Embed Size (px)
Citation preview
Analyse organisationnelle de deux hôpitaux réputés à succès en République Démocratique Populaire Lao (RDP Lao)
Mémoire
Ashken N’doh Sanogo
Maîtrise en santé communautaire (santé mondiale) Maître ès sciences (M. Sc.)
Québec, Canada
© Ashken N’doh Sanogo, 2016
Organizational analysis of two hospitals considered as success stories in the Lao Popular Democratic Republic (Lao PDR)
Mémoire
Ashken N’doh Sanogo
Sous la direction de : Daniel Reinharz – Directeur de recherche
iii
RÉSUMÉ Problématique : À l'instar de beaucoup de pays en développement, la qualité des services
offerts dans les hôpitaux de la RDP Lao, surtout périphériques, est souvent critiquée. Il est
dès lors intéressant d'examiner les cas "à succès", ceux dont on considère qu'ils devraient
être des modèles pour le pays.
Tel est le cas de 2 hôpitaux de la province de Vientiane, dont le développement a été
soutenu par la Coopération luxembourgeoise.
Méthodologie: Cette étude est une étude de cas multiples portant sur deux hôpitaux (Maria
Teresa et Vang Vieng). Elle visait à étudier les facteurs organisationnels associés à la
perception par les travailleurs en santé et les femmes enceintes ou en post-partum, de la
performance des soins obstétricaux offerts dans ces hôpitaux. Des entrevues individuelles,
basées sur des thématiques découlant du cadre conceptuel de l'étude ont été réalisées.
Résultats : L'analyse des résultats montrent une grande satisfaction tant de la part des
travailleurs des hôpitaux que des utilisatrices de services, avec les services offerts, même si
certains services attendus ne sont pas systématiquement offerts. Les principaux facteurs
associés à la fonctionnalité perçue des deux hôpitaux sont liés à deux aspects : un
investissement dans les ressources humaines et un investissement dans l'accessibilité de
population-cible aux services obstétricaux. L'investissement en ressources humaines a porté
sur des stratégies visant l'expertise de tous, cliniciens et non cliniciens, la valorisation du
travail du personnel et la création d'une ambiance d'équipe plaisante. L'investissement dans
l'accessibilité a porté sur les barrières géographiques et économiques, ainsi que sur la
diffusion d'information dans la communauté sur l'importance des soins périnatals.
Conclusion : Un investissement dans les ressources humaines et l'accessibilité aux services
permet aux hôpitaux régionaux de la RDP Lao de devenir fonctionnels et performants.
Mots clés : soins obstétricaux, coopération luxembourgeoise, qualité des services de santé,
ressources humaines, RDP Lao.
iv
ABSTRACT Problematic: Like many developing countries, the quality of services provided in Lao
hospitals, especially in remote regions, is often criticized. It is therefore interesting to
examine "successful" cases hospitals that are considered by many as models for the rest
country. Such is the case of two hospitals in the province of Vientiane, whose evolution
was supported by Luxembourg Cooperation.
Methodology: This study is a multiple case study took place in two hospitals (Maria Teresa
and Vang Vieng). It aimed to study organizational factors associated with the perception by
health workers and pregnant or postpartum, of the performance of obstetric care. Individual
interviews, based on themes derived from the conceptual framework of the study were
performed.
Results: Analyses of the results show a great satisfaction with the services offered by both,
hospital workers and users, even if some expected services are not routinely offered.
The main factors associated with the perceived functionality of the two hospitals are related
to two aspects: an investment in human resources and an investment in the accessibility of
the target population to obstetric services. The investment in human resources focused on
strategies aiming the improvement of the expertise detained by all, clinicians and non-
clinicians, the recognition of the work done by the staff and the creation of a pleasant
atmosphere for team work. Investment in accessibility focused on geographical and
economic barriers, as well as on providing information on the importance of perinatal care
to the community.
Conclusion: An investment in human resources and in the accessibility to services allows
regional hospitals of the Lao PDR to become functional and efficient.
Key words: Obstetric care, Luxembourg cooperation, quality of care, human resources,
RDP Lao.
v
TABLE DES MATIÈRES
Résumé…………………………………………………………………………………......iii Abstract…………………………………………………………………………………….iv Liste des figures .......................................................................................................................... vii
Liste des annexes ....................................................................................................................... viii Liste des abréviations .................................................................................................................. ix
Remerciements ............................................................................................................................... x Definitions .................................................................................................................................... xi
1. Introduction ....................................................................................................................... 1 1.1 Issue ................................................................................................................................................ 1 1.2 Research question and objectives ............................................................................................. 4
2. Context ................................................................................................................................. 5 2.1 General informations .................................................................................................................. 5 2.2 Organization of the health care system ................................................................................... 6 2.3 Financing of the health care system ......................................................................................... 7
3. Litterature review ............................................................................................................ 9 3.1 General information .................................................................................................................... 9
3.1.1 The hierarchy of health care settings in developing countries ............................................... 9 3.1.2 Recommended obstetrical care in low-income and middle-low income countries ......... 9
3.2 Performance of obstetrical care .............................................................................................. 10 3.2.1 Introduction .......................................................................................................................................... 10 3.2.2 The concept of performance ........................................................................................................... 11 3.2.3 The determinants of the performance of obstetrical care ...................................................... 11
4. Conceptual framework ................................................................................................ 19 5. Methodology ................................................................................................................... 23
5.1 Design ........................................................................................................................................... 23 5.2 Characteristics of the health professionals who were interviewed (criteria for inclusion and exclusion) ....................................................................................................................... 23 5.3 Place and population of the study .......................................................................................... 23 5.4 Source of data collection .......................................................................................................... 25 5.5 Data analyses .............................................................................................................................. 27 5.6 Ethic considerations .................................................................................................................. 27
6. Results ............................................................................................................................... 28 6.1 Supply of services ....................................................................................................................... 28
6.1.1 Human resources ................................................................................................................................ 28 6.1.2 Material resources .............................................................................................................................. 29 6.1.3 Financial resources ............................................................................................................................ 31 6.1.4 Organization of services ................................................................................................................... 32 6.1.5 External factors perceived by the staff to explain the performance of obstetrical care 35
vi
6.2 Demand of services: general satisfaction .............................................................................. 36 6.3 The interface between demand and offer of services ......................................................... 37
7. Discussion ........................................................................................................................ 39 7.1 Interpretation ............................................................................................................................. 39 7.2 Strengths and limitations of the study .................................................................................. 41
Conclusion .................................................................................................................................. 44 Références .................................................................................................................................. 45
Annex ............................................................................................................................................ 50
vii
LISTE DES FIGURES
Figure 1: Framework for understanding the links between organizational context, people management, psychological consequences for employees, employee behaviour and organizational performance (Susan Michie et al., 2004)……………………………………………... 19
Figure 2: Conceptual framework for the study…………………………………………………………… 22
viii
LISTE DES ANNEXES
Annex 1 : Themes of discussion………………………………………………………………………………… 50 Annex 2 : Recruitment document ………………………………………………………………………………52 Annex 3 : Letter of verbal consent……………………………………………………………………………... 54 Annex 4 : Document of written consent……………………………………………………………………... 61 Annex 5 : Confidentiality commitment document………………………………………………………. 65
ix
LISTE DES ABRÉVIATIONS LuxDev Lux-Development (LD)
LL-HSSP Lao-Luxembourg Health Sector Support Program
MDGs Millennium Development Goals
PHC Primary Health Care
MoH Ministry of Health
MNCH Maternal, Neonatal and Child Health
EmONC Emergency Obstetric and Newborn Care
BEmONC Basic Emergency Obstetric and Newborn Care
CEmONC Comprehensive Emergency Obstetric and Newborn Care
ANC Antenatal care
WHO World Health Organization
MHV Model Health Village
OPA Operational Partnership Agreements
HSS Health Sector Strategy
HSDP Health Sector Development Plans
SBAS Skilled Birth Attendance Strategy
UNPD United Nations Development Program
UNICEF United Nations Children’s Fund
Lao PDR Lao Popular Democratic Republic
IFMT Institut de la Francophonie pour la Médecine Tropicale
x
REMERCIEMENTS Je remercie tout d’abord le Dr Daniel Reinharz pour avoir cru en moi et accepté de me superviser le présent travail. Sa disponibilité, ses conseils, et son support m’ont été d’une très grande aide. Je remercie aussi le Dr Frank Haegeman de la coopération luxembourgeoise pour son accueil et ses conseils. Mes remerciements vont également au Dr Philaysak Naphayvong sans qui la rédaction de présent document dans le contexte Lao aurait été difficile. Je n’oublie pas ma famille qui m’a toujours soutenu moralement et financièrement; c’est aussi grâce à elle que j’en suis là aujourd’hui. Enfin, je remercie toute l’équipe de l’IFMT et de la coopération luxembourgeoise à Vientiane qui ont été si accueillants avec moi, et toutes les personnes de près ou de loin qui ont participé à la réalisation de cette étude.
xi
DEFINITIONS (Lux Dev, 2013; Lux Dev, 2014)
Maternal death: A maternal death is defined as the death of a woman while pregnant or
within 42 days of termination of pregnancy, irrespective of the duration and site of the
pregnancy, from any cause related to or aggravated by the pregnancy or its management,
but not from accidental or incidental causes.
Classification of maternal death causes:
Direct causes of maternal mortality: Death caused by obstetric complications or
interventions, misdiagnosis, improper management and their consequences.
Indirect causes of maternal mortality: Death caused by pre-existing underlying
disease or by pregnancy-induced aggravation of this condition.
Maternal mortality ratio (MMR): Number of maternal deaths per 100,000 live births of a
region within a defined year.
Maternal mortality rate: Number of maternal deaths per 100,000 women of the age 15 -
49 within a year. This indicator represents the risk associated with each pregnancy.
Life time risk: The risk of death from complications during pregnancy and after childbirth
within reproductive age. This indicator is widely used for comparing risks for women
between high-income and low-income countries, as well as between regions and localities.
Danger signs:
Antepartum: Puffiness of face, hands and feet; severe headache, dizziness and
blurring of vision; perfused bleeding; severe abdominal pain; severe pallor; little or
no movement of fetus; convulsion; fever; water breaking before birth is due.
Intrapartum: Profuse bleeding; amniotic fluid is stained with green or black
meconium; labor duration more than 12 hours; fever; severe headache, dizziness
and blurring of vision; convulsion; prolapsed umbilical chord.
Postpartum: Profuse bleeding; foul smelling vaginal discharge; severe pallor; severe
headache, dizziness and blurring of vision; high fever more than 2 days; breast
swollen and red; swollen and painful vulva and/or vagina.
1
1. Introduction
1.1 Issue
In Lao PDR, where public primary health services can hardly meet the basic health needs of
the population, various modalities of care and preventive services have been piloted or
implemented at a larger scale, in different districts, by NGOs or bilateral cooperation
agencies.
The official development cooperation of the Grand Duchy of Luxemburg, Lux-
Development (LuxDev) provides since 1997 assistance in the health sector. Between 1997
and 2008, it has implemented several health projects regarding the management and
provisions of hospital services (LAO/002, LAO/005, and LAO/015), the strengthening of
nurse training in the Vientiane Province (LAO/010), the support to policy development and
the establishment of a national Medical Equipment Management (MEM) system
(LAO/009) (Lux Dev, 2013).
In 2008, a new program called Lao-Luxemburg Health Sector Support Program LAO/017
LL-HSSP (2008-2013) was implemented, targeting the 1 million inhabitants of the 29
districts of the Vientiane, Bolikhamxay and Khammouane provinces in central Laos (Lux
Dev, 2014). This program aimed at supporting the government in its efforts to reduce
poverty in the country and to reach the Millennium Development Goals (MDGs) (Lux Dev,
2014). LAO/017 LL-HSSP is considered as a substantial contributor to the national and
provincial progresses seen in MDG 4 (reduction of chiLuxDev mortality) and MDG 5
(improvement of maternal health). In 2007, only 23 per cent of all deliveries nationwide
were attended by trained personnel while the MDG aimed at a minimum of 50 per cent.
Although no data by province existed at that time, there is no indication that the situation
was strongly different from one province to another, particularly outside the Capital of
Vientiane province. The fact that in December 2013, nearly 44 per cent of all deliveries in
Bolikhamxay province were attended by trained personnel suggests that the program was
probably quite effective. Similar positive trends are suspected in Vientiane and
Khammouane provinces. It is reasonnable to foresee now that, in the provinces supported
by LuxDev at least, MDG 4 and MDG 5 targets will be met.
2
The specific objectives of LAO/017 LL-HSSP are to assist the Lao MoH (MoH) in
implementing and operationalizing several initiatives: the long-term Health Sector Strategy
(HSS)1 (2000-2020), the Primary Health Care (PHC)2 Strategy and the Health Sector
Development Plans (HSDP)3. All together, these initiatives reflect the eight priorities of the
Lao MoH; hygiene & prevention, hygiene & health promotion, communicable disease
control, planning, international cooperation, finance, training & research, human resource
management. This is operationalized through activities aiming at strengthening the quality
of health services and reaching a larger share of the population, especially the poorest, the
more vulnerable and those living in the most remote areas in the three target provinces.
LAO/017 LL-HSSP more specifically targets women of reproductive age and less than five
years old children. It aims at improving access as well as coverage for a safer delivery
under the Skilled Birth Attendance Strategy (SBAS)4. It also substantially supports the
implementation of the Maternal, Neonatal and Child Health (MNCH) package (Lux Dev,
2014). This package also includes a LAO/017 LL-HSSP specific contribution of 1 million €
to the National Immunisation Program for the procurement of new cold chain equipment,
and 200 000 € per year contribution to the nationwide procurement of standard childhood
vaccines and vaccines for pregnant women. The LAO/017 LL-HSSP supported activities
have contributed to improve maternal, neonatal and child health preventive services, as well
as the quality of emergency obstetric and new-born care (EmONC). These positive effects
are attributed mainly to the acquisition of more clinical skills by the clinical staff and more
effective management abilities by the administrators (Lux Dev, 2014).
LAO/017 LL-HSSP has been followed by a new program called LAO/027 LL-HSSP
(2014-2020). LAO/027 LL-HSSP is in continuity with the former program. The new
project takes place in a context where there is an increased budget allocated by the Lao
1 HSS is a component of the Lao MoH five-year development plan that focuses on five interrelated aspects of health services (human resources, finance, governance, organization & management, health services delivery, health information system). 2 PHC has its foundation in the Declaration of Alma Ata (WHO, 1978). It is a component of the MoH five-year plan. It aims at making primary health care accessible to all 3 HSDP which is related HSS is concerned with planning 4 SBAS is a strategy of the MoH aiming at improving the number of deliveries by skilled birth attendants.
3
Government to the health sector. The money available should allow a gradual hand-over of
the funding of several of the key activities supported by LAO/017 to the government.
LOA/027 LL-HSSP aims at supporting the implementation of updated sector policies
(Health Sector Reform Framework 2013-2025) with a specific focus on nutrition and
maternal, new-born and child health (MNCH)5 (Lux Dev, 2013). LAO/027 LL-HSSP
focuses on strengthening the health system at the district level in the three central
provinces. This is done through the delivery of high-quality and accessible MNCH services
to the population, especially to the population of the remote areas. The project considers the
six World Health Organization (WHO, 2010) building blocks: health financing strategies;
mother and child access to MNCH preventive and curative care; services delivery
development based on Primary Health Care (PHC); human resources training; training of
senior staff members in Health information systems utilization for planning; equipment of
health facilities to provide essential health care services; and Operational Partnership
Agreements (OPA – a form of contractual arrangement) as a mean to continue to improve
governance.
