in order to generate the country specific land cover distribution grids used in the context of the present project. Before applying the process, the following layers, projected according to the country specific UTM projection (see chapter 6) have to be added in ArcGIS (see section 6.2.3): - The land cover distribution grid developed in the context of the Global Mapping project [17]; - The urban extend distribution layer developed in the context of the Global Rural-Urban Mapping Project (GRUMP) [18]; From there, the following steps are following in ArcGIS: 1. Reclassify the land cover distribution grid using the simplify list of classes reported in Annex 6; 2. Reclassify the GRUMP urban/rural mask for the urban areas to appear as “NoData” and the rual ones with the value “1”; 3. Use the Spatial Analyst Tools>Math>Times tool from ArcGIS to multiply the reclassified lancover distribution grid from step 1 with the reclassified GRUMP layer from point 2 and save the result in a new file. This will generate “NoData” holes in the land cover layer where there are urban areas in GRUMP 4. Reclassify the “NoData” category from the raster layer resulting from step 3 into category 2 (Urban areas) nd save the result in a new file 5. Reclassify category 6 (Water) from the grid generated under point 4 into the “No Data” category and save the result in the final file. Doing this reduces the calculation time when using AccessMod

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 8 – Protocol used to spatially distribute the number of birth in each country This annex describes the steps (Figure C) followed to generate the birth distribution grid used in the context of the present project.

Figure C – Process used to generate total number of births spatial distribution grid Before applying the process described in Figure C, the following layers, projected according to the country specific UTM projection (See Chapter 6), and resampled to match the resolution used in the context of this project for raster GRIDS, have to be added in ArcGIS: - 2008 Landscan population distribution grid [19]. - Travel time distribution grid resulting from the application of the second module of AccessMod (see section 7.1); - Province boundaries (see section 6.2.1) 79

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

- GRUMP urban-rural mask (see section 6.2.3) In addition to that, the following data is to be available in an excel file for use during the process: - National level urban/rural Crude Birth Rate (CBR) (see section 6.1.1); - Province level number of birth (Annex 4). From there, the following steps have been applied in ArcGIS: 1. Reclassify the travel time distribution grid resulting from the application of the second module of AccessMod to obtain a mask in which any cell located outside of the country, corresponding to water areas or being inaccessible by feet or motor vehicle are attributed a value of “0” while all the other cells containing a travel time are attributed a value of “1”; 2. Reclassify the 2008 Lanscan population grid to remove the population in cells where the final total number of births will be bellow 1 births per square meter in rural areas. In the case of the Lao People's Democratic Republic this corresponds to any cell with less than 38 births (rural CBR is equal to 26, see Section 6.1.1) 3. Apply the mask generated under point 1 to the resampled 2008 landscan population distribution grid using the Spatial Analyst > Math > Times tool in ArcGIS; 4. Reclassify the GRUMP urban/rural mask to obtain the spatial distribution the urban/rural CBR figures identified for the country; 5. Multiply the grid resulting from step 4 with the 2008 Landscan population distribution grid on which the travel time mask has been applied in step 2 to obtain the spatial distribution of births based on the urban/rural CBR; 6. Use the Province boundaries layer in raster format as the input layer in the Spatial Analyst>Zonal>Zonal Statistics tool in ArcGIS to extract the total number of birth per administrative divisions from the grid generated in step 5 and save the result as a dbf file; 7. Import the dbf resulting from step 6 in Excel and calculate a Province level specific correction factor to be applied on the spatial distribution of births obtained under step 5 to get the consistency with the total number of birth observed in each Province; 8. Join the resulting correction factor table to the attribute table of the Province boundaries layer using the common code and convert the shape file into a raster grid presenting the same resolution than the population distribution grid using the Conversion Tools>To Raster>Polygon to Raster tool in ArcGIS (please set the extent of the resulting grid to match the travel time distribution grid and snap it to this grid as well by specifying it in the Environment settings>General Settings window that can be opened from the bottom of the Polygon to Raster tool data input window); 9. Multiply the grid obtained under point 8 with the spatial distribution of births obtained under point 5 to obtain the final spatial distribution of births based on both the country level Urban/Rural CBR and Province level number of births. 80

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 9 – Province level number and percentage of births where the household is located within 2 hours of travel time to a BEmOC (including CEmOC) facility for both scenarios Province code [14] Province name [14] 2011 Estimated nbr of birth (using 2008 CBR estimated from 2010 fertility rate) Number of births located within 2 Percentage of births located within Number of births located within 2 Percentage of births located within hours of travel to a BEmOC 2 hours of travel to a BEmOC hours of travel to a BEmOC 2 hours of travel to a BEmOC (including CEmOC) with the (including CEmOC) with the (including CEmOC) with the (including CEmOC) with the combined walking + vehicle combined walking + vehicle walking/carried only scenario walking/carried only scenario scenario scenario

LAO001 LAO002 LAO003 LAO004 LAO005 LAO006 LAO007 LAO008 LAO009 LAO010 LAO011 LAO012 LAO017 LAO021 LAO014 LAO015 LAO022

3,271 4,276 5,344 16,834 7,735 10,092 3,140 9,514 7,365 4,238 10,903 23,694 2,972 9,520 13,681 6,213 6,537 145,329

6 0 5,128 14,458 3,887 9,379 0 1,301 407 2,893 9,017 21,707 1,533 7,647 13,679 0 6,229 97,270 Values obtained with AccessMod Calculated variables

0.2% 0.0% 96.0% 85.9% 50.3% 92.9% 0.0% 13.7% 5.5% 68.3% 82.7% 91.6% 51.6% 80.3% 100.0% 0.0% 95.3% 66.9%

0 0 1,197 3,353 310 1,093 0 0 0 41 315 2,486 0 0 6,579 0 976 16,350

0.0% 0.0% 22.4% 19.9% 4.0% 10.8% 0.0% 0.0% 0.0% 1.0% 2.9% 10.5% 0.0% 0.0% 48.1% 0.0% 14.9% 11.3%

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 10 – Travel time between each BEmOC (including CEmOC) and the nearest CEmOC travel time to the nearest CEmOC (Min) 0 0 0 0 256 107 0 0 53 0 58 0 0 0 0 0 0 0 Code of the nearest CEmOC C3 C7 C4 C5 C14 C14 C8 C11 C5 C12 C12 C1 C2 C6 C9 C10 C13 C14 Name of the Nearest CEmOC Bolikhamxay Khamkeuth Champasack (District) Champasack(Pakse) Xiengkhouang Xiengkhouang Khammouane(Thakek) Phongsaly Champasack(Pakse) Savannakhet Savannakhet 103 H 109H Friendship(Mittaphab) H Mahosot MCH Hospital Setthathilat Xiengkhouang

EmOC Code C3 C7 C4 C5 B4 B3 C8 C11 B2 C12 B1 C1 C2 C6 C9 C10 C13 C14

EmOC Type CEmOC CEmOC CEmOC CEmOC BEmOC BEmOC CEmOC CEmOC BEmOC CEmOC BEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC

Province Name Bolikhamxai Bolikhamxai Champasak Champasak Houaphan Houaphan Khammouan Phongsali Salavan Savannakhet Savannakhet Vientiane Capital Vientiane Capital Vientiane Capital Vientiane Capital Vientiane Capital Vientiane Capital Xiangkhouang

Village Name B. Pakxan-Tai B. Chengsavang B. Dontalat B. Lakmeuang B. Xam Tai B. Nathouan B. Laophoxay B. Vatkeo B. Khong-Khoum 5 B. Thahae B. Donghen-Tai B. Phonpapao B. Phaxay B. Phonsavang B. Kaoyod B. Kaoyod B. Donkoi B. Phonsa-At-Neua

Health Facility Name Bolikhamxay Khamkeuth Champasack (District) Champasack(Pakse) Xam Tai Viengthong Khammouane(Thakek) Phongsaly Khongsedone Savannakhet Adsaphangthong 103 H 109H Friendship(Mittaphab) H Mahosot MCH Hospital Setthathilat Xiengkhouang

