Lao People's Democratic Republic : Greater Mekong Subregion Border Areas Health Project

Sovereign Project | 53290-002

The project aims to improve access to quality health services for populations residing in and passing through the border provinces of Champasak, Phongsali, and Savannakhet. Investments will support the (i) upgrading and renovation of health facilities and equipment and workforce development in three provincial and two district hospitals; (ii) delivery of a comprehensive program of workplace, community-based, and facility-based programs services for female and male migrant workers and border area communities; and (iii) rollout of an electronic medical record (EMR) and unique health identifier UHI) to strengthen continuity of care between border area health facilities.

Project Details

  • Project Officer
    Elfving, Rikard N.
    Sectors Group
    Request for information
  • Approval Date
    27 March 2024
  • Country/Economy
    Lao People's Democratic Republic
  • Sector
    • Health
Project Name Greater Mekong Subregion Border Areas Health Project
Project Number 53290-002
Country / Economy Lao People's Democratic Republic
Project Status Approved
Project Type / Modality of Assistance Grant
Loan
Source of Funding / Amount
Grant 0945-LAO: Greater Mekong Subregion Border Areas Health Project
Asian Development Fund US$ 4.95 million
Loan 4442-LAO: Greater Mekong Subregion Border Areas Health Project
Concessional ordinary capital resources lending US$ 20.00 million
Operational Priorities OP1: Addressing remaining poverty and reducing inequalities
OP2: Accelerating progress in gender equality
OP3: Tackling climate change, building climate and disaster resilience, and enhancing environmental sustainability
OP7: Fostering regional cooperation and integration
Sector / Subsector

Health / Health system development

Gender Effective gender mainstreaming
Description The project aims to improve access to quality health services for populations residing in and passing through the border provinces of Champasak, Phongsali, and Savannakhet. Investments will support the (i) upgrading and renovation of health facilities and equipment and workforce development in three provincial and two district hospitals; (ii) delivery of a comprehensive program of workplace, community-based, and facility-based programs services for female and male migrant workers and border area communities; and (iii) rollout of an electronic medical record (EMR) and unique health identifier UHI) to strengthen continuity of care between border area health facilities.
Project Rationale and Linkage to Country/Regional Strategy

Determinants of health in border area communities are complex. Strengthened regional cooperation and integration (RCI) in the GMS has driven the subregion's economic growth. Population movement facilitated by RCI has generated a unique set of health challenges linked to the dynamics of communicable disease spread, health-seeking behaviors of migrants, and workplace and social determinants. In the Lao PDR, health challenges linked to mobility are most evident in border areas where migrants pass through and reside. These areas serve as both a transit point for departing and returning cross-border migrants and a destination for internal migrants seeking job opportunities in special economic zones (SEZs). Health systems in these border areas are inadequately equipped to respond to mobility-linked health challenges, as illustrated during the coronavirus disease (COVID-19) pandemic. Migration is just one of the multiple factors influencing health in border areas of the Lao PDR. In the country's northern area, ethnic diversity and low socioeconomic status, coupled with geographic remoteness and weak health infrastructure, impact health outcomes of border area communities.

Macroeconomic instability and inflation act as a catalyst for migration. The impact of COVID-19 pandemic on the labor market in the Lao PDR, including income and job losses, was substantial at 5% of the gross domestic product (GDP). After contracting by 0.5% in 2020, the economy commenced a gradual recovery, with the GDP expanding by 2.3% in 2021 and 2.5% in 2022. While the GDP is forecasted to expand by 3.7% in 2023 and 4.0% 2024, challenges remain. Unsustainable public debt along with high foreign currency debt servicing needs exert depreciation pressure on the kip. Macroeconomic instability and inflation in double digits since 2022 have eroded the domestic purchasing power. This has led to an increasing number of Lao nationals seeking work in neighboring GMS countries, predominantly in Thailand, where earning capacity is higher. High rates of poverty in rural areas also act as catalysts for internal migration. Rural workers are drawn by employment opportunities in the country's SEZs, strategically located in border areas to take advantage of GMS economic corridors.