In a meeting with the LL-HSSP health system-strengthening advisor it appeared that there
were some places where the project was extremely successful. In particular, there are two
hospitals in the province of Vientiane (Maria Teresa and Vang Vieng hospitals) that are
considered as examples for the rest of the country (UNFPA, 2011; Lux Dev, 2013;
Vongvichit E. et al, 2013). Two other meetings, one in the office of the United Nation
Population Fund (UNFPA) and one in the office of the World Health Organization
convinced us that studying these success cases might bring useful information for the entire
health care sector.
5 MNCH package is a document made by the MoH aiming at outlining a unified strategy and planning framework to guide stakeholders in designing, implementing, evaluating maternal, neonatal, child health, immunization and nutrition programs under a stronger government leadership.
4
1.2 Research question and objectives The study aims to answer the following question:
What organizational factors are perceived by stakeholders to affect the performance of
obstetric health services in two hospitals in the province of Vientiane, Lao PDR?
The aim of the research is to study the perception of the evolution of the performance of
obstetric services in two hospitals (Maria Teresa hospital and Vang Vieng hospital)
supported by LuxDev in the province of Vientiane.
The specific objectives of this study are:
To analyze the perceptions of health care workers regarding facilitating factors and
barriers associated with the performance of obstetric health care services;
To analyze the perceptions of pregnant women and mothers regarding facilitating
factors and barriers associated with the performance of obstetric health care
services.
5
2. Context
2.1 General informations
Lao PDR is a landlocked country with a population of 6.4 million inhabitants. It is located
in the heart of Southeast Asia, having no outlet to the sea. It is surrounded by China to the
north, Vietnam to the east, Cambodia to the south and Thailand and Myanmar to the west.
The country is divided into 18 provinces and 142 districts (Kongsap Akkhavong, 2014;
UNFPA, 2011). Its capital is Vientiane. The majority of the active population works in the
agriculture sector (Kongsap Akkhavong, 2014). The ethnic composition is very diverse;
there are about 49 distinct groups, although this number may vary according to the
classification system used (UNICEF, 2013). Lao PDR went through a remarkable
development process in recent years, allowing the country in 2011 to cross the threshold of
lower middle-income countries. But it is still the least developed country of the western
pacific region (UNDP, 2011). Between 1980 and 2010, life expectancy at birth increased
from 49 to 67 years. Infections, poverty, lack of access to rural health services,
malnutrition, bad road making difficult the rapid transport of women to hospital, and the
use of opium and other drugs are the main causes of premature mortality (MoH, 2009). The
proportion of the population living below the national poverty line declined from 45% in
1992 to 27.6% in 2010 (UNDP, 2011). However, disparities in income distribution have
increased. Poverty remains prevalent, especially in remote and mountainous areas.
Although the situation is improving rapidly, several rural areas continue to have a lack of
access to clean water supply, sanitation and electricity (Kongsap Akkhavong, 2014).
Regarding maternal and child health, Lao PDR has made progress in pursuing the 4th and
5th objectives of the Millennium Development Goals, namely the reduction of infant and
neonatal mortality, and the reduction of maternal mortality. However, the situation remains
improvable. Although maternal mortality rate has diminished from 660 in 2005 to 220/100
000 lives birth in 2012, it is still the highest in Southeast Asia (WHO, 2012). This rate can
be compared with the situation in its neighbours where it stands at 26 in Thailand, and 49 in
Vietnam (WHO, 2012). In Lao PDR, in 2011, 42% of women nationwide had delivered
their baby in presence of a skilled birth attendant (the vast majority of skilled attendants
work in a health facility, only a few of them go at the mother’s home). Access to
6
emergency obstetric care is difficult among others, because hospitals do not always have
obstetric and neonatal facilities (MoH, 2009). For example, the rate of caesarean sections is
2%, while the expected rate, according to the world health organization, is around 10-15%,
reflecting, partly, the lack of facilities to perform this procedure when required (WHO,
2012).
2.2 Organization of the health care system
A health care system consists of all the organizations, institutions, resources and people
whose primary purpose is to improve health (WHO, 2010). A health system needs staff,
funds, information, supplies, transport, communications and overall guidance and direction
to function. Strengthening health systems means addressing key constraints in each of these
areas (WHO, 2010).
In Lao PDR, there are in the public sector 7 central hospitals in the capital Vientiane
(including three specialized centers), 4 regional hospitals, 16 provincial hospitals, 142
district hospitals, and 894 health care centers (WHO, 2014). The private health sector is
poorly developed and is generally considered to be of poor quality. Those who have money,
tend to use health services in neighboring countries. But the private sector is expanding. It
consisted in 2010 of 222 private clinics, 1193 private pharmacies and many traditional
medical practitioners.
The public health care system is tiered into four levels: central, provincial, district and
village (Kongsap Akkhavong, 2014). The central level includes central and university
hospitals that provide tertiary care and are recognized as the health care referral centers of
the country. However, in practice, they provide also primary care services, including
children’s vaccination, to the urban population. Indeed, the different levels of the
« pyramid » in practice are not well integrated, with poorly organised referrals, and weak
supervision from higher to lower level. On the outskirts, provincial hospitals cover 18
provinces, while district hospitals exist in 142 districts. In the nearly 10 000 villages
nationwide, there are 894 health centers. There were 2.7 physicians per 10 000 inhabitants
in 2012 compared to 12.2 per 10 000 in neighboring Vietnam. The number of hospital beds
is low: 1.5 beds per 1000 inhabitants in 2012 against 2 per 1000 in Vietnam (WHO, 2012).
7
2.3 Financing of the health care system
Health care costs are mainly borne by the patients. Administration costs are in a great part
supported by external help, in addition to revenue from the general taxation (WHO, 2014).
In 1996 health care fees were introduced. Services are now charged in most public and
private health care facilities, although, formally at least, there are exemptions in public
institutions for certain vulnerable groups of the population, such as the poor, pregnant
women and children under 5 years. The cost in the private sector is obviously higher.
However, it is not strictly regulated (WHO, 2014).
Lao PDR has a rather decentralized health care system and a decentralized administrative
system as well. Provincial governments have significant control over revenues and
provincial health budgets (WHO, 2014). As a consequence, health spending per capita as
well as government coverage can vary considerably between provinces and districts.
According to WHO estimates, government spending on health (MoH budget and social
security expenditures on health) as a share of GDP in 2012 was 1.5 percent in Lao PDR,
compared to 2.2 percent in Nepal, 3.0 percent in Thailand, and 2.8 percent in Vietnam
(World Bank, 2015). In other words, compared to international standards, Lao PDR
government’s spending on health is low, and relies more heavily on out-of-pocket
expenditures and external assistance (World Bank, 2015).
Some insurance system exists. Indeed, in recent years, the government has implemented
several social health protection policies to increase utilization rates and reduce the health
system’s reliance on direct out-of-pocket payments through mainly the Health Equity
Funds (HEFs) and the Mother and Child Health (MCH) policy, with the aim to attain
universal health coverage by 2020 (World Bank, 2015). HEFs were established in 2007 to
provide free public health care services for the poor by removing major barriers to health
facility/health services access such as transportation and costs of pharmaceuticals and other
health care costs. The Free MCH Policy, endorsed by the Prime Minister (implemented in
2013), makes, theoretically at least, all pregnant women and children under the age of 5
years exempt from fees related to prenatal care, deliveries and child health at all health
centers and public hospitals (World Bank, 2015). Moreover, there is a private social
security scheme for employees of the formal private sector, a social security fund for
8
government employees, a community health insurance for self-employed and employees of
the informal sector, and a health equity fund for the poor (Kongsap Akkhavong, 2014).
However, coverage is not universal. The majority of the population has still no coverage
and for those who are covered, only part of the cost of services consumed are reimbursed
by the insurances.
9
3. Litterature review
3.1 General information
3.1.1 The hierarchy of health care settings in developing countries
In most developing countries, the basis of the provision of health lies on a 4-tier pyramidal
system consisting of health care centers, district hospitals, regional hospitals and central
hospitals (Cecile E, 2011; WHO, 1991). Essential care is supposed to be provided in health
centers. District hospitals provide care to people referred by health care centers. They
usually lack surgery facilities. District hospitals are expected to provide more technical-
supported services as surgery care. Specialized care is generally provided in central
hospitals.
When resources are available at these levels, care becomes streamlined. But in many
places, settings suffer from a lack of resources, making the passage from one level to
another less straightforward (WHO, 1991).
3.1.2 Recommended obstetrical care in low-income and middle-low income countries
Obstetric care includes services provided to women during their pregnancy, at delivery and
in the postpartum period. It also covers care for newborns. It aims at preventing the
occurrence of avoidable health problems during the pregnancy, at detecting abnormal
conditions, and at providing medical assistance if required (WHO, 1991; WHO, 1994).
The World Health Organization recommends that all pregnant women receive primary
obstetrical care. The essential obstetrical care are expected to be provided at the two lower
levels of the health care structure, the health centers and the district hospitals (WHO, 1991;
WHO, 1994):
Health centers are the principal place where antenatal care (ANC) is offered. ANC
is important for a pregnant woman. It is where the health of the woman and the
foetus is monitored. It is where the risk level of the pregnancy is defined (WHO,
2004). In Lao PDR, the percentage of women who received ANC has increased
10
from 35% in 1990 to 54% in 2011 (Vongvichit E. et al., 2013). However, the time
and the frequency of the visits are not optimal. The WHO recommends at least 4
prenatal visits during pregnancy with the first one done during the 1st trimester. This
is rarely achieved (Bonono R.C. et al. 2012).
Health centers are supposed to be able to provide parenteral antibiotic, parenteral
oxytocic drugs, parenteral sedatives for eclampsia, and to perform manual removal
of placenta and manual removal of retained products.
Professionals in the health centers should also be able to use partographs.
Partographs are used to monitor the progress of labor, but also to track the status of
the mother and the foetus during labor. They collect data on items such as foetal
heart rate, contractions and maternal pulse, and cervical dilation (Lavender T. et al.,
2012; WHO, 2015). It is a tool recommended by WHO because it allows health
professionals to easily detect potential problems. It is a help to the decision making
process before delivery (for example, regarding transfer of the patient to specialised
structures) (WHO, 2015). The use of partograms is included in the components of
BEmONC (Basic Emergency Obstetric and Newborn Care). All health centers
should be able to provide these services.
District hospitals should be able to offer all the above services plus surgery
(performing caesarean sections), anaesthesia, safe blood transfusion, and the
provision of care to sick and low-birth weight newborns, including resuscitation.
These components are included in the CEmONC (Comprehensive Emergency
Obstetric and Newborn Care). All district hospitals are supposed to be able to
provide these services (WHO, 2015).
3.2 Performance of obstetrical care
3.2.1 Introduction
In low-income and middle-low income countries, obstetric care system is often considered
as non-optimal. A direct consequence of this non-optimality is the maternal mortality rate
(MMR). Effectively, MMR varies tremendously across the world, from 4 to 920 per 100
000 live births. However, in remote communities without health care, it can be as high or
even higher than 2000 per 100 000 live births (Vongvichit E. et al., 2013). The lifetime risk
11
of death is 1 per 16 women in Sub-Saharan Africa. It is 1 per 25 000 in high-income
countries (World Bank, 2013; Vongvichit E. et al., 2013). The broad strategies that have
made it possible to reduce maternal and perinatal mortalities are well known: provision of
antenatal care, management of labor and delivery by qualified personnel, financial and
material resources, and availability of emergency obstetric care (EmOC).
3.2.2 The concept of performance
Performance refers to efficient use of resources, i.e. the production of the highest level of
health considering the resources available. WHO considers that this concept should not be
reduced to some efficiency measurement. It must also take into account the following four
criteria (WHO, 2000):
The general level of the health of the population, for example through the measure
of the life expectancy weighted by incapacities, i.e. Disability-Adjusted Life Year
(DALY);
The distribution of health across groups of the population (measure of health
inequalities);
The consideration for the patient by health care providers, i.e. consideration about
human dignity, confidentiality of medical information, opportunity to participate in
medical choices, ability to choose a provider, attention given to the customers' need
(speed of care, quality of rooms, food in the hospital...), access to social support
networks for patients and families in difficulty;
The fairness of the financial contribution, which appeals to the financial capacity of
the individuals.
3.2.3 The determinants of the performance of obstetrical care
The determinants of the performance of obstetric care are numerous. They are usually
classified into two main families: determinants related to the supply of services and
determinants related to the demand of services.
12
3.2.3.1 Determinants related to the supply of services
Determinants of the performance of care are here categorized into four categories: human
resources, material resources, financial resources, and organization of services.
a) Human resources
Reaching the objectives pursued by the health care system requires a well-trained and
committed staff. In many low and middle-income countries, many places are devoid of
professionals. There is a need to significantly increase the number of health workers to
meet the needs of the population (WHO 2009). World, the shortage is estimated at about
2.3 million for doctors, nurses and midwives, and over 4 million for health workers (WHO,
2009). Yet, the right number of personal cannot easily be calculated as this would require
taking into consideration numerous factors related to accessibility issues, equity, quality,
effectiveness and efficiency. And in countries where there is shortage of health personal,
the technical capacity to identify and assess crucial policy issues related to human resources
is often lacking (WHO 2009).
In 2006 WHO report, Lao PDR was identified as one of the 57 countries in the world that
suffered most from the lack of qualified health professionals. Indeed, in the country, few
health professionals can make safe deliveries and most of them are concentrated in urban
areas where a minority of the population lives (MoH, 2009). Also, in recent years, the net
increase of the labor force was lower than the growth rate of the population. The majority
of the staff working in health facilities is poorly trained. This is particularly marked at the
district level. Salaries are low and technical expertise limited. Moreover, not enough jobs
are created to absorb new health care professionals (MoH, 2009). Finally, it is suspected
that many health workers do not reach the expected productivity (MoH, 2009). The
welcoming of patients in health facilities is not always good, especially towards ethnic
minorities (MoH, 2009).
In summary, insufficient human resources, low salary offered in the public system, poor
competence, lack of laboratory and imaging equipment for medical interventions (such as
medication) are probably important contributors to the capacity of the health care system to
13
meet its objective, hence to its performance. These problems are particularly predominant
in Lao PDR (MoH, 2009; Sychareun et al., 2013).
b) Material resources
The availability of material and medicines are essential for the performance of obstetric
care. WHO has published a list of essential materials for obstetrical care that are supposed
to be available in any health care system (Maya K, 2004; WHO, 2011).
Healthcare facilities providing pregnancy and childbirth care must be clean and orderly.
They must have a clean water supply, good lighting, reliable heating where needed, and
basic furnishings (Maya K, 2004). The labor room should be located close to the delivery
room and both should provide comfort and privacy for the mother. A clean toilet and
shower should also be located within easy access of the labor and delivery rooms. The
drugs and vaccines listed as essential drugs by the WHO should be available (WHO, 2011).
Depending on the level of care, the operating room should be within reasonable access of
the labor and delivery rooms and have the capacity for emergency obstetric surgery (Maya
K, 2004 ; WHO, 2011). For instance, all healthcare providing emergency obstetric surgery
(district hospitals) should normally have the equipment and supplies required for
emergency obstetric surgical procedures, anesthesia, blood transfusion. Emergency trolleys
and drug boxes should be checked on a daily basis and replenished when necessary.