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 11 – Province level travel time statistics Nbr of BEmOC, Nbr of CEmOC including Province code [14] Province name [14] facilities in CEmOC, facilities the province in the province LAO001 LAO002 LAO003 LAO004 LAO005 LAO006 LAO007 LAO008 LAO009 LAO010 LAO011 LAO012 LAO017 LAO021 LAO014 LAO015 LAO022 Attapu Bokeo Bolikhamxai Champasak Houaphan Khammouan Louang-Namtha Louangphabang Oudomxai Phongsali Salavan Savannakhet Xekong Vientiane Vientiane Capital Xaignabouli Xiangkhouang Total 0 0 2 2 2 1 0 0 0 1 1 2 0 0 6 0 1 18 0 0 2 2 0 1 0 0 0 1 0 1 0 0 6 0 1 14 Closest BEmOC facility to the province C4 C11 C3 C4, C5 B3, B4 C8 C11 B3, C14 C11 C11 B2 B1, C12 B2 C1, C2, C6, C9, C10, C13 C1, C2, C6, C9, C10, C13 C14 C14 Travel time to the nearest BEmOC facility (hours) MIN 1.4 4.2 0.0 0.0 0.0 0.0 2.1 0.4 1.0 0.0 0.0 0.0 1.2 0.5 0.0 2.6 0.0 MAX 53.9 54.3 69.8 42.4 78.5 46.4 46.6 44.0 35.8 50.5 26.6 44.4 39.1 39.0 13.3 34.7 57.1 MEAN (birth weighted) 5.5 7.4 0.6 0.9 5.5 0.9 6.6 4.0 5.8 2.5 1.3 1.0 2.9 1.6 0.2 4.5 0.8

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 12 – Comparison between the estimated maximum coverage capacity obtained from Table 10 with the 2012 number of institutional deliveries for the BEmOC, including CEmOC, facilities where this information was available EmOC EmOC EmOC Type Code Code (assessment and (extended) (original) improvment plan) EM_003 BEmOC EM_073 BEmOC EM_015 C2 CEmOC EM_044 C11 CEmOC EM_006 CEmOC EM_074 BEmOC EmOC EmOC EmOC Type EM_045 BEmOC Code Code (assessment EM_075 BEmOCand (extended) (original) improvment plan) EM_041 BEmOC EM_033 CEmOC EM_047 BEmOC EM_036 CEmOC EM_040 CEmOC EM_068 CEmOC EM_002 BEmOC EM_022 BEmOC EM_046 BEmOC EM_017 C13 CEmOC EM_081 BEmOC EM_039 BEmOC EM_021 CEmOC EM_027 BEmOC EM_071 BEmOC EM_055 BEmOC EM_077 BEmOC EM_063 CEmOC EM_043 BEmOC EM_082 CEmOC EM_001 CEmOC EM_012 C9 CEmOC EM_016 C6 CEmOC EM_067 CEmOC EM_031 CEmOC EM_023 CEmOC EM_042 CEmOC EM_050 BEmOC EM_076 CEmOC EM_030 BEmOC EM_011 BEmOC EM_060 C12 CEmOC EM_029 B4 BEmOC EM_032 C8 CEmOC EM_038 CEmOC EM_065 CEmOC EM_053 CEmOC EM_079 C14 CEmOC EM_035 BEmOC EM_062 BEmOC EM_078 BEmOC EM_037 CEmOC EM_020 C4 CEmOC EM_010 BEmOC EM_069 BEmOC EM_061 BEmOC EM_028 B3 BEmOC EM_080 BEmOC EM_072 CEmOC EM_058 CEmOC EM_034 CEmOC EM_049 B2 BEmOC EM_054 CEmOC EM_051 BEmOC EM_004 CEmOC EM_057 BEmOC EM_025 BEmOC EM_056 B1 BEmOC EM_007 C3 CEmOC EM_013 C10 CEmOC EM_052 BEmOC EM_008 BEmOC EM_066 CEmOC EM_064 CEmOC EM_048 CEmOC EM_009 C7 CEmOC EM_005 BEmOC EM_019 C5 CEmOC EM_024 BEmOC EM_059 BEmOC EM_070 CEmOC EM_018 BEmOC EM_026 BEmOC Health facility name Maximum coverage Health capacity based on average facility number of assisted type deliveries by health facility type (Table 10) Number institutional deliveries (MOH, 2012) 17 17 324 210 104 45 Number 60 institutional 60 deliveries (MOH, 63 2012) 159 114 376 171 386 70 230 72 2575 73 243 207 248 95 258 97 732 98 743 606 3320 1195 783 693 540 706 314 714 317 123 1929 223 1979 326 2063 758 2081 132 395 137 2331 355 410 262 419 265 420 876 1070 887 749 265 426 989 439 173 777 1009 4913 183 472 465 1192 467 1268 195 3181 204 583 515 604 213 Percentage difference between the number of assisted deliveries and the estimated maximum coverage capacity 1229.41% 1229.41% 660.80% 525.24% 448.08% 402.22% Percentage difference between 276.67% the number of assisted deliveries 276.67% and the estimated maximum 258.73% coverage capacity 258.49% 249.12% 4.26% 233.33% 1.55% 222.86% -1.74% 213.89% -4.27% 209.59% -7.00% 175.36% -8.87% 137.89% -12.40% 132.99% -22.13% 130.61% -23.28% 116.67% -25.75% 106.28% -27.20% 89.47% -27.41% 85.98% -28.03% 83.89% -28.71% 83.74% -31.93% 78.48% -33.65% 74.85% -36.35% 73.22% -36.91% 71.21% -42.78% 64.96% -43.67% 60.56% -44.88% 51.91% -46.06% 50.19% -46.19% 49.89% -46.73% 48.03% -46.86% 47.92% -46.95% 32.76% -48.52% 30.64% -48.78% 30.13% -49.83% 23.50% -52.12% 22.58% -52.18% 22.06% -55.05% 15.90% -58.72% 10.78% -61.23% 10.68% -62.58% 6.10%

Xansai DHB 226 Xaysathan DHB 226 109H CH 2465 Phongsaly PH 1313 Tonpheung DHA 570 Maximum coverage Dakchung DHB 226 Health on average Samphanh DHB capacity based 226 Health facility name facility number of assisted DHB 226 Kalum type deliveries226 by health Nga DHB facility type (Table 10) Ngommalath DHA 570 May DHA 398 Sing DHB 392 Houn DHA 570 Xaysomboun DHB 392 Samanxai DHB 226 Mounelapamok DHB 226 Yod Ou DHB 226 Setthathilat CH 2465 Mork DHB 226 Nane DHB 226 Khong DHA 570 Soukhouma DHB 226 Thong Mixay DHB 226 Toumlan DHB 226 Nong Haed DHB 226 Xongkhone DHA 570 Pak Beng DHB 226 Kham DHA 570 Attapu PH 1313 CH 2465 Mahosot Friendship(Mittaphab) H DHA CH 2465 Vangvieng 570 Huaphanh PH 1313 Paksong DHB 392 Oudomxay PH 1313 Lakhonpheng DHB 226 Xekong PH 1313 Xiengkho DHB 226 Thaphabath DHB 226 PH 1313 Savannakhet Xam Tai DHA 398 Khammouane(Thakek) PH 1313 Nambak DHA 570 Maria Teresa PH 1313 Saravan PH 1313 Xiengkhouang PH 1313 DHB 226 Nalae Virabouli DHB 226 DHB 226 Thathome Luang Prabang PH 1313 Champasack (District) DHA 570 Pakkading DHB 226 Hongsa DHA 398 Thaphanthong DHB 226 Viengthong DHA 398 Khoune DHB 226 PH 1313 Xayabouly Champhone DHA 570 Luang Namtha PH 1313 Khongsedone DHA 398 DHB 392 Ta Oye Lao Ngame DHB 226 Bokeo PH 1313 Atsaphone DHB 226 Phonethong DHB 226 Adsaphangthong DHA 398 Bolikhamxay PH 1313 MCH Hospital CH 2465 Samoun DHB 226 Bolikhan DHB 226 Xanakham DHA 570 570 Seponh DHA Khua DHA 570 Khamkeuth DHA 570 Pha Oudom DHB 226 Champasack(Pakse) PH 1313 Pathoumphone DHB 226 Phin DHB 226 Pak Lai DHA 570 Bachieng DHB 226 Sanasomboun DHB 226