Migrants are vulnerable to a range of health threats. Factors relating to migrants' living, working, and transit conditions increase their susceptibility to communicable disease threats. Lao nationals migrating across borders lack pre-departure access to migration-specific health-care. These migrants are less likely to seek health-care in destination countries because of legal, social, and financial barriers. For example, enrollment in Thailand's Social Security Fund, which is intended to provide cover for migrants employed through formal employment channels, is estimated to be 42% of the target population. Migrants in domestic labor and part-time agriculture and construction roles (positions disproportionately filled by female migrants) are ineligible for the Social Security Fund cover. The Ministry of Public Health in Thailand operates a migrant health insurance scheme open to individuals in informal employment. However, enrollment is only available once the individual is within Thailand. Annual premiums are required to be paid upfront, and insurance cover is tied to a single facility, which is a disincentive to enroll.

Internal migrants, including those working in SEZs, are exposed to poor living conditions and long work hours in difficult and dangerous environments. Female migrants in the manufacturing sector are particularly vulnerable to such conditions. Failure by companies to provide access to essential health care, child-care services, and protection from sexual harassment, leads to high rates of attrition among female workers. Occupational health risks among factory workers are exacerbated by excessive heat and other climate-related hazards. The non-portability of national health insurance outside an individual's district of residence is an impediment to migrants' accessing health services in destination provinces.

Female migrants are vulnerable to gender-based violence and exploitation. Gender-based violence (GBV) is highly prevalent in the Lao PDR. Female migrants are vulnerable to physical, sexual, and emotional violence at all stages of the migration cyclein transit, within the workplace, and upon return to their homes. Human trafficking is also highly prevalent. The annual number of Lao nationals falling victim to trafficking is estimated to be as high as 10,000, however, very few cases of trafficking are officially recorded. Of those officially recorded, 94% of cases were women and 84% were victims aged 18 years and below. Women and adolescent girls from poor ethnic minority communities, including those from border provinces in the country's northern area, are among the groups most vulnerable to human trafficking.

The border provinces of Champasak and Savannakhet are major destination for migrants. Both Champasak and Savannakhet share a border with Thailand and serve as a major transit-points for migrant workers moving between the two countries. A combined 458,883 people passed through the provinces' two international checkpoints with Thailand in 2022. The total number of Lao nationals entering Thailand from each province is considered far higher than those recorded, given the countries' long, porous shared border. Champasak and Savannakhet are also major destination points for internal migrants, with the provinces' SEZs a major drawcard. The SavanSino SEZ, in the central point of the GMS EastWest Corridor, is home to over 100 companies employing more than 4,800 workers. The Champasak SEZ, on the outskirts of Pakxe city, houses 33 companies and 948 workers.

The dual demand for health services from local populations and migrants creates unique challenges for the health system in Champasak and Savannakhet. Low capacity of district hospitals in both provinces leads to patients routinely bypassing these facilities and seeking care at the provincial hospitals. Both provincial hospitals function as regional referral hospitals, accepting patients from neighboring provinces with lower service capabilities. Demand-side pressure is evident, with bed occupancy rates exceeding the 85% benchmark beyond which safety and efficiency are at risk. The average bed occupancy rate for the period 2019 to 2021 was 105.7% for Champasak Provincial Hospital and 90.2% for Savannakhet Provincial Hospital. Demand-side pressures are exacerbated by supply-side constraints. Both hospitals lack adequate infrastructure and equipment to deliver inpatient and outpatient services in line with demand, including for the treatment of noncommunicable diseases, maternal and child health (MCH) conditions, and surgical care.

Provincial health systems are poorly equipped to respond to migration-linked health issues. In the absence of a national migration health plan, the delivery of migrant health services at the provincial level is fragmented and ad hoc. Provincial hospitals lack mechanisms for the coordinated management of migrants seeking health care. Weak mechanisms for patient referral and data sharing between provincial health systems in the Lao PDR and neighboring countries comprise patient management. Deficiencies in provincial-level capabilities for responding to communicable disease threats and other cross-border health challenges, such as the importation of counterfeit drugs, jeopardize health security. Weak coordination between the provincial health office (PHO), the Department of Labour and Social Welfare, and SEZ operators in each province has left internal migrants with limited access essential health and social services (para. 6). Provincial health systems fall short in meeting their responsibilities for the provision of facility-based and community-based services for referral, counseling, and treatment of persons affected by human trafficking. Similarly, assigned functions for the identification, medical care, and referral of persons affected by GBV are not being met.