Guidelines for surgical scrub, aseptic technique, local anesthesia, spinal anesthesia,
ketamine, general anesthesia, blood safe practises should also be seen in operating rooms
(Maya K, 2004; WHO, 2011).
In many low-income and middle-income countries, these standards are not always
respected. Shortage of medicine and the lack of functional equipment are frequent (Maya
K, 2004). This has a direct impact on the performance of the health care system. Many
hospitals and health centers in Lao PDR suffer from this kind of shortage.
14
c) Financial resources
In most developing countries, resources consumed by the health sector come from the
different levels of the government, public donors, employers (directly or through insurance
arrangements), charitable organizations, private donors and users of health services.
In Lao PDR, the part of the government in budget allocated to health was 2% of the
National budget between 2010 and 2014, compared to 4.6% in Thailand, and 6% in
Vietnam for the same period (World Bank, 2015). But Lao PDR has a rather decentralized
health care system. Provincial governments have significant control over revenues and
provincial health budgets (WHO, 2014). As a consequence, health spending per capita as
well as government coverage can vary considerably between provinces and districts.
The various care structures must have a funding according to their needs. An effective
management process to avoid stock-outs materials is important; in other words, the money
must be well managed. As the concept of performance includes the concept of efficiency,
the question of the good use of money is a crucial one.
d) Organization of services
Several components allow describing an organization of services. These can be categorized
into the following elements: leadership, workload, teamwork, training opportunities, and
adaptation to the environment.
Leadership style is an important component of an organization as it influences the
performance of human resources. It is known that an effective leadership is generally a
leadership able to arouse a spirit of cooperation between the leader and the staff, as this
cooperation underlies the motivation to accomplish one's tasks (AMDD, 2003).
A functional organization also requires some flexibility. Since every health care facility has
different needs, strengths, and weaknesses, the leader is responsible of exploring how to
take them into account in order to make the organization able to sustain changes in the
environment (AMDD, 2003).
15
Leadership requires a team to lead. The team in the maternal and child health sectors is
expected to be constituted of people trained at international standards of care. Competent,
i.e. well trained, personal, is a key indicator used by WHO to measure the performance of a
health care system. In maternal health, lack of ongoing training, supervision and continuous
feedbacks are among the reasons for the low level of competent professionals often found
in developing countries (Perry C. et al., 2005). Moreover, health structures performance is
positively correlated to how many people constitute the staff; a lack of personal increases
the workload of the workers (V. Currie et al., 2005; E. West, 2010). Indeed, the workload
is an obvious factor associated with motivation and behaviour (Bradley S. et al., 2015).
Failure to adequately provide competent and sufficient human resources is a key
contributor to the gaps found in the provision of obstetric care, in demotivation and poor
satisfaction of the staff, hence to the performance of the organization (Bradley S. et al.,
2015).
3.2.3.2 Determinants of the performance of obstetric care related to the demand of services
On the demand side, several factors can influence the performance of obstetric care.
Theses determinants include geographical access to care (long distance to health facilities),
financial barriers, lack of information about PNC (education), miscommunication with
health care providers (or with facilities), and cultural believes (WHO, 2012; Vongvichit E.
et al., 2013).
a) Geographical access to care
The geographical access to care is an important determinant of the performance of the
organization. Indeed, in many low and middle-low income countries, the roads are very bad
especially in remote areas; it complicates access and is a source of discouragement for
patients (WHO, 2012; Vongvichit E. et al., 2013).
In Lao PDR, geographic access to health care can be difficult particularly in remote areas
and during the raining season. The roads from the villages to health facilities might be very
poor, even impracticable when it rains. In many villages there is no suitable vehicular to
transport people whatever the weather conditions are. Some families have farming trucks,
16
which can be used to bring women to the hospital, but they are extremely slow. In many
villages, going to health center or hospital requires being carried on a back as the facilities
can only be joined by walking. During the raining season, people might not be able cross
rivers due to flooding and destroyed bridges. Health care facilities can be far away. In 37
districts, about 25% of the population live more than two hours away from a health facility.
In 18 districts the percentage is even 50% (MoH, 2009; Vongvichit E. et al., 2013). Also,
some villages have no access to landlines or mobile phones. Therefore, women themselves
or relatives cannot contact or communicate with village health volunteers or health care
providers in health centers or hospitals (Vongvichit E. et al., 2013). One of the
consequences of this situation is that women can arrive at a health facility later than
required. This directly impact the outcome of the care provided, as the facility might not be
able to handle such an advanced case.
b) Financial barriers and lack of communication with health facilities
Another determinant related to geographical access is the cost. There is much evidence to
suggest that distance to facilities imposes a considerable cost on individuals and this may
reduce the demand (Vongvichit E. et al., 2013). Transportation cost to health facilities is a
problem for 28% women in Burkina Faso, 25% in northeast Brazil; in Bangladesh, it has
been found that it was the second most expensive item for patients after medicines (Ensor
T. et al., 2004). In Lao PDR, most of the maternal mortality is borne by deceased women
who were very poor and who could not access the facilities due to lack of money for
transportation (Vongvichit E. et al., 2013).
c) Cultural beliefs
Cultural beliefs and previous bad experiences with health care facilities are also important
factors (Thaddeus S. et al., 1994). For example, in many countries such as Nigeria,
Ethiopia, Tunisia, India and South Korea, the decision to seek care belongs to a husband or
an elder in the family; women might not be able to decide on their own (Thaddeus S. et al.,
1994), especially when they are not financially independent. Moreover, women do not
always realize the severity of complications of a pregnancy or might even prefer to stay at
home because of a previous bad experience with health centers (bad reception for example)
17
(Thaddeus S. et al., 1994). Here too, this might lead women to reach a health care facility
late. This can only affect the performance of the care provided.
Studies in Lao PDR have suggested that the position of women in society is still often
under the authority of the opposite sex. This and the fact that sometimes they feel less
comfortable to be examined by male health professionals are key reasons to explain why
they can be reluctant to go to a health care center (Boudreaux et al., 2014; MoH, 2009;
Sychareun et al., 2013). Moreover, in most health services, Lao language is the only spoken
language by health care profesionals: this constitutes a real barrier to the access to health
services by some ethnic groups that don’t speak Lao (Phathammavong Ali et al., 2010).
Many people in Lao PDR believe in spirits and ghosts. Their beliefs might prevent or delay
health care seeking (MoH, 2009; Vongvichit E. et al., 2013). Also, some ethnic groups have
delivery customs that prevent a secure accompanying. For example, in some of these
groups when a pregnant woman goes into labor, she is expected to stay alone in a hut,
which was built by her husband during her pregnancy. No one is allowed to stay in the hut
or support the woman during delivery. She is expected to deliver the child on her own,
including cutting the umbilical cord, often done with an unsterile bamboo knife. The
husband is supposed to wait outside the hut until hearing the cry of the child; thereafter he
will enter the hut to see his wife and newborn child. In other cultures, family members,
especially mothers and mother-in-law are convinced that they know how to support the
pregnant woman and provide safe delivery assistance (Vongvichit E. et al. 2013). One of
the consequences is that in these groups, most women do not visit health care providers for
antenatal care, as they only rely on the experience of older women to conduct the
pregnancy (Boudreaux et al., 2014; MoH, 2009; Sychareun et al., 2013; Vongvichit E. et al.
2013).
d) Lack of knowledge about pregnancy care
In Lao PDR like in many low-income and middle-low income countries, most women and
their relatives might be poorly informed on warning signs during pregnancy and delivery
(Vongvichit E. et al. 2013). This too might prevent PNC to provide optimal services, as
18
these women might not know when to consult when a need to see a health professional is
warranted.
19
4. Conceptual framework The conceptual framework on which is based the conceptual framework of the study,
provides a holistic view of dimensions associated with the performance of an organization
that is here applied to the provision of health care services (Susan Michie et al., 2004)
(figure 1). The framework aims to study the performance of an organization through a
sequence of influences. The first element consists of the context (organizational culture and
inter-group relationships, resources, including staffing and, physical environment).
The context influences human resource management (practices and strategies, design work,
workload and teamwork, employee involvement and control over the work, leadership and
support), which in turn will affect the well-being of employees (health and stress,
satisfaction and commitment, knowledge, skills, and motivation). This will then influence
the behavior of the workers (absenteeism and turnover, the task and contextual
performance, errors and near misses), with, as a consequence, an impact on the
organizational performance (figure 1).
Figure 1: Framework for understanding the links between organizational context, people management, psychological consequences for employees, employee behaviour and organizational performance (Susan Michie et al., 2004)
20
Susan Michie et al. (2004). Managing people and performance : an evidence based framework applied to health service organizations.
International Journal of Management Reviews, 5/6(2), 91-111.
21
Our evaluation will focus more specifically on the first two large aspects of the conceptual
framework: context and management of human resources, because they are more susceptible to
lead to recommendations (figure 2). Figure 2, which is inspired by Michie's conceptual
framework (Figure 1) represents the conceptual framework used to build the questionnaires of
this study.
22
Figure 2: Conceptual framework
23
5. Methodology
5.1 Design
A multiple case study with a descriptive-exploratory design was performed to study factors
associated with the perception of the performance of obstetrical care provided in two hospitals
supported by the LuxDev that are considered in the Lao health care system as success stories.
This design was considered as relevant, as up to now to our knowledge no study has been
performed on successful stories regarding hospitals in Lao PDR. Indeed, a performing a
descriptive and exploratory study is considered as a judicious first approach in order to gather
relevant information when the topic under study is rather unknown (Yin R.K., 2003).
5.2 Characteristics of the health professionals who were interviewed (criteria for inclusion and exclusion)
Participants to the project were selected by the directors of the hospitals. In each of the two
hospitals, five people were identified to participate to the study: the director, an obstetrician, an
obstetrical nurse, the head of the pharmacy department and the head of the accounting
department. These professionals were at their position for at least ten years. They all have a
university degree. Interviews were conducted in Lao with the help of a fully bilingual IFMT
student who served as a translator, or a LuxDev public health physician. They lasted an average
of 45 minutes and were recorded using a tape recorder. Interviews were translated into French
and transcribed by the IFMT student immediately after the interview.
5.3 Place and population of the study
The study took place in two hospitals situated in the province of Vientiane: Maria Teresa and
Vang Vieng hospitals.
Maria Teresa is the provincial hospital of the province of Vientiane. It is located in the capital of
the province, Phonehong. It has been built by LuxDev in the second half of the 90s. The design
and the implementation of the nursing services were initially done with the support of teaching
staff of the Faculty of Nursing of the University of Khon Kaen (North East of Thailand). The
hospital opened with 60 beds. It now has now 90 beds. Maria Teresa is a general hospital that
provides general surgery services. Caesarean sections can be performed. The hospital is
24
considered in the country as a model hospital regarding the quality of care provided, its
information system and its physical amenities. This hospital is a teaching hospital for the LuxDev
built school of nursing and midwives. It's also involved in the supervision of 4 other districts
hospitals (Keo Oudom, Viengkham, Thoulakhom, Hom) regarding the organization of nursing
services.
Vang Vieng hospital is a 30 beds district hospital of the Vang Vieng district of the province of
Vientiane. It has been built during the Indochina war by the Americans. In 2006,it was renovated
thanks to a project funded by the Belgian Technical Cooperation. Being a hospital with surgery
facilities, Vang Vieng hospital is almost considered as a provincial hospital. As such, it provides
surgery services to two other districts: Kasy and Met. It must be noted that during the renovation
period, a restructuration of the way services are offered took place. This allowed the hospital,
although it is not as Maria Teresa hospital a formal reference hospital for the province, to provide
CEmOCs.
The target population consisted of two sub-groups: 1) health care professionals involved in the
delivery of obstetric care and 2) pregnant and postpartum women. The latter were enrolled to
provide the perception of care from a "consumer" perspective.
Health care professionals were required to be in their current position for at least ten years. They
represent various positions of responsibility in the hospital. Interviews followed, as much as
possible, a hierarchical path. The first interviews were done with the manager at the highest level
of responsibility in the institution (the director) in each of the two hospitals. We then conducted
one interview with each of the following health staff in each of the 2 hospitals: an obstetrician, an
obstetrical nurse, the head of the pharmacy services, and the head of the finance services. The
choice of these persons was made by the director of the hospital. The director informed the staff
that some people would be interviewed and that these interviews would take place shortly, in
order to reduce interference of the study with the activities conducted in the hospital. The
researcher was constantly accompanied by an IMFT student who was present in the hospital for
another research project, and who served as a translator. In the second hospital, all interviews
were conducted the same day, as requested by the director. The researcher was accompanied by a
public health physician working for LL-HSSP. This physician acted as a translator.
25
In sum, in each of the hospitals, we conducted five interviews. All interviews took place at a
moment and in a place deemed suitable by the respondent, for a confidential interview.
Pregnant were recruited in the hospital during their prenatal visits with the help of the translators.
Postpartum women were also recruited in the hospital after giving birth. In the prenatal visits
waiting room, women were approached and presented the project. They were then asked if they
were eventually interested in participating to the study. If they agreed, they had to sign an
informed consent form. In one of the 2 hospitals, two pregnant women refused to participate to
the study whereas in the other one there was no refusal. Women in the consultation ward who
accepted to participate to the study were interviewed in the hospital, in the less noisy part of the
waiting room. Recruitment of post-partum women benefited from the help of the obstetrical
nurse, who explained and asked the women while they were recovering in the resting room after
giving birth if they were willing to participate to the study. All women accepted and were happy
to answer our questions. Interviews were made in theses rooms. In sum, in each hospital, we
interviewed 5 pregnant women and 5 postpartum women.
All interviews were conducted in Lao. The researcher asked questions, and the translator
translated in both directions. At the end of each interview, the researcher and translator carried
out the full translation of the interview into French and its transcription.
5.4 Source of data collection
Three types of information were collected using semi-structured individual interviews:
1. Information regarding the evolution or, in case of non-available data, the perception of the
evolution of the performance of obstetrical care;
2. Information on the perception of factors that might influence the evolution of the
performance of obstetrical care, particularly those related to the first 2 dimensions
(context and human resources management) of the conceptual framework;
3. Perception of users regarding the performance of care.
Evolution of the performance of care was estimated through indicators available at the hospitals,
particularly productivity indicators, as the compliance with the number of prenatal visits
recommended by WHO and the presence of WHO-recommended material and clinical guidelines
26
(Bonono R.C. et al., 2012). Indicators such as the evolution of the number of prenatal visits and
assisted deliveries over the last ten years were estimated by the obstetrician and the obstetrical
nurse on the basis of their experience. Interviews also tried to grasp the perception on non-
available indicators, as maternal mortality.
Factors associated with the perception of the evolution of the performance of care were explored
through semi-structured individual interviews. Interviews started with two very general
questions. The first question was about their perception of the evolution of the performance of
obstetric care over the last 10 years. The second question was about the perception of factors, as
resources availability, management structure, training, work division…that might, according to
the respondent, increase the performance of these services provided to pregnant women. People
were allowed to express freely their point of view and to speak without interruption, in order to
better catch the respondents' understanding of obstetric care. More precise questions were then
used to approach the various aspects of the conceptual framework according to the information
provided spontaneously.
Women's perception focused on how users perceive the attractiveness of the hospital and the
suggestions they might make in order for the services to better answer their needs and
expectations.
Individual interviews with health staff took on average 45 minutes, whereas those with pregnant
and postpartum women took on average 20 minutes. They were recorded using a tape recorder.