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 13 – Health facility level results of the geographic coverage analysis for BEmOC (including CEmOC) facilities EmOC EmOC Type Code (assessment and (original) improvment plan) C10 C9 C5 C13 C6 C2 C1 C14 C8 C12 C3 C11 C7 B1 B2 C4 B3 B4 CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC BEmOC BEmOC CEmOC BEmOC BEmOC Province name Vientiane Capital Vientiane Capital Champasack Vientiane Capital Vientiane Capital Vientiane Capital Vientiane Capital Xiangkhouang Khammouan Savannakhet Bolikhamxai Phongsali Bolikhamxai Savannakhet Salavan Champasack Houaphan Houaphan Province Code LAO014 LAO014 LAO004 LAO014 LAO014 LAO014 LAO014 LAO022 LAO006 LAO012 LAO003 LAO010 LAO003 LAO012 LAO011 LAO004 LAO005 LAO005 Health facility name MCH Hospital Mahosot Champasack(Pakse) Setthathilat Friendship(Mittaphab) H 109H 103 H Xiengkhouang Khammouane(Thakek) Savannakhet Bolikhamxay Phongsaly Khamkeuth Adsaphangthong Khongsedone Champasack (District) Viengthong Xam Tai Health facility type CH CH PH CH CH CH CH PH PH PH PH PH DHA DHA DHA DHA DHA DHA Total Maximum coverage capacity 4,913 3,320 3,181 2,575 2,465 2,465 2,465 2,081 1,979 1,929 1,313 1,313 1,268 777 749 570 398 398 34,159 AccessMod processing order 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Travel time at the catchment area border (min) 7 17 9 32 41 56 69 19 21 5 9 43 76 14 9 10 36 50 Normal deliveries covered 4,913 3,320 3,181 2,575 2,465 2,465 2,465 2,081 1,979 1,929 1,313 1,313 1,268 777 749 570 398 398 34,159 Number of Coverage institutional capacity deliveries (MOH, not used 2012) 0 4913 0 3320 0 3181 0 2575 0 1195 0 324 0 NA 0 2081 0 1979 0 1929 0 1009 0 210 0 1268 0 777 0 749 0 355 0 265 0 223 26,353

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 14 – Births referred to CEmOC for complication and corresponding number of EmOC surgical teams in CEmOC facilities Health facility name Health facility type Modeled number of Difference Expected number of EmOC Expected number of EmOC surgical Gap in terms of Gap in terms of Estimated number births referred to Number of births between the real surgical teams to cover the teams to cover the number of number of EmOC number EmOC surgical of current EmOC CEmOC facilities for delivered by Cnumber of Cbirths referred by the model births delivered by C-section in surgical teams when teams when team derived from blood transfusion sections (MOH, sestions with (140 C-sections per year as the 2012 (140 C-sections per year as considering the considering the the 2010 EmOC and/or C-section (5% of 2012) those referred by maximum workload per EmOC the maximum workload per EmOC modeled number of number of C-sections needs assessment births at BEmOC level) the model surgical team) surgical team) referred births performed in 2012 123 123 65 63 28 123 124 65 98 135 128 196 166 245 1682 NA 51 8 27 5 112 176 102 182 242 272 463 434 1070 NA -72 -57 -36 -23 -11 52 37 84 107 144 267 268 825 0.9 0.9 0.5 0.5 0.2 0.9 0.9 0.5 0.7 1.0 0.9 1.4 1.2 1.8 12.01 NA 0.4 0.1 0.2 0.0 0.8 1.3 0.7 1.3 1.7 1.9 3.3 3.1 7.6 22.5 NA NA 1 0 0 11 0 1 2 2 1 2 7 2 29 NA 0.5 0.4 0.3 0.2 0.1 -0.4 -0.3 -0.6 -0.8 -1.0 -1.9 -1.9 -5.9 -11.3 NA NA -0.9 0.2 0.0 -10.2 1.3 -0.3 -0.7 -0.3 0.9 1.3 -3.9 5.6 -6.9

103 H 109H Phongsaly Khamkeuth Champasack (District) Friendship (Mittaphab) Xiengkhouang Bolikhamxay Khammouane (Thakek) Savannakhet Setthathilat Champasack (Pakse) Mahosot MCH Hospital Total