The border province of Phongsali faces unique health challenges. Phongsali, a remote border province, is ethnically diverse, with 81.3% of its population belonging to minority, non-Lao-Tai ethnic groups. The province ranked lowest in the 2021 provincial human development index, an indicator of disparity in poverty rates and in access to essential services including health-care when compared to other provinces. Phongsali is among the weakest performing provinces on measures of child mortality and maternal health. For example, neonatal mortality rate is 27 per 1,000 live births, compared to the national rate of 18 per 1,000 live births. Among pregnant women, only 37% were delivered in health facilities, increasing risks to both the mother and the child.

The poor operational condition of hospitals is a binding constraint to health care delivery in Phongsali. Facilities at Bounnua Provincial Hospital, Bountai District Hospital, and Phongsali District Hospital are in a deteriorated state. The physical layout of each hospital is unsuited to functional requirements. Clinical equipment is outdated or no longer operational because of inadequate maintenance. The health workforce is under-skilled, a consequence of the province's geographic remoteness and the limited opportunities for continuous professional development. Remoteness is also a barrier to recruiting qualified staff, leaving hospitals reliant upon retired personnel to provide clinical and surgical services. Deficiencies in financial and quality management within individual hospitals perpetuate these constraints. The impact is reflected in service utilization rates for the three hospitals, which fall below the national average for equivalent facility types. Hospitals fail to deliver on assigned functions, particularly for surgical and obstetric care. Patients at Bounnua Provincial Hospital are routinely referred to neighboring Oudomxai province where service capacity is higher, contributing to patient overload at Oudomxai Provincial Hospital.

Border area health systems are vulnerable to climate change impacts. Climate change is projected to impact people movement in the GMS. Changing weather patterns that lead to longer dry seasons and more intense rainfall, drive out-migration from rural areas where a high proportion of the population is dependent on natural resources for their livelihoods. Climate change mitigation solutions, such as the construction of hydropower dams, can also lead to population displacement. Climate-related events, including storms and floods, threaten the integrity of health infrastructure. Key information on climate vulnerability is needed to understand the impacts on target populations. Effective response requires preemptive investments to increase capacity of border area health systems to respond to anticipated impacts.

Government strategy. Improving the quality of human resources to foster national development is a priority under the government's National Socioeconomic Development Plan 20212025 (NSDP). The NSDP recognizes the opportunity to benefit from the country's young population of migrant workers who can contribute to drive rapid growth. Enabling women and ethnic groups to improve their livelihoods, promoting broader social participation, and contributing to socioeconomic development are also prioritized. Progressing to the UHC by ensuring more inclusive and better-quality health care services, including investments in provincial and district hospitals, is a key strategy under the NSDP. The MOH's Health Sector Reform Strategy provides the guiding framework for health sector efforts to achieve UHC. Investments in health services are also guided by the government's climate resilience commitments for the health sector, which include (i) increasing the resilience of public health infrastructure and water supply systems; and (ii) improving public health services capacity to adapt and cope with climate change.

Lessons learned. The ministries of health in the Lao PDR and neighboring GMS countries collectively recognize the need to include migrants and other vulnerable populations in national plans and health system to accelerate progress toward UHC. Devolving responsibility to provincial-level units for planning and management of cross-border and community-based activities targeting migrant and mobile populations will, when guided by a clear strategic and results framework, strengthen RCI efforts. Interventions for health system strengthening and for addressing migration-linked risks should be underpinned by assessment of the vulnerabilities that impact health, livelihoods, and mobility. Information and communication technology is a key enabler for achieving and measuring the UHC. Effective digital transformation requires coordination across, and harmonization of, investments of government stakeholders and development partners, guided by an investment road map.