If the participant did not want to be recorded, handwritten notes were taken. One postpartum
woman refused to be recorded. The recording and the written notes are confidential. Interviews
with the staff in one of the hospitals went extremely well. Participants were clearly happy to
discuss, the impression was that there was no waffling. People seemed to speak freely. On the
other hand, in the other hospital, there might have been some stonewalling answers. Questions
about the medication management system seemed to have annoyed some of the participants. The
translator told the researcher that people said that too many questions were asked and that some
of the information required was confidential. Postpartum and pregnant women were clearly
happy to participate to the study. They answered to our questions freely, with no pressure. We
could really feel they were happy to give their point of view.
27
Themes for discussion were inspired by the Service availability and readiness assessment
(SARA) questionnaire of the World Health Organization (WHO, 2014) in order to fit our
conceptual framework (Annex).
5.5 Data analyses
Analyses consisted in codifying the transcripts according to the different dimensions of the
conceptual framework. No software was used. The researcher and one of his supervisors coded
the data independently. A consensus was sought each time a disagreement emerged on the
proposed codification.
Furthermore, analyses were based on the triangulation of information: only ideas or concepts
supported by at least 2 people interviewed were considered.
5.6 Ethic considerations
The project has been approved by the Ethics and Research Committee of Laval University (REB)
under the number 2015-086 / 28-05-2015. It has also the approval of the Lao MoH. All study
participants must freely sign an informed consent form. The nature of the research and the use of
interviews were explained by the researcher. Respondents were notified that their participation is
voluntarily and that they can suspend the participation to the project at any time, without
constraints or consequences. The confidentiality of their statements was also guaranteed: their
names and any information that might lead to the identification of the participants were
anonymized as soon as the verbatim was transcribed. A similar commitment to confidentiality
was also signed by the researcher. The verbatim records consent forms; commitments to
confidentiality and pre-interviews completed questionnaires were identified with a number and
kept in a locked file provided for this purpose. All materials will be destroyed two years after the
end of the research.
28
6. Results Results will be presented in two sections: 1) supply of services, and 2) demand for services.
6.1 Supply of services
6.1.1 Human resources
The main message conveyed by all those who were interviewed is the fact that there is no
fundamental problem regarding human resources in the hospitals. The involvement of LuxDev
was justified by serious problems regarding the competence of the clinical and management staff.
The project that was implemented in both places completely solved the problem.
« Ten years ago, physicians of districts and provincials hospitals did not have the required
technical expertise in case of obstetrical complications » (interviews number 1 and 6,
(1,6#)).
« Today, the staff is better formed than in the past, and then more competent. Thanks
to the LAO/017 LL-HSSP, nurses, midwives, and physician have received a three
months of complement formation in the most functional hospital in the country
(Mahosot hospital of the capital Vientiane). Now, there is no death here for
approximately 500 deliveries each year » (6,8,9 #).
Improvement in the competence of the staff is mainly attributed to a project (the LAO/017 LL-
HSSP program) that sought support for the hospital staff not so much from Western countries,
but above all from people, nurses and physicians from Thailand, a country that is culturally close
to Lao PDR, whose language is perfectly spoken but any Lao person who has a television at
home, and that is considered as a relatively performing country regarding its health care system.
The other source of support, which Cuba that provided doctors to the hospitals, is also considered
as a key factor. Cuba cannot be fully considered as a Western country. It has experience in
dealing with places where medical personal is poorly trained. It has the knowledge required for a
practice in the conditions the resources, material and financial, that prevail in the two Lao
hospitals.
29
« In this hospital, there is also some nurses and physicians from Thailand that came
here to give us more advice about the welcoming of the patients, the organization of
work, and the technical expertise » (8,9 #).
« This hospital is related to some Thai hospitals that are reputed for the quality of
their service. The hospital has received advice from Thai hospitals regarding the
welcoming, respect and listening to the patient. This is why the hospital is deemed
and is increasingly popular» (3,4,5 #).
« Also, some specialist from Cuba worked with us here. In our Obstetric service, an
obstetrician from Cuba is responsible of Obstetrical complications such as surgery.
The staff learns a lot from him during caesarean for example » (3,4 #).
In sum, the perception is that in the two hospitals, LuxDev involvement has led to the acquisition
of a real expertise by the staff thanks mainly to a project that made use of expertise in countries
that might be quite open to the Lao context and realities. Teaching and training staff were
accepted because they were considered as able to grasp the constraints that health care
professionals face when one has to work in a Lao province. This acceptance of the teaching staff
by the hospital professionals is seen as a key factor for the acquisition of new competences.
6.1.2 Material resources
The availability of material resources has improved over the last ten years. In none of the
hospitals is there now shortage of a medication listed by the MoH as an essential drug.
« In this hospital a, for example, the mainly missing drug was a drug called
Hydralazine. It is a drug used to treat women in pre-eclampsia. Due to the lack of
technical expertise, no one knew how to detect pre-eclampsia so we did not buy the
drug because it was not a priority. Today, with the improvement of technical
expertise, the used of medicine increased a lot, and there is no stock-out of
recommended drugs » (2#).
« There is some big progress regarding the drugs here. The low level of physicians in
the past has made that they used to use a very few quantity of drugs. Today, they use
more drugs than in the past. There is no stock-out of drugs because today, for the
30
purchase of drugs for obstetric care for example, the hospital's director has signed
contracts with pharmaceutical companies (sogly pharma, Interpharma, cbf pharma)
that sends us automatically every three months the drugs they need. For example, if
their quarterly budget is 3000 dollars for drugs, they order for 3000 dollars. They sell
them forward to make a profit. If they do not sell all their stock, they keep the rest for
emergencies. And if in the emergency stock there are certain drugs of which the
expiring date has passed, they return them to the pharmaceutical company to
exchange with valid drugs. These are the terms of the contract signed by the director
with these companies » (10#).
Moreover, the hospitals have been able to increase their number of beds and get some equipment
as ultrasounds. Regarding the availability of equipment, there is much more caregivers materials
than in the past.
« In this hospital, we have now 35 beds while in the past we had only approximately
15 beds » (6,8,9 #).
« Here, we have now 90 beds while in the past we had 20 to 25 beds » (1,3,4 #).
« Today, in this hospital, we have some modern and well-maintained equipment as
ultrasound. The only problem is that we don’t have incubators in case of premature
baby. We are obliged to transfer premature baby in the provincial hospital where
there have incubators. It is expensive and the parents cannot always afford it » (8#).
This evolution is due to several factors:
« Here, the renovation of the hospital was comprehensive: buildings were renovated,
the necessary equipment was bought, but progressively, as the services improved over
a 2 year period, and for each major equipment (ultrasound, laboratory equipment) the
concerned staff received several months of training at Mahosot. The list of drugs was
also progressively expanded, at the request of the doctors who finished their
additional training at Mahosot (e.g. eclampsia treatment), or on the advice of Thai
nurses (disinfectants). Team management meetings, verbal case autopsies, financial
31
management techniques were introduced: all building blocks of the Health System
were addressed simultaneously. A similar process was used for the other hospital »
(LuxDev).
According to the participants, one of the key factors that explain why the condition of material
supply has improved to such a satisfactorily level is the acquisition of professional skills.
Administrators and care providers better now what kind of material is needed. They also know
how to manage their acquisition and their use. Having found an effective way to train the staff
seems to be an essential ingredient of providing the material support essential to the performance
of the organization. One notes the consensus about the importance to improve competences by
the clinical and administrative staff concomitantly in order to get a more effective management of
material resources needed in the hospital.
6.1.3 Financial resources
Before 2008 there were three sources of funding in both hospitals: LuxDev, the government and
the patients. Since 2008, funding depends only on the government and the patients.
« In the past, this hospital was funded initially by the Luxembourg government, and
patients. Since 2008, it is only the patients and the government that finances.
Therefore, I can’t tell you how the process of financing works, it is the hospital secret
» (1,5 #).
The withdrawal of LuxDev financial contribution was made possible by the introduction of a
modern and user-friendly financial management system and training accountants to its use.
« The finance sector has changed over the last 10 years. In the past, the accounting
system was really basic that is to say that everything was noted by hand.
Now, with the contribution of Luxembourg, we have computers and everything is
written in Excel. This system of financial management is now used throughout the
province » (7#).
Vang Vieng and Maria Teresa have more benefits than other health facilities in the province.
Being responsible of other districts hospitals, they receive patients from these districts, and have
32
therefore more revenue and so more benefits. For example, in term of drugs purchase, the system
is well organized.
« Financially, this hospital is a district hospital A. That means that we are the
reference for other districts hospitals (Kasy and Mets districts hospitals), which are
type B. They have then more patients than Type B districts hospitals and therefore
more money due to the benefits.
For the purchase of drugs for obstetric care for example, the hospital's director has
signed contracts with pharmaceutical companies (sogly pharma, Interpharma, cbf
pharma) that sends them automatically every 3 months, medications they need » (6,7
#).
6.1.4 Organization of services
6.1.4.1 Leadership
a) Identification of the leader In both hospitals, leadership is considered as an important factor. In both settings, the leader in
any of the sector is usually the person with the most experience, although it is the privilege of the
director to appoint someone if he thinks this individual has more abilities to lead a team. There
seem to be recognition of the value of such a way of proceeding. The respondents seem to be
extremely satisfied with this way of managing the organization, although they might be a little
biased: all of them are leaders in their own sector.
“Here, there are no predefined leader in obstetrical care, it is experience that
determines the leader. In other words, for example, when a patient arrives, among the
staff that is there at this time, it is the oldest that is automatically the leader.” In the
pharmaceutical service, it is the same way: “we all have the same degree in
pharmacy, it's my experience that makes me the leader” (1,2,3,4,5 #).
“Here, the leader of the teams is defined by the hospital director. But it is generally
the most experienced person” (6, 7, 8, 9,10 #).
The recognition of the value of such a way of proceeding has been made possible thanks to the
hospitals cooperation with the Belgian Technical Cooperation (BTC) and the LuxDev.
33
« The whole process of the reform was based on the resolution of the problems. We
(BTC and LuxDev) had to sometimes to use tricks: for example, the director in the
past was opposed to reforms. LuxDev gave him a scholarship to allow him
undertaking public health studies during 2 years, to keep him away from the hospital.
When he came back that was it, the reform had taken ground, and he couldn't change
anything. We also associated the district governor to the reform. He co-signed the
"performance contracts" for the staff (performance-based incentives) » (LuxDev).
b) Style of leadership
Respondents put a lot of emphasis on the fact that the hospitals were small, hence with a small
staff. Everyone knows everyone. Added to the fact that the hospitals are well equipped, especially
compared with other same level hospitals, and the staff is well trained, this makes ideal
conditions for a rather friendly atmosphere. Leaders declare themselves extremely open to the
points of view of everyone in the team. They pretend that the way the communicate their orders
is through discussion, not imposition.
”There are no barriers among us. We can discuss of everything with the chief; he
always listening of our concerns and takes it in consideration” (2,3,4 #)
“I am the leader here in obstetrics but there are others people with the same
experienced as me in this service. I communicate a lot with them and with the staff, to
better understand their point of view” (8#).
6.1.4.2 Teamwork and workload
All respondents emphasized the fact that the functionality of the hospital lies on the capacity to
build real team, where each member knows what is expected from him, where each member
respects the others, and where each has the desire to help the others. Two major strategies are
deployed to build such a team: attribution the leadership as much as possible to those in the team
with most experience, and a trial period at the beginning of new hiring. During the trial period, a
new member is assessed not only on his competence, but also on his personality. People are
definitively hired is the general assessment in the team is that the new member has the qualities
required to become a real partner. Personalities seem to prevail over competence.
34
« For 15 years I work here. I am satisfied with my job. The staff works together as a
real team; they respect the system; stand together and get along well; so it's easy to
work there. When a new nurse or physician comes, he observes first how things work
here. After this period, he will work under the supervision of someone experienced.
Then it will go through an assessment of competence and integration to the team. It
does not necessarily choose the best, you have to have a good character that is to say
it must integrate well and get along with team members. The number of staff is
sufficient, everyone does his job, and there is no extra hours and workload » (1#).
However, there is some particularise in the management style: in one of the hospitals, a 3-month
rotations between different departments of the hospital has been imposed by the director. Every 3
months, the entire staff of a clinical team has to go to another unit. For example, those working in
obstetrics go to the emergency department. However, the team sticks together. It's the entire team
that moves around. The main reason of this policy is to enable all clinical members with the
abilities to work in another services. This is a kind of guarantee against a sudden and unexpected
shortage of personal. This system is unique in Laos.
6.1.4.3 The working environment
Organizationally, it was reported during the interviews that there was a good work atmosphere.
The staff gets well along. There is a lot of mutual help and collaboration. This was also made
possible thanks to the cooperation with LuxDev as shown in the quotation below:
« In both hospitals, and independently, we focused on "team management". Decisions
are often taken in-group: it actually reinforced the director's authority, while reducing
his burden of responsibility. In addition, transparent financial management and the
fact that there is no payment under the table have reduced tensions between staff and
ended the system of different groups with a different leader, who distributed the
envelopes thereafter. The new transparent system is easier for everyone. This was set
up with the continuous and regular support of BTC projects, and LuxDev still
separated at this time » (LUXDEV).
35
6.1.5 External factors perceived by the staff to explain the performance of obstetrical care
Two external factors have, according to the respondents, contributed to improve tremendously
the performance of care in the two hospitals: family planning and road access.
6.1.5.1 Family planning and women education
In Lao PDR, a lot of efforts have been deployed to allow access to family planning. Many
projects related to family planning have been implemented all over the country. Women are now
more knowledgeable in this field. One of the main benefits of family planning is that it leads
women to realize that they are responsible for the well-being of their children. Being able to have
children at the best moment for them and the number they wish to have comes with a price: they
are in some way liable for the health of their children. Prenatal and postnatal care becomes
extremely important. Women are more ready to be compliant with demands by the health care
system. This has a positive impact on its performance.
Regarding women awareness, in one of the hospitals, one way that was used was to provide
education to women as follows:
« In two regions (Lao, Loum), fairly prosperous, and open to Thai television (so economically
strong), nurses wandered from villages to villages to provide education to women and families
about pregnancy. Women are becoming better informed and come for antenatal care and hospital
deliveries. This was achieved under the leadership of the MCH Director of the hospital »
(Luxdev).
6.1.5.2 Access to care
The access to health care centers and hospitals are also key factors. Roads have been built. It has
provided to thousands of women and easier and quicker way to get services when needed. Once
people realize they can travel easily, they just do it. Distances have been reduced. This too has a
real impact on the performance of the care provided.
36
6.2 Demand of services: general satisfaction
At Maria Teresa hospital, 5 pregnant and 5 postpartum women were interviewed while in Vang
Vieng they were 5 pregnant and 4 postpartum women. All women were able to read and write.
We therefore assumed that they fully understood the questions asked.
The most striking observation, present in both hospitals, was the extremely high level of
satisfaction by users of obstetrical services.
« I'm glad to come to this hospital because the doctors and nurses greet me very well,
and the service is fast. As soon as I arrive they come to me, talk with me, take care of
me. I wait about 10 minutes before starting the consultation. It's important to me have
a good and fast service » (2#).
« Nurses of the mother-child services give me many tips about the food I have to eat
and my daily workload. In addition, the service is free, fast, and the staff is very
kind » (2,5 #).
« The members of my family and some friends advised me to come here. They have
had good experiences here, they told me that the service was fast and good. In
addition, antenatal and childbirth are free; I just have to buy the drugs » (1, 11 #).