CH CH PH DHA DHA CH PH PH PH PH CH PH CH CH

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 15 – 83 facilities considered in the first scale-up scenario EmOC Code B27 B39 C17 B24 C18 C19 B7 B22 B32 C3 C7 B6 B16 B23 B26 B30 B31 C4 C5 C20 C21 B3 B41 C16 C22 C8 C23 B17 C24 C25 B18 C26 C27 B19 B21 C28 C29 EmOC Type BEmOC BEmOC CEmOC BEmOC CEmOC CEmOC BEmOC BEmOC BEmOC CEmOC CEmOC BEmOC BEmOC BEmOC BEmOC BEmOC BEmOC CEmOC CEmOC CEmOC CEmOC BEmOC BEmOC CEmOC CEmOC CEmOC CEmOC BEmOC CEmOC CEmOC BEmOC CEmOC CEmOC BEmOC BEmOC CEmOC CEmOC Province Name Attapu Attapu Attapu Bokeo Bokeo Bokeo Bolikhamxai Bolikhamxai Bolikhamxai Bolikhamxai Bolikhamxai Champasak Champasak Champasak Champasak Champasak Champasak Champasak Champasak Champasak Champasak Houaphan Houaphan Houaphan Houaphan Khammouan Khammouan Louang-Namtha Louang-Namtha Louang-Namtha Louangphabang Louangphabang Louangphabang Oudomxai Oudomxai Oudomxai Oudomxai Province Code LAO001 LAO001 LAO001 LAO002 LAO002 LAO002 LAO003 LAO003 LAO003 LAO003 LAO003 LAO004 LAO004 LAO004 LAO004 LAO004 LAO004 LAO004 LAO004 LAO004 LAO004 LAO005 LAO005 LAO005 LAO005 LAO006 LAO006 LAO007 LAO007 LAO007 LAO008 LAO008 LAO008 LAO009 LAO009 LAO009 LAO009 Village Name B. Mitsamphan B. Xaysomboun (B. Somboun) B. Lak 3 B. Pha-Oudom B. Huayxai B. Tonpheung B. Sisavat B. Pakkading-Nua B. Thabok B. Pakxan-Tai B. Chengsavang B. Nongkok B. Veunkhen B. Lak 40 B. Oupalat B. Souanphak B. Sukhuma B. Dontalat B. Lakmeuang B. Kangkhong B. Pakxong B. Nathouan B. Xiangkho B. Xam Tai B. Misouk B. Laophoxay B. Nhommalath-Nua B. Khonchan B. Nongbouavieng B. Xiangchai B. Nalao B. Phoumok B. Phonsa-At B. Don-En B. Pakbeng B. Phonsavan B. Donkeo Health Facility Name Samanxai Xansai Attapu Pha Oudom Bokeo Tonpheung Bolikhan Pakkading Thaphabath Bolikhamxay Khamkeuth Bachieng Mounelapamok Pathoumphone Phonethong Sanasomboun Soukhouma Champasack (District) Champasack (Pakse) Khong Paksong Viengthong Xiengkho Xam Tai Xamneua Khammouane (Thakek) Nhommalath Nalae Luang Namtha Sing Nane Luang Prabang Nambak Nga Pak Beng Houn Oudomxay Health Facility Type DHB DHB PH DHB PH DHA DHB DHB DHB PH DHA DHB DHB DHB DHB DHB DHB DHA PH DHA DHB DHA DHB DHA PH PH DHA DHB PH DHB DHB PH DHA DHB DHB DHA PH Latitude 14.67275 14.919683 14.8245 20.08722 20.280247 20.29219 18.560868 18.3251915 18.3716234 18.372457 18.1830535 15.245633 14.370752 15.1915032 15.109803 15.3015615 14.636905 14.7881854 15.118188 14.1164289 15.177657 20.08325558 20.81364 19.9933100 20.412778 17.390163 17.606437 20.5301581 20.997463 21.1903285 19.505265 19.866 20.631015 20.281334 19.8927368 20.147292 20.1526669 Longitude 106.633306 107.208944 106.826333 100.82378 100.413768 100.09898 103.7180513 103.9935483 103.200827 103.665072 104.9893011 105.929761 105.861467 106.1452273 105.684528 105.742993 105.787933 105.8110083 105.799531 105.8547936 106.231659 103.3709865 104.14689 104.6336800 104.046638 104.806824 105.171629 101.4434297 101.412048 101.1500301 101.885587 102.1187 102.461902 101.975172 101.136657 101.461886 101.4731436 Northing 1622766.309 1650321.179 1639716.687 2226608.656 2249152.588 2251425.884 2052721.412 2026457.782 2032242.18 2031911.436 2010438.095 1685707.426 1588903.584 1679829.475 1670585.292 1691816.969 1618314.149 1635056.248 1671554.521 1560770.697 1678348.17 2221526.043 2301757.744 2210782.878 2257449.04 1922727.983 1946652.387 2274010.084 2326056.438 2348072.881 2159704.159 2199232.823 2283377.008 2245507.086 2204258.376 2231718.493 2232289.103 Easting 675877.6976 736661.8272 696532.7829 63089.0371 20719.382 -12197.35116 364715.9884 393646.9693 309912.5769 358970.3825 498868.5608 599845.0345 592882.4988 623017.3425 573555.7067 579766.1878 584852.2781 587277.2358 585910.5848 592266.1985 632311.436 329668.7803 411225.2354 461679.1931 400532.3833 479480.7102 518208.9962 129540.7425 126919.6398 100162.8448 173084.4663 198248.2549 235510.1898 184040.8482 95363.85405 130059.683 131250.5532 Source coordinate NGD village dataset NGD village dataset NGD village dataset NGD village dataset Google Map NGD village dataset NGD village dataset NGD village dataset NGD village dataset Google Map NGD village dataset NGD village dataset NGD village dataset NGD village dataset NGD village dataset NGD village dataset Google Map NGD village dataset Google Map NGD village dataset NGD village dataset NGD village dataset NGD village dataset NGD village dataset NGD village dataset Google Map Google Map NGD village dataset Google Map NGD village dataset NGD village dataset NGD village dataset NGD village dataset NGD village dataset NGD village dataset NGD village dataset NGD village dataset Number Maxium coverage Final coverage institutional capacity based on capacity for the deliveries (MOH, health facility type scaling up analysis 2012) (Table 10) 70 226 226 17 226 226 606 1,313 1,313 195 226 226 989 1,313 1,313 104 570 570 472 226 472 410 226 410 123 226 226 1,009 1,313 1,313 1,268 570 1,268 604 226 604 230 226 230 204 226 226 173 226 226 213 226 226 248 226 248 355 570 570 3,181 1,313 3,181 207 570 570 540 392 540 265 398 398 317 226 317 223 570 570 693 1,313 1,313 1,979 1,313 1,979 159 570 570 132 226 226 887 1,313 1,313 376 392 392 243 226 243 2,331 1,313 2,331 326 570 570 63 226 226 98 226 226 171 570 570 706 1,313 1,313

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR Number Maxium coverage Final coverage institutional capacity based on capacity for the deliveries (MOH, health facility type scaling up analysis 2012) (Table 10) NGD village dataset 114 398 398 NGD village dataset 60 226 226 NGD village dataset 72 226 226 NGD village dataset 467 570 570 NGD village dataset 210 1,313 1,313 NGD village dataset 314 226 314 NGD village dataset 426 226 426 NGD village dataset 183 226 226 NGD village dataset 258 226 258 NGD village dataset NA 226 226 NGD village dataset 749 570 749 NGD village dataset 758 1,313 1,313 NGD village dataset 265 392 392 NGD village dataset 777 398 777 NGD village dataset 439 226 439 NGD village dataset 583 226 583 NGD village dataset 419 226 419 Virabouli district admin office 395 226 395 NGD village dataset 1,070 570 1,070 Google Map 1,929 1,313 1,929 NGD village dataset 1,192 570 1,192 NGD village dataset 732 570 732 Google Map 2,063 1,313 2,063 Google Map 783 570 783 Google Map 465 570 570 NGD village dataset 386 392 392 Google Map NA 2,465 2,465 Google Map NA 2,465 2,465 Google Map 1,195 2,465 2,465 Google Map 3,320 2,465 3,320 Google Map 4,913 2,465 4,913 Google Map 2,575 2,465 2,575 NGD village dataset 262 398 398 NGD village dataset 95 226 226 NGD village dataset 17 226 226 NGD village dataset 515 570 570 NGD village dataset 876 1,313 1,313 NGD village dataset 45 226 226 NGD village dataset 60 226 226 Google Map 714 1,313 1,313 NGD village dataset 420 226 420 Google Map 73 226 226 NGD village dataset 97 226 226 NGD village dataset 137 226 226 NGD village dataset 743 570 743 Google Map 2,081 1,313 2,081 Source coordinate Total 71,345

EmOC Code B14 B29 B42 C30 C11 B12 B13 B28 B36 B37 C15 C31 C32 B1 B5 B25 B33 B38 C33 C12 C35 C34 C36 C38 C37 C39 C1 C2 C6 C9 C10 C13 B9 B35 B40 C40 C41 B8 B10 C42 B11 B15 B20 B34 C43 C14

EmOC Type BEmOC BEmOC BEmOC CEmOC CEmOC BEmOC BEmOC BEmOC BEmOC BEmOC CEmOC CEmOC CEmOC BEmOC BEmOC BEmOC BEmOC BEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC BEmOC BEmOC BEmOC CEmOC CEmOC BEmOC BEmOC CEmOC BEmOC BEmOC BEmOC BEmOC CEmOC CEmOC

Province Name Phongsali Phongsali Phongsali Phongsali Phongsali Salavan Salavan Salavan Salavan Salavan Salavan Salavan Salavan Savannakhet Savannakhet Savannakhet Savannakhet Savannakhet Savannakhet Savannakhet Savannakhet Savannakhet Vientiane Vientiane Vientiane Vientiane Vientiane Capital Vientiane Capital Vientiane Capital Vientiane Capital Vientiane Capital Vientiane Capital Xaignabouli Xaignabouli Xaignabouli Xaignabouli Xaignabouli Xekong Xekong Xekong Xiangkhouang Xiangkhouang Xiangkhouang Xiangkhouang Xiangkhouang Xiangkhouang

Province Code LAO010 LAO010 LAO010 LAO010 LAO010 LAO011 LAO011 LAO011 LAO011 LAO011 LAO011 LAO011 LAO011 LAO012 LAO012 LAO012 LAO012 LAO012 LAO012 LAO012 LAO012 LAO012 LAO021 LAO021 LAO021 LAO021 LAO014 LAO014 LAO014 LAO014 LAO014 LAO014 LAO015 LAO015 LAO015 LAO015 LAO015 LAO017 LAO017 LAO017 LAO022 LAO022 LAO022 LAO022 LAO022 LAO022