Impact

Protection for vulnerable communities from the adverse health impacts of regional integration strengthened

Project Outcome
Description of Outcome

Access to quality health services for populations residing in and migrating through selected border areas improved

Progress Toward Outcome
Implementation Progress
Description of Project Outputs

Health services in selected border areas strengthened

Gender-responsive health services for migrants and other vulnerable persons in border areas enhanced

Digital systems for integrated delivery of health services implemented

Status of Implementation Progress (Outputs, Activities, and Issues)
Geographical Location Nation-wide
Safeguard Categories
Environment B
Involuntary Resettlement C
Indigenous Peoples B
Summary of Environmental and Social Aspects
Environmental Aspects
Involuntary Resettlement
Indigenous Peoples
Stakeholder Communication, Participation, and Consultation
During Project Design
During Project Implementation
Business Opportunities
Consulting Services Individual Consultant Selection (ICS) will be used for the recruitment of 17 consultants with a total estimated cost of about $1.8 million, with 54% of this value is planned for international consultants ($0.84 million) and 46% for national consultants ($0.72 million). Two consultancy firms, one for detailed design and construction supervision (DDCS) for the length of the project and one for the monitoring and evaluation (i.e., baseline, mid-term and end line evaluations), will be selected by QCBS method, together with a total estimated value of about $0.98 million.
Procurement Of the total procurement value, 76% is proposed to be procured through open competitive bidding ($13.2 million), with 27% ($3.6 million) will be advertised internationally and 73% ($9.6 million) nationally. Consulting firms will be engaged by quality- and cost-based selection (QCBS) method with total estimated value of about $0.98 million. Individual consultancy services, with total estimated value of about $1.56 million, will be advertised via ADB's CMS platform. Request for Quotation (RFQ) method for goods and non-consulting services, is proposed for a total estimated value of $1.1 million. Limited competitive bidding (LCB) and Direct Contracting (DC) is used for 3 packages which in value represent in both cases only 2% of the total procurement value.
Responsible ADB Officer Elfving, Rikard N.
Responsible ADB Department Sectors Group
Responsible ADB Division Human and Social Development Sector Office (SG-HSD)
Executing Agencies
Ministry of Health
Timetable
Concept Clearance 04 Dec 2019
Fact Finding 17 Jul 2023 to 27 Jul 2023
MRM -
Approval 27 Mar 2024
Last Review Mission -
Last PDS Update 10 Apr 2024

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Safeguard Documents See also: Safeguards
Safeguard documents provided at the time of project/facility approval may also be found in the list of linked documents provided with the Report and Recommendation of the President.

Title Document Type Document Date
Greater Mekong Subregion Border Areas Health Project: Initial Environmental Examination Initial Environmental Examination Oct 2023
Greater Mekong Subregion Border Areas Health Project: Ethnic Group Development Plan Indigenous Peoples Plans/Indigenous Peoples Development Plans Oct 2023
Greater Mekong Subregion Border Areas Health Project: Involuntary Resettlement Due Diligence Report Safeguards Due Diligence Reports Oct 2023

Evaluation Documents See also: Independent Evaluation

None currently available.


Related Publications

None currently available.


The Access to Information Policy (AIP) establishes the disclosure requirements for documents and information ADB produces or requires to be produced in its operations to facilitate stakeholder participation in ADB's decision-making. For more information, refer to the Safeguard Policy Statement, Operations Manual F1, and Operations Manual L3.

Requests for information may also be directed to the InfoUnit.

  • 01 Apr 2024 | News Release

    ADB to Help Lao PDR Improve Access to Health Services in Border Areas

    ADB has approved a financing package of $24.9 million, inclusive of a $4.95 million Asian Development Fund grant, to help improve access to quality health services in the border provinces of Champasak, Phongsali, and Savannakhet of the Lao People’s Democratic Republic.

Tenders

No tenders for this project were found.

Contracts Awarded

No contracts awarded for this project were found

Procurement Plan

None currently available.