« I'm not in the common room of postpartum because I had a caesarean. I am satisfied
with the services that I received here throughout my pregnancy to my birth. Always a
good reception, and the staff is friendly and polite.
I really trust the health workers here. This is my third pregnancy and I have always
delivered here because I feel » (10 #).
« This is my second pregnancy; I have always been welcomed very well here. The
nurses are always smiling and happy to see me. They know that I live so far away, so
I sometimes entitled to preferential treatment. They also take news of my family; it is
pleasure to come here, I trust in nurses » (11 #).
37
Women consider that services are fast, that the staff is very welcoming, kind, well-intentioned.
Nurses and doctors listen to women concerns. Women fully trust the staff. They also appreciate
the fact that ANC and delivery are free. Not a single complain was heard. Women have needs and
expectations. Those seem to be satisfactorily fulfilled.
6.3 The interface between demand and offer of services
The interface between the demand and the offer of services can be observed through activities
deemed important in obstetrical care, as for example, advices given to women regarding her
pregnancy and her baby.
In one of the hospitals, according to the women, information is systematically provided on breast-
feeding, the respect of the immunization calendar for the baby, and the diet women are expected
to comply with during and after a pregnancy. Above all, information provided was considered as
understandable and relevant.
« I have got many tips. The nurses explained how to meet the baby's immunization
schedule (follow the immunization schedule). I have to rest a lot and avoid work, i
must also eat healthy and do not skip meals. I was also advised to practice exclusive
breastfeeding and also how i had to breastfeed; breastfeeding methods (how to
position the baby so that it is comfortable, how to keep him). I have no
recommendation to make, the service free and all goes well. Nurses also gave me
complimentary milk in box » (4 #).
« This is my third pregnancy so I'm experienced. However, I still received advice on
exclusive breastfeeding during the six first months, the respect of the vaccination
schedule. Since I had a C-section, I was advised to drink soups for now and eat only
light foods in general » (10 #).
In the other hospital, advices seem to be less systematic, quite dependent on the will of the nurses
to provide it or not.
« I did not have any advice on breastfeeding, immunization schedule, but I already
know how it goes as it is my second child. Also, in my village, there are often people
coming to awareness of vaccination » (11 #).
38
« The nurses advised me during my pregnancy to eat well balanced all day, and
follow the immunization schedule for my child. But they did not talk about
breastfeeding » (12 #).
« This is my second pregnancy. I got advice for all my pregnancies to practice
exclusive breastfeeding up to 6 months, and follow the vaccination schedule (during
the interview, a nurse was explaining the vaccination calendar to my husband) » (14
#).
All women were asked to by the nurses to have at least 4 prenatal visits. All women were
convinced of the importance to comply with this request and all did it, with one exception, a
Hmong woman who only had 2 visits. This woman did not speak Lao. She needed her husband to
translate what the personal said. Unfortunately, the child of this woman died. It is supposed that
this woman arrived at the hospital for delivery too late. However, the real cause for the stillbirth
wasn't known by the professional who reported it.
« I come now to my fifth prenatal visit, it is always a pleasure because the service is
quick and takes good care of me » (11 #).
« I have just given birth to my second baby and I made 6 antenatal here before my
birth » (17 #).
This is a Hmong woman wearing her first pregnancy. We know she is a Hmong because she did
not speak Lao. It was her husband who translated the interview. The baby was born dead in his
stomach before his arrival at the hospital.
« My water broke yesterday and I went to the health center of my village. There, I
was told that I had to go to the district hospital. It took me about 50 minutes (25km
by bike) with my husband to get to this hospital. When I arrived, the staff saw that my
case was serious and took care of me first. So I was well received. When i woke up,
they told me that my baby was dead before I got here and that they had not done
anything. Before my delivery, I made only two antenatal visits are in the village
health center » (13 #).
39
7. Discussion
7.1 Interpretation The aim of the research was to study the perceived evolution of the performance of obstetric
services in two hospitals that are considered in the Lao health care system as success stories and
that were supported by LuxDev in the province of Vientiane. More specifically, we aimed to
analyze the perceptions of health care workers regarding facilitating factors and barriers
associated with the performance of obstetric health care services; and also the perceptions of
pregnant women and mothers regarding facilitating factors and barriers associated with the
performance of obstetric health care services.
To achieve these objectives, we used a multiple case study. Based on the different dimensions of
our conceptual framework, the following findings can be presented.
Both hospitals seem to fulfill their mandate. Vang Vieng hospital is a district hospital, serving
around 150 000 population. It provides CEmONC services in addition to BEmONC (WHO,
2015). Maria Teresa is the provincial referral hospital (i.e. regional hospitals), for the whole
province of approximately 400 000 population. It has more specialists and offers more services
(Cecile E, 2011; WHO, 1991). Maria Teresa is also a teaching hospital for a LuxDev built school
of nursing and midwifery. Both hospitals therefore respect the WHO norms regarding obstetrical
care in low- and middle-income countries.
If we refer, based on WHO concept (WHO, 2000), performance as the efficient use of resources
to increase the general level of the population health, to decrease health inequities across sub-
groups of the population, to improve the level of satisfaction felt by the patients regarding
services received and to secure fairness in the financial contribution by the patients, we can
propose that the two hospitals are performant.
This efficiency seems to lie above all on the investment done in human resources. One of the
main hospital development strategies was to assure training through professionals with
experience, coming from other tropical countries, notably Thailand and Cuba. One expects a
better receptivity to advices when being taught by people expected to be facing in their daily
40
activities, similar contexts and challenges. Also, the staff received additional three-to six months
context based training in a central hospital, by a Lao specialist staff, hence people whom they can
trust for understanding their common difficulties. Also, the trainers of central hospital
subsequently assisted the hospitals of Vientiane and Vang Vieng in (re) organizing the different
departments. These strategies seem to have been particularly effective. The staff feels that it is
now better trained. There is a general appraisal that the staff is more competent; managers and
clinicians know better what they need to do. There is no out of stock essential material or
medication supposed to be available in this kind of hospitals (Maya K, 2004; WHO 2011). The
main consequence of this increase in competencies is the attractiveness of the hospitals. Both
receive more patients than other provincial health structures. The percentage of live births within
health facilities has ever increased over the last 15 years in Vientiane province, and is now over
50 % (it is 38 % nationwide, MDG 4 Report 2014). Patients mentioned that they can feel the
quality of services and their usefulness, leading them to adopt expected behavior by a pregnant
woman (Thaddeus S. et al., 1994). A welcome side effect of this consequence is that it allows the
hospitals to generate more profit, for payment of performance based incentives to staff and for
procurement of consumables and equipment. This result is remarkable considering the fact that
Lao PDR is characterized be a serious lack of qualified staff (WHO, 2009; MoH, 2009).
Another factor that seems to support the quality of services is related to the hierarchical structure.
Leaders of work teams are generally chosen among the most experienced persons, hence
someone seen by coworkers as having the legitimacy to lead. This was set up with the help of
LuxDev, which encouraged a transparent management style based upon a problem solving
approach. The consequence is an acknowledged pleasant environment and solidarity inside the
teams. Defining the kind of leadership most susceptible to lead to broad acceptance by colleagues
is probably a key factor of the functionality of the hospitals (AMDD, 2003).
The last major factor that emerged as a probable determinant of the success of the hospital was
the concern regarding accessibility to services (WHO, 2012; Vongvichit E. et al., 2013).
Accessibility was not limited to road improvements. It also concerned information regarding
pregnancy and family widely spread in the community. Women know better the importance of
prenatal care. And they can access to these services. Also, a special fund (Health Equity Fund)
allowed free health care for predefined poor population groups, which improved financial access.
41
Yet, the system can still be improved. Interviews with women revealed for example that advices
given on pregnancy (breastfeeding, immunization schedule, diet during and after pregnancy)
were not always systematic or complete.
Interpreting this success story implies examining the role of external factors, particularly the role
of the bilateral cooperation to put in place the actual model followed by the two hospitals. Indeed,
the cooperation was the essential factor. Many of its activities were sought in order to bring the
hospitals to undertake this journey. Experience with the Lao context, a good knowledge of the
country, and interpersonal links contributed in devising the operationalization of the project with
a preoccupation of finding what specific activities might be effective.
Interestingly, all this was subtly implemented, in close collaboration with the hospital direction,
the provincial health directorate, and even the MoH at a high level. Local authorities acquired
ownership of this “management change process.” Hospital staff who were interviewed spoke as if
it was mainly thanks to this change process that their hospitals were better performing. This
might be the most relevant sign of the success of the entire project, considering that its main aim
was to empower the professionals. The literature tells us that there are three types of
empowerment (Ninacs, 2003): individual (which corresponds to a process of ownership power by
a person or group), community (that is to say, the people of the place are responsible for the
entire community), and organizational (which represents both the process appropriation of power
by an organization and the community within which a person or another organization are
empowered). All three types are fulfilled in our cases.
In our study, LuxDev focused on the appropriation of skills by the Lao health authorities as well
as by the hospital personnel.
7.2 Strengths and limitations of the study The results of this study must be interpreted taking into account the strengths and limitations of
the approach.
Regarding internal validity one notes the use of a conceptual framework to orientate the
questions, the variability in the position occupied by the respondents, the fact that both people on
42
the offer and the demand sides were interviewed, and the desire of all people asked to be
interviewed to fully participate to the study. Above all, sayings were extremely coherent. All this
contributed to the strengths of the study. Yet, the researcher didn't speak the Lao language. He
therefore needed a translator. The fact that the translator was a Lao physician, fluent in French
and English, well trained in research, makes us confident that a bias brought by the intervention
of a third party has been minimized as much as possible. Also, one should highlight the fact that
employees were selected by the directors of the hospitals. We cannot exclude the possibility that
the persons interviewed have a more favorable understanding of the situation than other people
working in the hospital. Moreover, the subjectivity of the researcher in the interpretation of what
the respondents say makes the generalization impossible. However, this bias was limited in a
certain amount by the help of translators who understood extremely well the project and the
population, and by a coding performed independently by the researcher and his supervisor. On
the other hand, the support received by Vientiane province in general, and the two studied
hospital in particular, through the LuxDev cooperation, including extensive technical assistance,
created a particularly favorable environment, which is a priori not replicable at a large scale in
Laos. This external support, beyond focusing on human resource an organizational development,
also secured simultaneously all other elements of the “health system building blocks (WHO)”:
good infrastructure and equipment, initial sufficient stock of consumables, health financing
mechanisms and good accounting practices, governance and an improved hospital information
system. All this contributed to the satisfaction of health service providers, and ultimately in
higher client satisfaction, for obstetrical as well as for general hospital in-and-outpatient care.
External validity is generally low in qualitative studies, because the sample is not representative
of the population. Yet, the search of the diversity of opinions that was done and the fact that
interviews were framed into a context that was described in detail allow readers to identify which
of the study finds might apply to their own environment.
This study is a first attempt to explore hospitals in a developing country that are renowned for the
quality of services provided. Yet, this is an exploratory study based on a qualitative methodology.
Other studies are required in order to fully understand the functionality of the hospital. For
example, studies linking organizational results with outcomes as maternal mortality rates would
43
be welcome. It is our hope that the study presented here will lead to further projects in order to
better identify how quality care can be provided to populations living in poor countries.
44
Conclusion This study shows that it is possible to implement high quality peripheral hospital in a developing
country as Lao PDR. With some highly thought investment in human resources and in
accessibility issues, services that respond to the need of the population can be offered. As
maternal and child health are in most countries a national priority having been able to identify
factors that lead to an improvement in a key determinant of health makes us hope that work, as
the one presented here, become more common for the benefit of the mothers, their children and
their families everywhere in the world.
45
Références Adams O. et al. (1999). Imbalances inhuman resources for health: Can policy formulation and
planning make a difference? Human resources for health development Journal, 3(1).
Averting Maternal Death & Disability Program (AMDD). (2003). Quality Improvement of Emergency Obstetric Care: Leadership Manual. EngenderHealth and Mailman School of Publich Health, Columbia University.
Bernis de L. (2005). La mortalité maternelle dans le monde. Extrait des mises à jour en gynécologie et obstétrique, tome XXIX
Bonono R.C. et al. 2012. Optimiser l'utilisation des services de consultation prénatale au Cameroun. Note d'information stratégique (NIS)
Boudreaux, C. et al. (2014). Assessing the elimination of user fees for delivery services in Laos. PLoS One, 9(3), e89784. doi: 10.1371/journal.pone.0089784
Bossert T. et al. (2010). Planification stratégique des ressources humaines pour la santé : Évaluation des facteurs financiers, éducationnel, administratifs et politiques. Bibliothèque de l'Organisation mondiale de la santé, ISBN 978 92 4 254731 1
Bradley S. et al. (2015). Too few staff, too many patients: a qualitative study of the impact on obstetric care providers and on quality of care in Malawi. BMC Pregnancy and Childbirth.
Cecile E. (2011). Systemes de santé des pays de sud-Outils d’analyse. Carrefour des projets santé
Codjia L. (2008). Management des ressources humaines de la santé. WorLuxDev Health organization-Organisation de coopération et de développement économique (OCDE). PowerPoint presentation
Coghlan, B. et al. (2014). The impact on child wasting of a capacity building project implemented by community and district health staff in rural Lao PDR. Asia Pac J Clin Nutr, 23(1), 105-111. doi: 10.6133/apjcn.2014.23.1.16
Currie, V. et al. (2005). Relationship between qualitu of care, staffing levels, skill mix and nurse autonomy: litterature review. Journal of Advanced Nursing, 51(1): p.73-82
David P. B. et al. (2006). Teamwork as an Essential Component of High-Reliability Organizations. Health Serv Res, 1576-1598.
de Sa, J. et al. (2013). Identifying priorities to improve maternal and child nutrition among the Khmu ethnic group, Laos: a formative study. Matern Child Nutr, 9(4), 452-466. doi: 10.1111/j.1740-8709.2012.00406.x
46
Douanghachanh X. et al. (2010). Availability and use of emergency obstetric care services in public hospitals in Lao PDR: A systems analysis. BioScience Trends. 4(6): 318-324
Dussault, G., Cadre pour l'analyse de la main-d'oeuvre sanitaire. Ruptures, 2000. 7(2): p. 62
Dr Ataur. (2014). Immunization Programme in Lao PDR. PowerPoint presentation.
Dr Viorica. (2012). Child health and Nutrition overview in Lao PDR. World Band PowerPoint presentation
Ensor T. et al. (2004). Overcoming barriers to health service access: influencing the demand side. Oxford University Press, Health Policy and Planning, 19(2): 69-79.
Holmes, W. et al. (2007). Influences on maternal and child nutrition in the highlands of the northern Lao PDR. Asia Pac J Clin Nutr, 16(3), 537-545.
Khamhoung, K. et al. (2000). Nutritional status of pre-school children and women in selected villages in the Suvannakhet Province, Lao PDR--an intervention trial. Southeast Asian J Trop Med Public Health, 31 Suppl 2, 63-74.
Khatri, N. (2006). BuiLuxDeving HR capability in health care organizations. Health Care Management Review, 31(1): p.45-54
Kongsap Akkhavong, C. P. et al. (2014). The Lao People's Democratic Republic health system review.