Village Name B. Na-Kang B. Naxai B. Tai B. Hatdua B. Vatkeo B. Lakhonsi-Kang B. Houaynamsan B. Thetsaban B. Samakixay/Thedsaban B Vapi-Nua B. Khong-Khoum 5 B. Phonkeo B. Thetsabanmuang B. Donghen-Tai B. Hatdokkeo B. Pasomxai B. Thasalakham B. Boungkham B. Kengkok-Thong B. Thahae B. Oudomsouk B. Thongsimuang B. Phonmy-Tai B.Viengkeo B. Sanakham B. Phouhouaxang-Nua B. Phonpapao B. Phaxay B. Phonsavang B. Kaoyod B. Kaoyod B. Donkoi B. Phonsa-At B. Gnai B. Doikao B. Xaignamoungkhoun B. Nalao B. Kao B. Kengkian B. Vatluang B. Phiavat B. Nakhon-Neua B. Thamxai B. Sibounhuang B. Chomthong-Tai B. Phonsa-At-Neua

Health Facility Name May Samphanh Yod Ou Khua Phongsaly Lakhonpheng Lao Ngame Samoun Toumlan Vapy Khongsedone Saravan Ta Oye Adsaphangthong Atsaphone Phin Thaphanthong Vilabouly Champhone Savannakhet Seponh Xongkhone Maria Teresa Vangvieng Xanakham Xaysomboun 103 H 109H Friendship (Mittaphab) Mahosot MCH Hospital Setthathilat Hongsa Thong Mixay Xaysathan Pak Lai Xayabouly Dakchung Kalum Xekong Khoune Mork Nong Haed Thathome Kham Xiengkhouang

Health Facility Type DHA DHB DHB DHA PH DHB DHB DHB DHB DHB DHA PH DHB DHA DHB DHB DHB DHB DHA PH DHA DHA PH DHA DHA DHB CH CH CH CH CH CH DHA DHB DHB DHA PH DHB DHB PH DHB DHB DHB DHB DHA PH

Latitude 21.1720210 21.4030167 22.121667 21.07168 21.68306 15.8936131 15.4603566 16.2938134 15.9863945 15.668902 15.5893320 15.720861 16.0767577 16.70318233 16.84464 16.5321477 15.976094 16.96833 16.454306 16.550388 16.69749 16.2263614 18.369005 18.920978 17.913292 18.9046576 17.949504 17.95524 18.004856 17.960062 17.95969 17.934285 19.70818 17.596575 19.40934 18.204477 19.238952 15.452183 15.732386 15.345786 19.329917 19.159377 19.4964198 18.987475 19.6293994 19.446694

Longitude 102.7273880 101.9727538 101.797722 102.504289 102.1091606 105.5646719 106.1594922 106.8893092 106.2300602 105.909863 105.8051069 106.424651 106.6214591 105.2811138 105.336458 106.0184709 105.7733297 105.94861 105.189803 104.746533 106.2019 105.1985077 102.532139 102.446094 101.677153 103.0943925 102.633591 102.620909 102.625523 102.611838 102.613249 102.648482 101.337665 101.202333 101.3514 101.402149 101.71239 107.277914 106.752048 106.721331 103.368917 103.695359 103.9863411 103.60562 103.5623603 103.20312

Northing 2342876.649 2369779.513 2449773.147 2332112.112 2400536.734 1757249.082 1709580.065 1802369.878 1767819.578 1732520.837 1723673.41 1738573.261 1778105.647 1846741.191 1862398.965 1828074.936 1766444.745 1876295.558 1819198.748 1829834.841 1846476.578 1793984.746 2032782.18 2094028.79 1983735.391 2091359.755 1986194.653 1986846.866 1992333.763 1987393.063 1987349.955 1984489.702 2183331.725 1949596.729 2150180.232 2016545.416 2130537.672 1709635.494 1740177.137 1697306.762 2138140.158 2118286.117 2156070.752 2100022.788 2171106.917 2151239.371

Easting 264035.7632 186126.3057 169616.7873 240686.5348 200853.7156 560447.8355 624390.7123 701873.1572 631623.6115 597509.8876 586315.8381 652648.9794 673435.8057 529969.4675 535843.2276 608679.549 582751.737 600993.9163 520260.8318 472956.5737 628145.4953 521214.6105 239229.487 231004.2109 147902.0579 299291.6278 249356.417 248020.6785 248579.9078 247066.3432 247215.3254 250913.0412 115996.1811 96821.83881 116730.7987 119360.746 154326.7985 744426.1779 687312.5647 684779.2679 328651.659 362906.6809 393628.5285 353219.179 349254.2315 311364.7135

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 16 – Health facility level results for the first scale-up scenario EmOC code Facility name Province name Number of AccessMod institutional Facility type EmOC type processing deliveries (MOH, order 2012) PH CH PH PH PH PH PH PH PH PH PH PH DHA PH PH DHA PH DHA DHA DHA CH DHA DHA DHA DHA DHB DHA DHA CH DHA PH DHA DHA DHA PH DHB DHA DHB DHB CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC BEmOC CEmOC CEmOC CEmOC BEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC BEmOC BEmOC BEmOC CEmOC 3181 4913 1979 2331 1929 2081 693 887 989 606 210 758 1192 876 706 207 1009 1070 465 1268 1195 262 355 515 749 45 159 326 NA 732 2063 223 467 783 714 395 265 419 265 7 1 11 8 12 9 16 17 14 13 19 20 24 21 18 33 15 25 39 23 6 43 32 40 28 76 35 36 4 30 10 34 38 26 22 53 41 51 55 Travel time at the catchment area border (min) 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 Modeled number of births covered by the second scenario 24,345 22,313 18,435 10,533 9,967 6,303 4,713 4,671 3,443 3,114 2,405 2,236 2,029 1,923 1,873 1,555 1,416 952 843 809 647 603 580 510 458 422 406 337 244 213 200 181 144 128 113 112 110 107 98 Equivalent number of skilled birth attendants needed to cover the demand (benchmark from Section 6.3) 243.5 127.5 184.4 105.3 99.7 63.0 47.1 46.7 34.4 31.1 24.0 22.4 27.1 19.2 18.7 20.7 14.2 12.7 11.2 10.8 3.7 8.0 7.7 6.8 6.1 5.6 5.4 4.5 1.4 2.8 2.0 2.4 1.9 1.7 1.1 1.5 1.5 1.4 1.3 Total number of potential SBA (MOH, 2012) 222 110 147 201 240 17 8 74 65 91 46 94 37 12 104 37 71 51 57 54 261 34 29 17 38 26 32 37 NA 40 21 16 23 28 19 28 15 24 28 Gap in terms of skilled births attendants to comply with the result of the first scenario 21.5 17.5 37.4 -95.7 -140.3 46.0 39.1 -27.3 -30.6 -59.9 -22.0 -71.6 -9.9 7.2 -85.3 -16.3 -56.8 -38.3 -45.8 -43.2 -257.3 -26.0 -21.3 -10.2 -31.9 -20.4 -26.6 -32.5 NA -37.2 -19.0 -13.6 -21.1 -26.3 -17.9 -26.5 -13.5 -22.6 -26.7

C5 C10 C8 C26 C12 C14 C22 C24 C18 C17 C11 C31 C35 C41 C29 C20 C3 C33 C37 C7 C6 B9 C4 C40 C15 B8 C23 C27 C1 C34 C36 C16 C30 C38 C42 B38 B3 B33 C32

Champasack (Pakse) MCH Hospital Khammouane (Thakek) Luang Prabang Savannakhet Xiengkhouang Xamneua Luang Namtha Bokeo Attapu Phongsaly Saravan Seponh Xayabouly Oudomxay Khong Bolikhamxay Champhone Xanakham Khamkeuth Friendship (Mittaphab) Hongsa Champasack (District) Pak Lai Khongsedone Dakchung Nhommalath Nambak 103 H Xongkhone Maria Teresa Xam Tai Khua Vangvieng Xekong Vilabouly Viengthong Thaphanthong Ta Oye

Champasak Vientiane Capital Khammouan Louangphabang Savannakhet Xiangkhouang Houaphan Louang-Namtha Bokeo Attapu Phongsali Salavan Savannakhet Xaignabouli Oudomxai Champasak Bolikhamxai Savannakhet Vientiane Bolikhamxai Vientiane Capital Xaignabouli Champasak Xaignabouli Salavan Xekong Khammouan Louangphabang Vientiane Capital Savannakhet Vientiane Houaphan Phongsali Vientiane Xekong Savannakhet Houaphan Savannakhet Salavan