Lavender T. et al. (2012). Effect of partogram use on outcomes for women in spontaneous labour at term. Cochrane Databse of Systematic Reviews, Issue 8 Art No.: CD005461. DOI:10.1002/14651858.CDoo5461. pub3
Lux Dev. (2014). Interim final report Lao/017 Lao-Luxembourg Health Sector Support Programme (LL-HSSP). Luxembourg Cooporation. Not publised
Lux Dev. (2013). Project document Lao/027 Lao-Luxembourg Health Sector Support Programme - Phase 2. Luxembourg Coorporation. Not published
Masuno, K. et al. (2009). Scaling up interventions to eliminate neonatal tetanus: factors associated with the coverage of tetanus toxoid and clean deliveries among women in Vientiane, Lao PDR. Vaccine, 27(32), 4284-4288. doi: 10.1016/j.vaccine.2009.05.024
Maya K. et al. (2004). Intra partum and Emergency Obstetric Care Standards. MoH of Afghanistan.
Mikiel-Kostyra K. et al. (2002). Effect of early skin-to-skin contact after delivery on duration breastfeeding: a prospective cohort study. Acta Paediatr, 91 (12): 1301-6
MoH, L. P. (2009). Strategy & Planning Framework Integrated package of MNCH services 2009 - 2015 (10 may 2009). MoH report.
47
MinistryOfHealth. (2014). Success Factors for Women's and Children's Health. WHO, World Bank.
MoH. (2015). Provincial Health Personnel Development Plan. Vientiane Provincial Health Department, MoH report.
Mizuno K. et al. (2004). Mother-infant skin-to-skin contact after delivery results in early recognition of won mother’s milk odour. Acta Paediatr, 93(12):1640-5
Nikiema L. et al. (2011). Evaluation de l'utilisation du partogramme pour la surveillance du travail d'accouchement dans le district sanitaure de Kaya. African Journal Online. Vol 34, No 1-2
Ninacs W. A. (2003). Empowerment: cadre conceptuel et outil d’évaluation de l’intervention sociale et communautaire. La coopérative de consultation en développement
Phathammavong, O. et al. (2010). Antenatal care among ethnic populations in Louang Namtha Province, Lao PDR. Southeast Asian J Trop Med Public Health, 41(3), 705-716.
Programme des Nations-Unies pour le développement (PNUD). (2011). Rapport sur le développement humain 2011. Durabilité et Équité: Un Meilleur Avenir pour Tous. Programme des Nations-Unies pour le Développement, ISBN-13:978-92-1-226037-2.
Susan Michie et al. (2004). Managing people and performance : an evidence based framework applied to health service organizations. International Journal of Management Reviews, 5/6(2), 91-111.
Sychareun, V. et al. (2013). Provider perspectives on constraints in providing maternal, neonatal and child health services in the Lao People's democratic republic: a qualitative study. BMC Pregnancy ChiLuxDevbirth, 13, 243. doi: 10.1186/1471-2393-13-243
Weiner, E. A. et al. (2011). Antenatal education for expectant mothers results in sustained improvement in knowledge of newborn care. J Perinatol, 31(2), 92-97. doi: 10.1038/jp.2010.108
Kong Sayasinh. (2014). Etude de la réponse immunitaire à la vaccination anti-hépatite B des jeunes enfants dans la province de Khammouane, RDP Lao. Mémoire de Master, IFMT
Perks, C. et al. (2006). District health programmes and health-sector reform: case study in the Lao People's Democratic Republic. Bull World Health Organ, 84(2), 132-138. doi: /S0042-96862006000200014
Perry, C., et al. (2005). Validating a work group climate assessment tool for improving the perofrmance of public health organizations. Human Resources for Health, 3(1): p.10
Salas et al. (1992). Toward an Understanding of Team Performance and Training. Annual review of psychology, page 3-29.
48
Smith-Jeantsch K.A. et al. (2001). Uncovering Differences in Team Competency Requirements: The Case of Air Traffic Control Teams. Erlbaum, page 31-54.
Thaddeus S. et al., 1994. The three delays model. Soc Sci Med. 38: 1091-1110
Thomas E.J. et al. (2004). Translating Teamwork behaviours from aviation to healthcare: development of behavioural markers for neonatal resuscitation. Qual Saf Health Care; 57-64.
United Nations Children’s fund (UNICEF). (2008). La situation des enfants dans le monde 2009. La santé maternelle et néonatale. Fonds des Nations Unies pour l'enfance.
United Nations International Children's Emergency Fund. (updated in 2013). In brief: Lao PDR. Viewed online in may 2015: http://www.unicef.org/french/infobycountry/laopdr_statistics.html.
United Nations Population Fund (UNFPA). (2011). Lao PDR: Emergency Obstetric and newborn care needs assessment in 12 selected province. United Nations population fund, NAtional Institute of Public Health
United States AID (USAID). (2012). Soins obstétriques et néonatals essentiels (SONE). Corporation Jhpiego
Vongvichit E. et al. (2013). Report on Lao PDR Maternal Death Review 2011-2013. United Nations Population Fund
Weiner, E. A. et al. (2011). Antenatal education for expectant mothers results in sustained improvement in knowledge of newborn care. J Perinatol, 31(2), 92-97. doi: 10.1038/jp.2010.108
West, E. (2001). Management matters: the link between hospital organisation and quality of patient care. Quality in Health Care. 10(1): p. 40-48.
World Bank (2013). Materna mortalitiy ration (modeled estimate, per 100, 00 live births). Accessed online. Achttp://data.worLuxDevbank.org/indicator/SH.STA.MMRT
World Bank. (2015). Health expenditure, total (% of GDP). World Health Organization expenditure database. Consulted online.
World Bank. (2015). International Development Association Project Appraisal Document on a proposed credit in the amount of SDR 9.4 million and a proposed grant in the amount of SDR 9.4 million to the Lao People’s Democratic Republic for a health governance and nutrition development project. Health, Nutrition, and Population Global Practice East Asia and Pacific Region
World Health Organization. (1978). Declaration of Alma-Ata, International Conference on Primary Health Care. USSR, 6-12.
49
World Health Organization. (1991). Essential elements of obstetric care at first referral level. World health organization.
World Health Organization. (1994). Mother-Baby Package: Implementing safe motherhood in countries. Division of family health, World Hlealth Organization.
World Health Organization. (1999). Nouveau Kit Sanitaire d'Urgence 98. World health organization. WHO/DAP/98.10
World Health Organization. (2000). L'OMS évalue les systèmes de santé dans le monde. Communiqué de presse: Rapport sur la Santé dans le Monde 2000.
World Health Organization. (2004). Forte augmentation du nombre de femmes qui bénéficient de soins prénatals. Centre des médias, communiqué de presse de l'OMS.
World Health Organization. (2009). Manuel de suivi et d'évaluation des ressources humaines pour la santé comprenant des applications spécialement adaptées aux pays à revenu faible ou intermédiaire. Inis communication, Bibliothèque de l'Organisation Mondiale de la Santé, ISBN 9789242547702.
World Health Organization. (2010). Monitoring the buiLuxDeving blocks of health systems: A handbook of indicators and their measurement strategies. World Health Organization. ISBN 978 92 4 156405
World Health Organization. (2011). Standard List of Medical Equipment & their technical specifications and standards. World Health Organization, page 1-27.
World Health Organization. (2012). Maternal mortality. http://www.who.int/mediacentre/.
World Health Organization. (2012). Statistiques sanitaure mondiale 2012. World Health organization.
World Health Organization. (2014). 2014- HealthFinancing Laos WHO 2005-2011 World Health organization
World Health Organization. (2015). Effets de l'utilisation du partogramme sur les résultats en cas de travail spontané à terme. Bibliothèque de santé génésique de l'OMS
Wyss, K. (2004). An approchoach to classifying human resources constraints to attaining health-related Millennium Development Golad. Human Resources for Health. 2(1): p.11
Yin R.K. (2003). Case Study Research: Design and Methods. Social Science third edition. 181p
50
Annex Annex 1 : Themes of discussion
I. Interviews with individuals working in the obstetrical health care sector
A preliminary meeting with the director of the hospital to present the study and to get permission to interview health professionals. It will help us to identify at least one person at the following position (hospital management, clinical management, financial management, medicine, nursing, pharmacy). Finally, we will ask him as much as possible the performance indicators of obstetric care available in the hospital.
A) General questions ü Name ü What is your position in this hospital? (Nurse, physician, pharmacist) ü Number of years in this position? Where have you been trained and in what areas? How
many years? B) The understanding of performance
ü Can you please tell us about your perception of the evolution of the performance of obstetrical care in your hospital over the last 10 years?
Concepts to be explored through this question:
ü According to you, what is performance of obstetrical care? ü Do you think it is important to monitor performance? ü According to you, how these indicators of performance of obstetrical care changed over
the time? C) The perception of factors that might influence the evolution of the performance of obstetrical care
ü According to you, what might explain the level of performance of your hospital in obstetrical care?
Concepts to be explored through this question: There are 3 major types of factors that influence the performance: human, material, and financial resources
ü Can you speak first about the human factor (leadership, workload, teamwork, hierarchy, control, training opportunities…) and what influence performance in these factors?
ü Can you now speak about the availability of material resources (equipment, drugs, …) ü Finally, do you have some constrains about the financial resources in obstetrical care? ü In the way the work is organized (hierarchy, control, organizational culture, inter-
professional relationship), is it favourable or not?
D) Example for illustrating the situation
ü According to you, do you have a good system of investigation after the deaths of pregnant women to know the cause?
51
Do you have any self-reflection on maternal deaths? If yes, tell us about the common causes of women death (came to late, the
partograph was not used, stockout of oxytocin, or blood, lack of skills for episiotomy for example…)? What is done to change that? For example, if a woman dies because of a hemorrhage during or just after delivery, what might be the principal reasons? And what's going to happen in the hospital after such a tragic event, according to you?
E) Health professional’s satisfaction
ü And to finish, can you please tell us about how satisfied you are with your current job? And why?
II. Interviews with women (pregnant and post-partum)
ü According to you, are you fully satisfied with the services that you received in this hospital because of your pregnancy? And why?
Concept to be explored:
ü Can you please tell us about understanding by doctors, midwives and nurses, of your needs?
ü Can you please tell us about understanding by doctors, midwives and nurses of your expectations?
ü Can you please tell us about the gentleness of doctors, midwives and nurses with you? ü Can you please tell us about the efforts by doctors, midwives and nurses to give
information to you (breast feeding, artificial milk, skin contact, Vitamin K injection)? ü Can you please tell us about the prenatal and delivery care? Are they affordable for you?
52
Annex 2: Recruitment document
Texte de recrutement des participants (french version)
Mesdames, Vous êtes invité à participer à un projet de recherche dans le cadre d’un travail d'un étudiant canadien, Monsieur Ashken Sanogo, sous la supervision du Dr Daniel Reinharz, professeur à l’Université Laval au Canada et directeur de l’Institut de la Francophonie pour la Médecine Tropicale (IFMT) à Vientiane.
Ce projet de recherche porte sur les femmes enceintes qui fréquentent ou ont fréquenté le centre de santé. Il vise à analyser le point de vue de personnes travaillant dans le secteur de santé et celui des femmes enceintes ou qui ont accouché, par rapport à l'efficacité des services offerts dans les centres de santé soutenus par la Coopération luxembourgeoise.
Nous aimerions pouvoir vous interroger sur ce sujet. La discussion avec vous durera 30 à 45 minutes. Si vous êtes d’accord, l’entrevue sera enregistrée à l’aide d’un magnétophone. Si vous préférez ne pas être enregistré, des notes manuscrites seront prises. L'enregistrement et les notes écrites ne pourront être entendus et vus que par le chercheur, Monsieur Ashken, et son directeur de travail, Monsieur Daniel. Ils seront détruits dans les deux ans qui suivront le dépôt du rapport final, soit en automne 2017. Dans ce rapport, il sera absolument impossible de vous identifier. Vous pouvez donc parler librement. Vous êtes entièrement libre de participer à cette entrevue et vous pourrez vous retirer de l’étude en tout temps, sans avoir à fournir de raison. Il n'y aura aucune conséquence si vous vous retirez. Vous avez aussi la liberté de ne pas répondre à toutes les questions qui vous seront posées.
Si vous désirez obtenir des informations complémentaires ou si vous voulez participer à l’étude, veuillez donner vos coordonnées à l’accueil du centre de santé pour que l’on vous recontacte.
Si vous acceptez de participer à cette recherche, vous devez savoir que : Ø Cette recherche a été approuvée par le comité d’éthique de l’Université Laval au Canada, et
par le ministère de la santé de la RDP Lao. Ø Votre participation est volontaire. Vous pouvez refuser de participer. Ø Les données recueillies seront confidentielles et votre anonymat sera garanti dans le rapport
de l'étude. Ø Vous pouvez toujours contacter le centre de santé si vous avez besoin d’informations
complémentaires.
53
Text of recruiting participants (english version)
Ladies, You are invited to participate in a research project as part of a work by a Canadian student, Mr. Ashken Sanogo, under the supervision of Dr. Daniel Reinharz, professor at Laval University in Canada and director of the Institute Francophonie for Tropical Medicine (IFMT) in Vientiane. This research project focuses on pregnant women who attend or have attended the health center. It aims to analyze the perspective of those working in the health sector and that of pregnant women who gave birth, compared to the efficiency of services in health centers supported by the LuxDev Cooperation.
We would like to ask you about this. The discussion lenght will be approximately 30 to 45 minutes. If you agree, the interview will be recorded using a tape recorder. If you prefer not to be recorded, handwritten notes will be taking. The recording and the written notes will be heard and seen by the researcher, Mr. Ashken, and his work director, Mr. Daniel. They will be destroyed within two years following the tabling of the final report, in fall 2017. In this report, it will be absolutely impossible to identify you. So you can speak freely. You are entirely free to participate in this interview, and you can withdraw from the study at any time without giving any reason. There will be no consequences if you withdraw. You also have the freedom not to answer all questions asked to you.
If you want more information or want to participate in the study, please provide your details at the reception of the health center so that we will be recontacted.
If you agree to participate in this research, you should know that: Ø This research was approved by the Ethics Committee of Laval University in Canada and
by the MoH of the Lao PDR. Ø Participation is voluntary. You can refuse to participate. Ø The data collected will be confidential and your anonymity will be guaranteed in the
report of the study. Ø You can always contact the health center if you need further information.
54
Annex 3 : Letter of verbal consent
Feuillet d’information pour un consentement verbal (french version)
Avant de vous demander si vous consentez à participer à ce projet de recherche, je vais vous présenter le projet de recherche et vous dire ce qui est attendu de votre participation. Je vous invite à me poser toutes les questions que vous jugerez utiles pour bien comprendre ces renseignements.
Présentation du chercheur
Cette recherche est réalisée dans le cadre d'un projet de fin d'étude de Monsieur Ashken Sanogo dirigé par le Pr Daniel Reinharz, professeur à l’Université Laval au Canada, et directeur de l’institut de la Francophonie pour la Médecine Tropicale (IFMT) à Vientiane. Elle a été approuvée par le Comité d’éthique de l’Université Laval.
Nature et objectifs du projet
Cette recherche a pour titre « Analyse d'une offre de soins en RDP Lao, soutenue par la Coopération luxembourgeoise ». Elle a pour but d’analyser le point de vue de personnes travaillant dans le secteur de santé et le point de vue des femmes enceintes ou qui ont accouché par rapport à l'efficacité des services offerts dans les centres de santé soutenus par la Coopération luxembourgeoise.
Déroulement du projet
Votre participation à cette recherche consiste à prendre part à une entrevue individuel de 30 à 45 minutes avec moi, Monsieur Ashken. Je travaille sous la supervision de personnes de la Coopération luxembourgeoise qui soutiennent ce centre de santé.