Geographic Accessibility EmOC code Facility name B25 C39 B41 B36 C25 B24 B15 C43 B16 B11 B1 B29 B27 B42 B18 B31 B34 B35 B10 B22 B12 B21 B7 B20 B19 C19 C28 B28 B17 B6 B14 B32 B37 B39 C21 B40 B5 B26 C9 C13 C2 B13 B23 B30 Phin Xaysomboun Xiengkho Toumlan Sing Pha Oudom Mork Kham Mounelapamok Khoune Adsaphangthong Samphanh Samanxai Yod Ou Nane Soukhouma Thathome Thong Mixay Kalum Pakkading Lakhonpheng Pak Beng Bolikhan Nong Haed Nga Tonpheung Houn Samoun Nalae Bachieng May Thaphabath Vapy Xansai Paksong Xaysathan Atsaphone Phonethong Mahosot Setthathilat 109 H Lao Ngame Pathoumphone Sanasomboun

Number of AccessMod Travel time at the institutional Analysis for Emergency Obstetric Care services in Lao PDR Province name Facility type EmOC type processing catchment area deliveries (MOH, order border (min) 2012) Savannakhet Vientiane Houaphan Salavan Louang-Namtha Bokeo Xiangkhouang Xiangkhouang Champasak Xiangkhouang Savannakhet Phongsali Attapu Phongsali Louangphabang Champasak Xiangkhouang Xaignabouli Xekong Bolikhamxai Salavan Oudomxai Bolikhamxai Xiangkhouang Oudomxai Bokeo Oudomxai Salavan Louang-Namtha Champasak Phongsali Bolikhamxai Salavan Attapu Champasak Xaignabouli Savannakhet Champasak Vientiane Capital Vientiane Capital Vientiane Capital Salavan Champasak Champasak DHB DHB DHB DHB DHB DHB DHB DHA DHB DHB DHA DHB DHB DHB DHB DHB DHB DHB DHB DHB DHB DHB DHB DHB DHB DHA DHA DHB DHB DHB DHA DHB DHB DHB DHB DHB DHB DHB CH CH CH DHB DHB DHB BEmOC CEmOC BEmOC BEmOC CEmOC BEmOC BEmOC CEmOC BEmOC BEmOC BEmOC BEmOC BEmOC BEmOC BEmOC BEmOC BEmOC BEmOC BEmOC BEmOC BEmOC BEmOC BEmOC BEmOC BEmOC CEmOC CEmOC BEmOC BEmOC BEmOC BEmOC BEmOC BEmOC BEmOC CEmOC BEmOC BEmOC BEmOC CEmOC CEmOC CEmOC BEmOC BEmOC BEmOC 583 386 317 258 376 195 73 743 230 420 777 60 70 72 243 248 137 95 60 410 314 98 472 97 63 104 171 183 132 604 114 123 NA 17 540 17 439 173 3320 2575 NA 426 204 213 45 56 57 59 54 64 83 29 62 50 27 71 63 72 61 60 78 74 82 52 58 70 47 77 69 31 37 73 81 44 42 65 79 80 46 75 48 67 2 3 5 49 66 68 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 Total

Modeled number of births covered by the second scenario 82 79 76 71 67 59 49 48 46 44 39 34 32 31 31 26 21 15 15 13 13 10 9 7 7 7 7 5 5 5 4 4 4 4 4 2 2 2 0 0 0 0 0 0 130,470

Equivalent number of skilled birth attendants needed to cover the demand (benchmark from Section 6.3) 1.1 1.1 1.0 0.9 0.9 0.8 0.6 0.6 0.6 0.6 0.5 0.5 0.4 0.4 0.4 0.3 0.3 0.2 0.2 0.2 0.2 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1,243.8

Total number of potential SBA (MOH, 2012) 37 24 27 21 24 28 5 11 30 15 35 15 26 24 33 40 70 81 66 10 24 34 21 16 22 23 43 18 24 27 27 15 NA 27 37 29 29 30 485 237 NA 40 38 20 4,342

Gap in terms of skilled births attendants to comply with the result of the first scenario -35.9 -22.9 -26.0 -20.1 -23.1 -27.2 -4.4 -10.4 -29.4 -14.4 -34.5 -14.5 -25.6 -23.6 -32.6 -39.7 -69.7 -80.8 -65.8 -9.8 -23.8 -33.9 -20.9 -15.9 -21.9 -22.9 -42.9 -17.9 -23.9 -26.9 -26.9 -14.9 NA -26.9 -37.0 -29.0 -29.0 -30.0 -485.0 -237.0 NA -40.0 -38.0 -20.0 -3098.2

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 17 – Travel time between each BEmOC and the nearest CEmOC facility in the context of the second scaleup scenario EmOC Code B8 B19 B15 B40 B34 B28 B41 B9 B35 B16 B33 B3 B39 B17 B24 B42 B5 B10 B36 B38 B6 B20 B32 B29 B1 B13 B27 B12 B22 B21 B11 B7 B18 B31 B25 B14 B37 B30 B26 B23 Province Name Xekong Oudomxai Xiangkhouang Xaignabouli Xiangkhouang Salavan Houaphan Xaignabouli Xaignabouli Champasak Savannakhet Houaphan Attapu Louang-Namtha Bokeo Phongsali Savannakhet Xekong Salavan Savannakhet Champasak Xiangkhouang Bolikhamxai Phongsali Savannakhet Salavan Attapu Salavan Bolikhamxai Oudomxai Xiangkhouang Bolikhamxai Louangphabang Champasak Savannakhet Phongsali Salavan Champasak Champasak Champasak Village Name B. Kao B. Don-En B. Nakhon-Neua B. Doikao B. Sibounhuang B. Thetsaban B. Xiangkho B. Phonsa-At B. Gnai B. Veunkhen B. Thasalakham B. Nathouan B. Xaysomboun (B. Somboun) B. Khonchan B. Pha-Oudom B. Tai B. Hatdokkeo B. Kengkian B. Samakixay/Thedsaban B. Boungkham B. Nongkok B. Thamxai B. Thabok B. Naxai B. Donghen-Tai B. Houaynamsan B. Mitsamphan B. Lakhonsi-Kang B. Pakkading-Nua B. Pakbeng B. Phiavat B. Sisavat B. Nalao B. Sukhuma B. Pasomxai B. Na-Kang B Vapi-Nua B. Souanphak B. Oupalat B. Lak 40 Health Facility Name Dakchung Nga Mork Xaysathan Thathome Samoun Xiengkho Hongsa Thong Mixay Mounelapamok Thaphanthong Viengthong Xansai Nalae Pha Oudom Yod Ou Atsaphone Kalum Toumlan Vilabouly Bachieng Nong Haed Thaphabath Samphanh Adsaphangthong Lao Ngame Samanxai Lakhonpheng Pakkading Pak Beng Khoune Bolikhan Nane Soukhouma Phin May Vapy Sanasomboun Phonethong Pathoumphone travel time to the nearest CEmOC (Min) 143 117 117 94 93 91 86 81 78 78 77 73 72 72 66 65 64 62 60 56 46 43 43 41 40 37 37 37 35 35 34 29 28 25 24 23 21 19 14 9 Code of the nearest CEmOC C42 C27 C14 C41 C39 C32 C22 C41 C40 C4 C15 C43 C17 C24 C18 C11 C33 C32 C31 C35 C5 C43 C3 C11 C33 C31 C17 C15 C3 C28 C14 C3 C41 C4 C35 C30 C15 C5 C5 C21 Name of the Nearest CEmOC Xekong Nambak Xiengkhouang Xayabouly Xaysomboun Ta Oye Xamneua Xayabouly Pak Lai Champasack (District) Khongsedone Kham Attapu Luang Namtha Bokeo Phongsaly Champhone Ta Oye Saravan Seponh Champasack (Pakse) Kham Bolikhamxay Phongsaly Champhone Saravan Attapu Khongsedone Bolikhamxay Houn Xiengkhouang Bolikhamxay Xayabouly Champasack (District) Seponh Khua Khongsedone Champasack (Pakse) Champasack (Pakse) Paksong

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 18 – Births referred to CEmOC for complication and corresponding number of EmOC surgical teams in CEmOC facilities for the second scale-up scenario CEmOC Code Health facility name Health facility type Modeled number of Difference Expected number of EmOC Expected number of EmOC surgical surgical teams to cover the teams to cover the number of births referred to Number of births between the real births referred by the model births delivered by C-section in CEmOC facilities for delivered by Cnumber of Cblood transfusion sections (MOH, sestions with (140 C-sections per year as the 2012 (140 C-sections per year as and/or C-section (5% of 2012) those referred by maximum workload per EmOC the maximum workload per EmOC births at BEmOC level) the model surgical team) surgical team) 1218 1116 922 527 498 320 239 234 175 157 124 115 111 128 94 78 72 50 42 40 32 33 26 29 20 17 12 11 10 9 7 6 27 6 5 3 8 0 1 0 0 0 0 6,522 463 NA 182 230 242 176 44 102 176 109 8 60 38 119 50 19 102 35 0 27 NA 5 20 38 0 0 NA 20 102 13 0 86 36 0 0 0 11 3 0 15 NA NA NA 2,531 -755 NA -740 -297 -256 -144 -195 -132 1 -48 -116 -55 -73 -9 -44 -59 30 -15 -42 -13 NA -28 -6 9 -20 -17 NA 9 92 4 -7 80 9 -6 -5 -3 3 3 -1 15 NA NA NA -2,831 8.7 8.0 6.6 3.8 3.6 2.3 1.7 1.7 1.3 1.1 0.9 0.8 0.8 0.9 0.7 0.6 0.5 0.4 0.3 0.3 0.2 0.2 0.2 0.2 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.0 0.2 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 3.3 NA 1.3 1.6 1.7 1.3 0.3 0.7 1.3 0.8 0.1 0.4 0.3 0.9 0.4 0.1 0.7 0.3 0.0 0.2 NA 0.0 0.1 0.3 0.0 0.0 NA 0.1 0.7 0.1 0.0 0.6 0.3 0.0 0.0 0.0 0.1 0.0 0.0 0.1 NA NA NA 18.1 Gap in terms of Gap in terms of Estimated number number of EmOC number EmOC surgical of current EmOC surgical teams when teams when team derived from considering the considering the the 2010-11 EmOC modeled number of number of C-sections needs assessment referred births performed in 2012 2 2 2 2 2 0 0 1 0 1 1 1 0 0 2 0 1 0 0 0 11 0 0 0 0 0 NA 0 2 NA NA 1 0 0 11 0 1 2 2 1 2 7 2 59.0 6.7 6.0 4.6 1.8 1.6 2.3 1.7 0.7 1.3 0.1 -0.1 -0.2 0.8 0.9 -1.3 0.6 -0.5 0.4 0.3 0.3 -10.8 0.2 0.2 0.2 0.1 0.1 NA 0.1 -1.9 NA NA -1.0 0.2 0.0 -11.0 0.0 -0.9 -2.0 -2.0 -1.0 -2.0 -7.0 -2.0 -12.6 1.3 NA -0.7 -0.4 -0.3 1.3 0.3 -0.3 1.3 -0.2 -0.9 -0.6 0.3 0.9 -1.6 0.1 -0.3 0.3 0.0 0.2 NA 0.0 0.1 0.3 0.0 0.0 NA 0.1 -1.3 NA NA -0.4 0.3 0.0 -11.0 0.0 -0.9 -2.0 -2.0 -0.9 NA NA NA -17.0

C5 C10 C8 C26 C12 C14 C22 C24 C18 C17 C11 C31 C35 C41 C29 C20 C3 C33 C37 C7 C6 C4 C40 C15 C23 C27 C1 C34 C36 C16 C30 C38 C42 C32 C39 C25 C43 C19 C28 C21 C9 C13 C2

Champasack (Pakse) MCH Hospital Khammouane (Thakek) Luang Prabang Savannakhet Xiengkhouang Xamneua Luang Namtha Bokeo Attapu Phongsaly Saravan Seponh Xayabouly Oudomxay Khong Bolikhamxay Champhone Xanakham Khamkeuth Friendship (Mittaphab) Champasack (District) Pak Lai Khongsedone Nhommalath Nambak 103 H Xongkhone Maria Teresa Xam Tai Khua Vangvieng Xekong Ta Oye Xaysomboun Sing Kham Tonpheung Houn Paksong Mahosot Setthathilat 109 H Total

PH CH PH PH PH PH PH PH PH PH PH PH DHA PH PH DHA PH DHA DHA DHA CH DHA DHA DHA DHA DHA CH DHA PH DHA DHA DHA PH DHB DHB DHB DHA DHA DHA DHB CH CH CH

46.6

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 19 – Health facility level results for the third scale-up scenario (first variant) EmOC Code (original) C10 C9 C5 C13 C6 C2 C1 C14 C8 C12 C3 C11 C7 B1 B2 C4 B3 B4 Health facility name Health facility EmOC Type type CH CH PH CH CH CH CH PH PH PH PH PH DHA DHA DHA DHA DHA DHA CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC BEmOC BEmOC CEmOC BEmOC BEmOC Province name Number of Births that would reach Total number of AccessMod Births covered in institutional the waiting home births to be processing 2 hours travel deliveries (MOH, between 2 and 6 hours coverted by the order time 2012) of travel time BEmOC facility 4913 3320 3181 2575 1195 324 NA 2081 1979 1929 1009 210 1268 777 749 355 265 223 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Total 22,313 0 24,345 0 891 0 0 7,730 18,435 9,967 1,428 3,300 809 1,467 1,948 580 3,371 688 97,270 11,788 0 9,995 0 106 0 0 10,161 543 54 0 4,754 2 50 7 53 280 63 37,857 34,100 0 34,340 0 997 0 0 17,891 18,978 10,022 1,428 8,053 811 1,517 1,956 633 3,651 751 135,127 Equivalent number of skilled birth attendants needed to cover the demand (benchmark from Section 6.3) 195 0 343 0 6 0 0 179 190 100 14 81 11 20 26 8 49 10 1,231.9 Gap in terms of skilled Potential number of births attendants to comply skilled birth attendants with the result of the first (MOH, 2012) secnario 110 485 222 237 261 NA NA 17 147 240 71 46 54 35 38 29 15 16 2,023.0 85 -485 121 -237 -255 NA NA 162 43 -140 -57 35 -43 -15 -12 -21 34 -6 -791

MCH Hospital Mahosot Champasack (Pakse) Setthathilat Friendship (Mittaphab) 109H 103 H Xiengkhouang Khammouane (Thakek) Savannakhet Bolikhamxay Phongsaly Khamkeuth Adsaphangthong Khongsedone Champasack (District) Viengthong Xam Tai

Vientiane Capital Vientiane Capital Champasak Vientiane Capital Vientiane Capital Vientiane Capital Vientiane Capital Xiangkhouang Khammouan Savannakhet Bolikhamxai Phongsali Bolikhamxai Savannakhet Salavan Champasak Houaphan Houaphan