Avantages et inconvénients possibles liées à la participation
Participer à cette recherche vous permet de faire connaitre votre point de vue sur la qualité des services que vous recevez dans ce centre de santé et cela en toute confidentialité. Si vous êtes d’accord, l’entrevue sera enregistrée à l’aide d’un magnétophone. Si vous préférez ne pas être enregistré, des notes manuscrites seront prises. Les bandes enregistrées et les notes manuscrites seront confidentielles. Si certaines questions vous mettent mal à l’aise, vous pouvez simplement refuser d’y répondre sans avoir à vous justifier. Vous pouvez aussi arrêter l’entrevue et quitter l’étude en tout temps sans contraintes ; dans ce cas, vos dires ne seront pas conservés à moins que vous m’autorisiez à les utiliser pour la recherche malgré votre retrait.
Confidentialité
Puisqu’en recherche, les chercheurs sont tenus protéger la vie privée des participants, voici les mesures de qui seront appliqués pour assurer la confidentialité du matériel et des données :
Durant la recherche :
55
- la confidentialité des données recueillies sera assurée. Il sera impossible de vous identifier dans nos rapports.
- la sécurité physique et informatique des données recueillies sera assurée; - Aucune copie des documents contenant des données d'entrevues ne sera gardée.
Lors de la diffusion des résultats (le rapport de recherche) : les noms des participants ne paraitront dans aucun rapport ni dans aucun texte publié; les résultats de la recherche seront présentés sous forme globale et les résultats individuels
des participants ne seront jamais communiqués; Après la fin de la recherche :
tout le matériel et toutes les données seront détruits, au plus tard en automne 2017, soit deux ans après le dépôt de mon mémoire.
Attestation verbale du consentement
Avez-vous bien compris le projet et les implications de votre participation? Acceptez-vous de confirmer, sur cet enregistrement audio, que vous consentez à y participer?
(Si nécessaire, demander aussi : Acceptez-vous que cette entrevue soit enregistrée également?)
Remerciements
Je vous remercie pour le temps et l’attention que vous acceptez de consacrer à votre participation.
Renseignements supplémentaires
Pour vous permettre de communiquer avec moi si vous le jugez nécessaire ou pour vous retirer du projet, je vous remettrai une copie du document que je suis en train de vous présenter et qui contient mes coordonnées.
Ashken Sanogo Étudiant à la maîtrise en santé communautaire Université Laval, Québec, Canada En collaboration avec l’Institut pour la Francophonie de Médecine Tropicale, Vientiane, RDP Lao Courriel: [email protected]
Plaintes ou critiques
En terminant, je souhaite vous informer que toute plainte ou critique sur ce projet de recherche pourra être adressée au Bureau de l’Ombudsman de l’université Laval. Ses coordonnées sont également inscrites sur le présent document dont je vous remets à l’instant une copie.
Pavillon Alphonse-Desjardins, bureau 3320 2325, rue de l’Université Université Laval Québec (Québec) G1V 0A6 Renseignements - Secrétariat : + 1 (418) 656-3081 Ligne sans frais : 1-866-323-2271
56
Courriel : [email protected]
Document for verbal consent (english version)
Before asking to you if you agree to participate to this research project, i will present the research project and tell you what is expected from you. I invite you to ask me any questions that you deem useful for understanding the information. Researcher Presentation
This research was conducted as part of the master thesis of Mr. Sanogo Ashken directed by Professor Daniel Reinharz, professor at Laval University in Canada, and director of the Institute of Tropical Medicine for the Francophonie (IFMT) in Vientiane. It has been approved by the Ethics Committee of Laval University.
Nature and project objectives
This research is entitled "Analysis of a care supply in Lao PDR, supported by the Luxembourg Cooperation". It aims to analyze the perspective of those working in the health sector and the views of pregnant women who gave birth regarding the relation to the efficiency of services in health centers supported by the Luxembourg Cooperation.
Project development
Your participation in this research is to take part in an individual interview 30 to 45 minutes with me, Mr. Ashken. I work under the supervision of people from Luxembourg Cooperation supporting this health center.
Possible advantages and disadvantages related to participation
Participate in this research allows you to show your views on the quality of services you receive in this health center in all confidentially.
If you agree, the interview will be recorded using a tape recorder. If you prefer not to be recorded, handwritten notes will be take. The tapes and handwritten notes will be confidential. If some questions put you uncomfortable, you can simply refuse to answer without having to justify yourself. You can also stop the interview and leave the study at any time without constraints; in this case, your words will not be saved unless you allow me to use them for research in spite of your withdrawal.
Confidentiality
Since research, researchers must protect the privacy of participants, here are the measures that will be applied to ensure the confidentiality of the material and data:
During the search: - The confidentiality of data is assured. It will be impossible to identify you in our reports.
57
- The physical security and informatic data collected will be ensured; - No copy documents with interview data will be kept. During the dissemination of results (the search report):
results will never be disclosed;
After the end of the search:
brief.
Certification verbal consent Do you understand the project and the implications of your participation? Will you confirm, on this recording, you agree to participate?
(If necessary, also ask: Do you accept that this interview recorded also)
Thanks Thank you for the time and attention you devote to agree to your participation. Additional Information To allow you to contact me if you consider it necessary or to withdraw from the project, I give you a copy of the document that i am trying to present and contains my contact information. Ashken Sanogo MSc student in Community Health Laval University, Quebec, Canada In collaboration with the Institute for Tropical Medicine Francophonie, Vientiane, Lao PDR Email: [email protected] Complaints or criticisms In closing, I wish to inform you that any complaint or criticism on this research project may be addressed to the Ombudsman's Office of the University Laval. Contact details are included in this document, which I give you now a copy. Pavillon Alphonse-Desjardins, Office 3320 2325 University Street Laval University Québec (Québec) G1V 0A6 Information - Secretariat: + 1 (418) 656-3081 Toll-free: 1-866-323-2271 Email: [email protected]
58
ໃບຍິນຍອມການສຳພາດ (Lao Version)
ກ່ອນທ່ານຈະຍິນຍອມໃຫ້ສຳພາດດັ່ງກ່າວ, ຂ້າພະເຈາ ຈະສະເຫນີໂຄງການວິໄຈແລະການຄາດຫມາຍ ໃນການປະກອບ
ສ່ວນຂອງທ່ານ. ຂ້າພະເຈາ ຂໍເຊີນທ່ານສອບຖາມລາຍລະອຽດ ທີ່ທ່ານເຫັນວ່າມີປະໂຫຍດ
ເພອເປັນການເຂາໃຈ.
ການສະເຫນີບົດຄນຄວ້າ
ບົດຄນຄວ້າວິໄຈດັ່ງກ່າວ ແມ່ນການສຶກສາ ປີສຸດທ້າຍ ຂອງທ່ານ Ashken Sanogo
ໂດຍການຊນຳຂອງທ່ານ ສຈ Daniel Reinharz, ອາຈານສອນປະຈຳມະຫາວິທະຍາໄລ Laval ປະເທດການາດາ ແລະອຳນວຍການ ສະຖາບັນການແພດ ເຂດຮ້ອນຝຼັ່ງໂກໂຟນີ (IFMT) ທີ່ນະຄອນຫຼວງວຽງຈັນ. ໂຄງການ
ໄດ້ຮັບການອະນຸມັດຂອງພະແນກຄນຄວ້າຈັນຍາທຳ ມະຫາວິທະຍາໄລ ລາວານ. ສະພາບແລະເປາຫມາຍຂອງໂຄງການ
ບົດຄນຄວ້າວິໄຈດັ່ງກ່າວ ມີຫົວບົດ ຊວ່າ « ວິໄຈການໃຫ້ບໍລິການ ການປິ່ນປົວ ຢູ່ ສປປ ລາວ, ອຸປະຖຳໂດຍໂຄງການຮ່ວມມື ລຸກຊຳບວກຊົວ». ແມ່ນເພື່ອຊອກຫາ ປັດໄຈ ທີ່ພາໃຫ້ການປະຕິບັດວຽກງານໄດ້ດີ ຂອງພະແນກແມ່ແລະເດັກ ໂດຍການຊ່ວຍເຫຼືອຂອງໂຄງການຮ່ວມມື ລຸກຊຳບວກຊົວ ໂດຍຄວາມເປັນຈິງ ແມ່ນເພື່ອ ວິໄຈ, ສຳລວດຕີລາຄາຄຳຄິດເຫັນ ຂອງພະນັກງານແພດຫມໍ ແລະຜູ້ຊົມໃຊ້, ແມ່ມານ ທີ່ໄປອອກລູກ,
ປັດໄຈ ທີ່ສາມາດເຮັດໃຫ້ການບໍລິການ ພແມ່ປະຊາຊົນຂອງຂະແຫນງວຽກງານ ຢູ່ສຸກສາລາ ທີ່ໄດ້ຮັບການຊ່ວຍເຫຼືອ ຈາກໂຄງການຮ່ວມມື ລຸກຊຳບວກຊົວ ມີປະສິດທິຜົນ.
ການຈັດຕງປະຕິບັດໂຄງການ
ການປະກອບສ່ວນຂອງທ່ານ ໃນການຄນຄວ້າວິໄຈດັ່ງກ່າວ ແມ່ນເພື່ອເອົາສ່ວນຫນຶ່ງໃນການສໍາພາດສ່ວນບຸກຄົນ 30 ຫາ 45 ນາທີກັບຂ້າພະເຈົ້າ, ທ່ານ Ashken. ຂ້າພະເຈົ້າເຮັດວຽກພາຍໃຕ້ການຊີ້ນໍາ ຂອງໂຄງການຮ່ວມມື Luxembourg ມີ່ໃຫ້ການຊ່ວຍເຫຼືອ ຢູ່ສຸກສາລາ.
ຜົນປະໂຫຍດແລະຂຫຍຸ້ງຍາກ ໃນການປະກອບສ່ວນສຳພາດ
ເຂົ້າຮ່ວມໃນການຄົ້ນຄ້ວານີ້ ອະນຸຍາດໃຫ້ທ່ານໃນການເຜີຍແພ່ ທັດສະນະຂອງທ່ານ ກ່ຽວກັບຄຸນນະພາບ ຂອງການບໍລິການທີ່ທ່ານໄດ້ຮັບ ຢູ່ສຸກສາລາແລະມັນເປັນຄວາມລັບ. ຖ້າຫາກວ່າທ່ານຕົກລົງເຫັນດີ, ການສໍາພາດ ຈະໄດ້ຮັບການບັນທຶກ
ໂດຍໃຊ້ການບັນທຶກເຄອງອັດສຽງ. ຖ້າຫາກວ່າ
ທ່ານຕ້ອງການຈະບໍ່ໄດ້ຮັບການບັນທຶກ, ຂຽນຂໍ້ຄວາມປະຕິບັດ. ເຄອງອັດສຽງ ແລະຂຽນຂໍ້ຄວາມ ທີ່ຈະເປັນຄວາມລັບ. ຖ້າຫາກວ່າ ບັນຫາບາງຢ່າງ ເຮັດໃຫ້ທ່ານບໍ່ສະດວກ, ທ່ານພຽງແຕ່ ສາມາດປະຕິເສດ
59
ທີ່ຈະຕອບ ໂດຍບໍ່ມີການ ໃຫ້ເຫດຜົນທີ່ທ່ານ. ນອກນັ້ນ ທ່ານຍັງ ສາມາດຢຸດເຊົາການສໍາພາດ ໄດ້ທຸກເວລາ; ໃນກໍລະນີນີ້, ຄໍາເວົ້າຂອງທ່ານ ຈະບໍ່ໄດ້ຮັບການບັນທືກ ເວັ້ນເສຍແຕ່ວ່າ ທ່ານອະນຸຍາດ ໃຫ້ຂ້າພະເຈົ້າ ນໍາໃຊ້ສໍາລັບການຄົ້ນຄວ້າເຖິງວ່າ ທ່ານຈະຢຸດ ເຊົາສຳພາດກໍຕາມ. ຮັກສາຄວາມລັບ ໃນການຄົ້ນຄວ້າວິໄຈ, ນັກຄົ້ນຄວ້າ ຕ້ອງປົກປັກຮັກສາຄວາມເປັນສ່ວນຕົວຂອງຜູ້ເຂົ້າຮ່ວມ,ມາດຕະການທີ່ຈະຖືກນໍາໃຊ້ເພື່ອຮັບປະກັນ
ຄວາມລັບ ຂອງອຸປະກອນ ແລະຂໍ້ມູນທີ່ມີ ລະອຽດດັ່ງລຸ່ມນ :
ໃນລະຫວ່າງການຄົ້ນຫາ: - ຮັບປະກັນ ໃນຮັກສາຄວາມລັບຂອງຂໍ້ມູນ
ຈະບສາມາດເປີດເຜີຍສະພາບຂອງທ່ານໄດ້ໃນບົດລາຍງານ ຂອງພວກເຮົາ. - ຄວາມປອດໄພຂອງຂໍ້ມູນທີ່ເກັບກໍາຂໍ້ມູນ ທີ່ເປັນສຳເນົາເອກະສານ ແລະໄອທີ ຈະໄດ້ຮັບການຮັບປະກັນ; - ບໍ່ເກັບຮັກສາໄວ້ ສໍາເນົາເອກະສານ ທີ່ມີຂໍ້ມູນການສໍາພາດ. ໃນລະຫວ່າງການເຜີຍແຜ່ສະຫຼຸບຜົນ (ບົດລາຍງານການຄົ້ນຄວ້າ :
· ຊື່ຂອງຜູ້ເຂົ້າຮ່ວມ ຈະບປາກົດຢູ່ໃນບົດລາຍງານ ແລະການພິມເຜີຍແຜ່ໃດໆ;
· ຜົນສະຫຼຸບ ຂອງການຄົ້ນຄ້ວາ ຈະໄດ້ຮັບການນໍາສະເຫນີໃນຮູບແບບລວມ ແລະຂມູນ ຂອງແຕ່ລະບຸກຄົນ ຈະບໍ່ຖືກສະຫຼຸບລາຍງານ;;
ພາຍຫຼັງການຄົ້ນຫາ : · ອຸປະກອນທັງຫມົດແລະຂໍ້ມູນທັງຫມົດຈະຖືກທໍາລາຍທີ່ສຸດໃນດູໃບໄມ້ລົ່ນປີ 2017,
ສອງປີຫຼັງຈາກຜ່ານ ການປ້ອງກັນບົດຄົ້ນຄວ້າແບບອີດສະຫຼະ ຂອງຂ້າພະເຈາ. ການຢັ້ງຢືນຍິນຍອມເຫັນດີທາງວາຈາ ທ່ານເຂົ້າໃຈດີ
ກ່ຽວກັບໂຄງການແລະຜົນກະທົບຂອງການມີສ່ວນຮ່ວມຂອງທ່ານ ແລ້ວບ? ໃຫ້ທ່ານຢືນຢັນ ການຕົກລົງເຫັນດີ ຂອງທ່ານທີ່ຈະເຂົ້າຮ່ວມ ລົງໃນເທບບັນທຶກສຽງ? (ຖ້າຫາກວ່າມີຄວາມຈໍາເປັນ,
ສອບຖາມເພມເຕີມອີກ: ທ່ານຕົກລົງເຫັນດີ ໃຫ້ບັນທຶກສຽງໄວ້)
ຂໍຂອບໃຈ ຂໍຂອບໃຈ ສໍາລັບການເສຍສະຫຼະເວລາແລະເອົາໃຈໃສ່
ໃນການໃຫ້ສຳພາດຂອງທ່ານ. ຂໍ້ມູນເພີ່ມເຕີມ ທ່ານສາມາດຕິດຕ ຫາຂ້າພະເຈົ້າ ໃນກໍລະນີ ທີ່ທ່ານເຫັນວ່າ ມີຄວາມຈຳເປັນ ຫຼື ເພື່ອທີ່ຈະຖອນຕົວຈາກການສຳພາດ, ຂ້າພະເຈົ້າ ຈະມອບສໍາເນົາຂອງເອກະສານສຳພາດ ແລະຂໍ້ມູນລາຍບະອຽດ ໃນການຕິດຕໍ່ພົວພັນ ກັບຂ້າພະເຈົ້າ.