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 20 – Births referred to CEmOC for complication and corresponding number of EmOC surgical teams in CEmOC facilities for the third scale-up scenario (first variant) Health facility type Gap in terms of Gap in terms of Modeled number of Difference Expected number of EmOC Expected number of EmOC surgical Estimated number surgical teams to cover the teams to cover the number of number of EmOC number EmOC surgical births referred to Number of births between the real of current EmOC CEmOC facilities for delivered by Cnumber of Cbirths referred by the model births delivered by C-section in surgical teams when teams when team derived from blood transfusion sections (MOH, sestions with (140 C-sections per year as the 2012 (140 C-sections per year as considering the considering the the 2010 EmOC those referred by maximum workload per EmOC the maximum workload per EmOC modeled number of number of C-sections and/or C-section (5% of 2012) needs assessment births at BEmOC level) the model surgical team) surgical team) referred births performed in 2012 0 0 403 41 32 50 1,115 71 949 577 0 1,815 0 1,705 6,756 NA 51 8 27 5 112 176 102 182 242 272 463 434 1070 NA 51 -395 -14 -27 62 -939 31 -767 -335 272 -1,352 434 -635 0 0 2.9 0.3 0.2 0.4 8.0 0.5 6.8 4.1 0 13.0 0 12.2 48.3 NA 0.4 0.1 0.2 0.0 0.8 1.3 0.7 1.3 1.7 1.9 3.3 3.1 7.6 22.5 NA NA 1 0 0 11 0 1 2 2 1 2 7 2 29 NA -0.4 2.8 0.1 0.2 -0.4 6.7 -0.2 5.5 2.4 -1.9 9.7 -3.1 4.5 25.8 NA NA -0.9 0.2 0.0 -10.2 1.3 -0.3 -0.7 -0.3 0.9 1.3 -3.9 5.6 -6.9

CEmOC Code

Health facility name

C1 C2 C11 C7 C4 C6 C14 C3 C8 C12 C13 C5 C9 C10

103 H 109H Phongsaly Khamkeuth Champasack (District) Friendship (Mittaphab) Xiengkhouang Bolikhamxay Khammouane (Thakek) Savannakhet Setthathilat Champasack (Pakse) Mahosot MCH Hospital Total

CH CH PH DHA DHA CH PH PH PH PH CH PH CH CH

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 21 – Health facility level results for the third scale-up scenario (second variant) EmOC Code (original) C10 C9 C5 C13 C6 C2 C1 C14 C8 C12 C3 C11 C7 B1 B2 C4 B3 B4 Health facility name Health facility EmOC Type type CH CH PH CH CH CH CH PH PH PH PH PH DHA DHA DHA DHA DHA DHA CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC CEmOC BEmOC BEmOC CEmOC BEmOC BEmOC Province name Number of Births that would reach Total number of AccessMod Births covered in institutional the waiting home births to be processing 2 hours travel deliveries (MOH, between 2 and 6 hours coverted by the order time 2012) of travel time BEmOC facility 4913 3320 3181 2575 1195 324 NA 2081 1979 1929 1009 210 1268 777 749 355 265 223 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Total 22,313 0 24,345 0 891 0 0 7,730 18,435 9,967 1,428 3,300 809 1,467 1,948 580 3,371 688 97,270 2,371 0 5,721 0 236 0 0 10,245 549 10 85 11,219 81 1,276 2,783 358 1,192 1,733 37,857 24,684 0 30,066 0 1,126 0 0 17,974 18,984 9,977 1,513 14,518 890 2,743 4,731 937 4,563 2,420 135,127 Equivalent number of skilled birth attendants needed to cover the demand (benchmark from Section 6.3) 141 0 301 0 6 0 0 180 190 100 15 145 12 37 63 12 61 32 1,294.9 Gap in terms of skilled Potential number of births attendants to comply skilled birth attendants with the result of the first (MOH, 2012) secnario 110 485 222 237 261 NA NA 17 147 240 71 46 54 35 38 29 15 16 2,023.0 31 -485 79 -237 -255 NA NA 163 43 -140 -56 99 -42 2 25 -17 46 16 -728

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 22 – Births referred to CEmOC for complication and corresponding number of EmOC surgical teams in CEmOC facilities for the third scale-up scenario (second variant) Gap in terms of Gap in terms of Modeled number of Difference Expected number of EmOC Expected number of EmOC surgical Estimated number surgical teams to cover the teams to cover the number of number of EmOC number EmOC surgical births referred to Number of births between the real of current EmOC CEmOC facilities for delivered by Cnumber of Cbirths referred by the model births delivered by C-section in surgical teams when teams when team derived from blood transfusion sections (MOH, sestions with (140 C-sections per year as the 2012 (140 C-sections per year as considering the considering the the 2010 EmOC those referred by maximum workload per EmOC the maximum workload per EmOC modeled number of number of C-sections and/or C-section (5% of 2012) needs assessment births at BEmOC level) the model surgical team) surgical team) referred births performed in 2012 0 0 726 44 47 56 1,248 76 949 636 0 1,740 0 1,234 6,756 NA 51 8 27 5 112 176 102 182 242 272 463 434 1070 NA 51 -718 -17 -42 56 -1,072 26 -767 -394 272 -1,277 434 -164 0 0 5.2 0.3 0.3 0.4 8.9 0.5 6.8 4.5 0 12.4 0 8.8 48.3 NA 0.4 0.1 0.2 0.0 0.8 1.3 0.7 1.3 1.7 1.9 3.3 3.1 7.6 22.5 NA NA 1 0 0 11 0 1 2 2 1 2 7 2 29 NA -0.4 5.1 0.1 0.3 -0.4 7.7 -0.2 5.5 2.8 -1.9 9.1 -3.1 1.2 25.8 NA NA -0.9 0.2 0.0 -10.2 1.3 -0.3 -0.7 -0.3 0.9 1.3 -3.9 5.6 -6.9

CEmOC Code

Health facility name

Health facility type

C1 C2 C11 C7 C4 C6 C14 C3 C8 C12 C13 C5 C9 C10

103 H 109H Phongsaly Khamkeuth Champasack (District) Friendship (Mittaphab) Xiengkhouang Bolikhamxay Khammouane (Thakek) Savannakhet Setthathilat Champasack (Pakse) Mahosot MCH Hospital Total

CH CH PH DHA DHA CH PH PH PH PH CH PH CH CH

Geographic Accessibility Analysis for Emergency Obstetric Care services in Lao PDR

Annex 23 – Summary of scale-up scenarios presented above (with MWH: Maternity Waiting Home; SBA: Skilled birth Attendant) Scenario Scenario 1

Action Upgrading the functionality of the EmOC facility network from 18 to 83 fully functional facilities based on the 2011 improvement plan. Upgrading the functionality and capacity (human resources) of the EmOC facility network from 18 to 83 fully functional facilities based on the 2011 improvement plan

Result For BEmOC: Geographic coverage of 49.1%; recruitment and relocation of SBAs. For CEmOC: analysis not performed For BemOC: Geographic coverage of 89.7%; Relocation and/or repurposing of 3'272 SBAs. One BEmOC further away than 2 hours from a CemOC. 9 Province above the universal accessibility coverage benchmark. For CemOC: Number of EmOC team could be sufficient but data gap does not allow confirming this. In any case, relocation of EmOC teams would be necessary For BEmOC: Geographic coverage of 92.9%; Relocation of a maximum of 1,271 SBAs. 10 Province above the universal accessibility coverage benchmark, 2 others very close to it. For CemOC: Same as for the 2nd scenario

Cost implications Facility upgrades; recruitment; relocation

Policy issues and modelling issues raised

Whether all EmOC functions are required in all facilities; SBA norms; data gaps.

Scenario 2

Facility upgrades; recruitment; relocation

SBA and EMOC team norms; data gaps.

Scenario v1.

Constructing maternity MWH , women attributed based on EmOC capacity (within 6 hours).

MWH Construction and maintenance costs; recruitment; relocation

Referral/attribution of pregnant women to waiting homes; SBA norms

Scenario v2.

Constructing maternity MWH , women attributed based shortest travel time (within 6 hours).

For BEmOC: Geographic coverage of 92.9%; Relocation of a maximum of 1,232 SBAs. 10 Province above the universal accessibility coverage benchmark, 2 others very close to it. For CemOC: Same as for the 2nd scenario

MWH Construction and maintenance costs; recruitment; relocation

Referral/attribution of pregnant women to waiting homes; SBA norms

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Technical Documents

Date d'adoption 3 octobre 2016

Source Organisation mondiale de la santé