ລາຍງານແຈ້ງເພອຊາບ, ບົດຄນຄວ້າດັ່ງກ່າວ Ashken Sanogo Étudiant à la maîtrise en santé communautaire ມະຫາວິທະຍາໄລ Laval, ເກເບັກ, ການາດາ ໂດຍການຮ່ວມມືກັບສະຖາບັນການແພດເຂດຮ້ອນຝຼັ່ງໂກໂຟນີ,
60
ນະຄອນຫຼວງວຽງຈັນ, ສປປ ລາວ Courriel: [email protected]
ຄໍາຮ້ອງທຸກ ຫຼືຄຳວິພາກວິຈານ ສຸດທ້າຍນ, ຂ້າພະເຈົ້າ ແຈ້ງໃຫ້ທ່ານຊາບວ່າ ທ່ານສາມາດຢືນຄໍາຮ້ອງທຸກ ຫຼືຄຳວິພາກວິຈານ ກ່ຽວກັບ
ໂຄງການຄົ້ນຄວ້ານີ້ ໄດ້ທີ່ Bureau de l’Ombudsman de l’université Laval ທີ່ຢູ່ລະອຽດ ສຳລັບ
ການຕິດຕໍ່ພົວພັນ ຂ້າງລຸ່ມນ ທີ່ຂ້າພະເຈົ້າຈະ ມອບວຳເນົາເອກະສານ ຈຳນວນຫນຶ່ງສະບັບໃຫ້ທ່ານ.
Pavillon Alphonse-Desjardins, bureau 3320 2325, rue de l’Université Université Laval Québec (Québec) G1V 0A6 Renseignements - Secrétariat : + 1 (418) 656-3081 Ligne sans frais : 1-866-323-2271 Courriel : [email protected]
61
Annex 4 : Document of written consent
Formulaire de consentement écrit (French version)
Titre de l’étude
Analyse d'une offre de soins en RDP Lao, soutenue par la Coopération luxembourgeoise
Contexte de l’étude
La RDP Lao est un pays pauvre. Les besoins en santé sont importants et il n'y a pas beaucoup d'argent pour essayer de répondre à ces besoins. Il est donc important d'évaluer si avec les ressources disponibles, il est possible rendre les services plus efficaces. Ce projet vise à analyser, du point de vue de personnes travaillant dans le secteur de santé et du point de vue d'utilisateurs, des femmes enceintes ou qui ont accouché, les facteurs qui pourraient influencer l'efficacité des services offerts à la population dans les centres de santé soutenus par la Coopération luxembourgeoise.
Participation à l’étude
La participation consiste en une entrevue de type individuelle d'environ 45 minutes avec un chercheur étranger, qui travaille sous la supervision de personnes en RDP Lao qui sont impliquées dans la gestion de projets de santé soutenus par la Coopération luxembourgeoise.
Si vous êtes d’accord, l’entrevue sera enregistrée à l’aide d’un magnétophone. Si vous préférez ne pas être enregistré, des notes manuscrites seront prises. Les bandes enregistrées et les notes manuscrites seront confidentielles. Seuls les chercheurs y auront accès. Elles seront détruites dans les 6 mois qui suivront le rapport final.
D'ailleurs, à la lecture du rapport final, il sera absolument impossible de vous identifier. Vous pouvez donc parler librement.
Vous êtes entièrement libre de participer à cette entrevue et vous pourrez vous retirer de l’étude en tout temps, sans avoir à fournir de raison ni à subir d’inconvénient ou de préjudice quelconque. Vous avez aussi la liberté de ne pas répondre à toutes les questions qui vous seront posées.
Si vous désirez obtenir des informations complémentaires, vous pouvez contacter les responsables de cette étude à l’adresse et au numéro de téléphone indiqués ci-dessous.
62
Je soussigné (nom du participant en lettres majuscules) consens librement à participer à la recherche intitulée « Analyse d'une offre de soins en RDP Lao, soutenue par la Coopération luxembourgeoise (RDP Lao) »
J’ai pris connaissance du formulaire et je comprends le but, la nature, les avantages, les risques et les inconvénients du projet de recherche. Je suis satisfait des explications, précisions et réponses que le chercheur m’a fournie, le cas échéant, quant à ma participation à ce projet.
______________________________________Date :__________________________ (Signature du participant/de la participante)
J’ai expliqué le but, la nature, les avantages, les risques et les inconvénients du projet de recherche au participant. J’ai répondu au meilleur de ma connaissance aux questions posées et j’ai vérifié la compréhension du participant. (N.B. : cette déclaration ne peut figurer que sur un formulaire signé en présence du participant)
______________________________________Date :__________________________ (Signature du chercheur)
Plaintes ou critiques
Toutes plaintes ou critiques concernant ce projet pourront être adressées au directeur de l’Institut de la Francophonie pour la Médecine Tropicale dont les coordonnées sont les suivantes :
Pr Daniel Reinharz IFMT BP 9519 Vientiane RDP Laos Courriel : [email protected] Responsables de l’étude Ashken Sanogo Étudiante à la maîtrise en santé communautaire Université Laval, Québec, Canada En collaboration avec l’Institut pour la Francophonie de Médecine Tropicale, Vientiane, RDP Lao Courriel: [email protected]
Daniel Reinharz Professeur Université Laval, Québec, Canada Directeur, Institut pour la Francophonie de Médecine Tropicale, Vientiane, RDP Lao Courriel: [email protected]
63
Document of written consent (version anglaise)
Title of the study
Analysis of a health care provision in the Lao PDR supported by the Luxemburg Cooperation
Context of the study
Laos is a poor country. Health needs are important and there is not a lot of money to answer those needs. It is therefore important to evaluate if services provided with the funds that are available are effective or if, with the resources that are available, it's possible to improve the effectiveness of the services provided. This project aims at analyzing, from the perspective of professionals working in the health care sector and the perspective of users, women who are pregnant or how have delivered, the factors that could influence the effectiveness of the services offered to the population in health care centers supported by the Luxemburg Cooperation.
Participation to the study
Participation consists of individual interviews of about 45 minutes with a foreign researcher, who works under the supervision of people in the Lao PDR involved in the management of health projects supported by the Luxemburg Cooperation.
With your approval, the interview will be recorded with a tape recorder. If you do not wish to be recorded, handwritten notes will be taken instead. The tapes and handwritten notes will be confidential. Only researchers will have access to them. They will be destroyed 6 months after the final report. In the research report it will be absolutely impossible for you to be identified. You can therefore speak freely.
You are completely free to participate to this interview and you can withdraw from the study at any time without giving any reason. You also have the freedom not to answer to some of the questions that will be asked.
If you want more information, you can contact the researchers of this study at the following address and telephone number.
I, (name of participant in capital letters) freely consents to participate in a research project entitled "Analysis of a health care provision in the Lao PDR supported by the Luxemburg Cooperation" I have read this form and understand the purpose, nature, benefits, risks and inconveniences of the research project. I am satisfied with the explanations, clarifications and answers that the researcher might have provided to me. ______________________________________Date: __________________________ (Signature of the participant / the participant)
64
I explained the purpose, nature, benefits, risks and inconveniences of the research to the participant. I answered to the best of my knowledge to the questions asked. I ensure that the participant understood the purpose of the study and the answers I provided to his questions. (Note: this statement may appear only on a form signed in the presence of the participant) ______________________________________Date: __________________________ (Researcher's signature) Complaints or criticisms All complaints about this project can be addressed to the Director of the Francophone Institute for Tropical Medicine: Daniel Reinharz Director IFMT BP 9519 Vientiane RDP Laos E-mail: [email protected]
65
Annex 5 : Confidentiality commitment document
FORMULAIRE D’ENGAGEMENT À LA CONFIDENTIALITÉ
Titre de l’étude : Analyse d'une offre de soins en RDP Lao, soutenue par la Coopération luxembourgeoise
Cette étude se fait sous la direction du Dr Daniel Reinharz professeur à l’Université Laval au Canada et directeur de l'Institut de la Francophonie pour la Médecine tropicale en RDP Lao. 1. Le but de la recherche est d’explorer des facteurs qui influencent le bon fonctionnement des services materno-infantiles soutenus par la Coopération luxembourgeoise. En effet, il vise à analyser, du point de vue de personnes travaillant dans le secteur de santé et du point de vue d'utilisateurs, des femmes enceintes ou qui ont accouché, les facteurs qui pourraient influencer l'efficacité des services offerts à la population dans les centres de santé soutenus par la Coopération luxembourgeoise. 2. Pour réaliser ce travail, l’équipe de recherche mène des entrevues avec des personnes travaillant dans le système de santé au niveau de la province, des districts ou des centres de santé, ou bien des patients qui consultent à ces endroits. Par la signature de ce formulaire, le chercheur s’engage auprès des participants à assurer la confidentialité des données recueillies. 3. En signant ce formulaire, je reconnais avoir pris connaissance du formulaire de consentement écrit signé avec les participants et je m’engage à : - assurer la confidentialité des données recueillies, soit à ne pas divulguer l’identité des
participants ou toute autre donnée permettant d’identifier un participant, un organisme ou des intervenants des organismes collaborateurs;
- assurer la sécurité physique et informatique des données recueillies; - ne pas conserver de copie des documents contenant des données confidentielles.
Je, soussigné, ___________________________________ , m’engage à assurer la confidentialité des données auxquelles j’aurai accès. _________________________________________________ Date : ____________________ Chercheur Si j’ai des questions à propos de la recherche, je peux contacter le directeur de recherche, le Pr Daniel Reinharz.
66
COMMITMENT FORM OF CONFIDENTIALITY
Title of the study: Analysis of a health care provision in the Lao PDR supported by the Luxemburg Cooperation This study is under the supervision of Dr. Daniel Reinharz professor at Laval University in Canada and director of the Francophone Institute for Tropical Medicine in Lao PDR. 1. The purpose of the research is to explore factors that influence the functioning of maternal and child health services supported by the Luxemburg Cooperation. 2. To carry out this research, the research team conducts interviews with people working in the health care system at the provincial, district, or health centers, or patients who consult at these places. By signing this form, the researcher makes a commitment to the participants that he will guarantee the confidentiality of the data. 3. By signing this form, I acknowledge having read the written consent form that was signed with the participants and I pledge: - To guarantee the confidentiality of the data, to not disclose the identity of participants or to divulge data that might be used to identify a participant, organization or a collaborating agency; - To ensure the physical and informatics security of the data collected; - Not to keep copies of documents containing confidential data. I , _____________________________________________ , agree to protect the confidentiality of the data to which I will have access. _________________________________________________ Date: ____________________ Researcher If I have some questions about the research, I can contact the supervisor, Professor. Daniel Reinharz.
67
ແບບຟອມສັນຍາເກັບຮັກສາຂມູນເປັນຄວາມລັບ (Lao Version) ຫົວຂການຄນຄວ້າ : ວິໄຈການໃຫ້ບໍລິການ ການປິ່ນປົວ ຢູ່ ສປປ ລາວ, ອຸປະຖຳໂດຍໂຄງການຮ່ວມມື ລຸກຊຳບວກຊົວ
ການສຶກສາຂມູນດັ່ງກ່າວ ແມ່ນພາຍໃຕ້ການຊີ້ນຳ ຂອງທ່ານ ດຣ Daniel Reinharz ອາຈານສອນປະຈຳ ຢູ່ມະຫາວິທະຍາໄລ Laval ປະເທດການາດາ ແລະອຳນວຍການ ສະຖາບັນການແພດເຂດຮ້ອນຝຼັ່ງໂກໂຟນີ ຢູ່ ສປປ ລາວ.
· ຈຸດປະສົງໃນການຄນຄວ້າ ແມ່ນເພື່ອຊອກຫາ ປັດໄຈ ທີ່ພາໃຫ້ການປະຕິບັດວຽກງານໄດ້ດີ ຂອງພະແນກແມ່ແລະເດັກ ໂດຍການຊ່ວຍເຫຼືອຂອງໂຄງການຮ່ວມມື ລຸກຊຳບວກຊົວ ໂດຍຄວາມ
· ເປັນຈິງ ແມ່ນເພື່ອວິໄຈ, ສຳລວດຕີລາຄາຄຳຄິດເຫັນ ຂອງພະນັກງານແພດຫມໍ ແລະຜູ້ຊົມໃຊ້,
ແມ່ມານ ທີ່ໄປອອກລູກ, ປັດໄຈ ທີ່ສາມາດເຮັດໃຫ້ການບໍລິການ ພແມ່ປະຊາຊົນຂອງຂະແຫນງ · ວຽກງານ ຢູ່ສຸກສາລາ ທີ່ໄດ້ຮັບການຊ່ວຍເຫຼືອຈາກໂຄງການຮ່ວມມື ລຸກຊຳບວກຊົວ ມີປະສິດທິຜົນ .
· ເພື່ອປະຕິບັດວຽກງານດັ່ງກ່າວ, ນັກສຳລວດຂມູນ ລົງໄປເກັບກຳສຳພາດພະນັກງານສັງກັດພະແນກ
· ສາທາລະນະສຸກແຂວງ, ເມືອງ ຫຼືວຸກສາລາ, ຫຼືຄົນເຈັບທີ່ໄປໃຊ້ບໍລິການ ຢູ່ສະຖານທີ່ດັ່ງກ່າວ.
ໃນການເຊັນສັນຍາແບບຟອມວະບັບນ, ນັກວິໄຈ ຈະປະຕິບັດຕຜູ້ໃຫ້ສຳພາດໂດຍຮັກສາ
· ບົດສຳພາດ ໄວ້ເປັນຄວາມລັບ ບເປີດເຜີຍ.
3. ໃນການລົງນາມເຊັນສັນຍາສະບັບນ, ຂ້າພະເຈາໄດ້ອ່ານແລະຮັບຮູ້ ເປັນລາຍລັກອັກສອນ
ດ້ວຍຄວາມພໍໃຈ ແລະຈະປະຕິບັດ ລະອຽດດັ່ງລຸ່ມນ :
⁃ ຮັບປະກັນຄວາມລັບ ຂອງຂມູນ, ບເປີດເຜີຍສະພາບຂອງຜູ້ໃຫ້ສຳພາດ ຫຼືຂມູນອື່ນໆ ທີ່ສາມາດເປີດເຜີຍຜູ້ໃຫ້ສຳພາດ ຫຼືສະຖານທີ່ ທີ່ໃຫ້ຄວາມຮ່ວມມື ໃນການສຳພາດ;
⁃ ຮັບປະກັນຄວາມປອດໄພ ຂອງຂມູນ ທີ່ເປັນເອກະສານ ແລະຜົນສະຫຼຸບ ຢູ່ໃນ ⁃ ຄອມພີມເຕີ;
⁃ ບເກັຍຮັກສາສຳເນົາເອກະສານ ຊຶ່ງເປັນຂມູນລັບ ຂອງຂສຳພາດໄວ້. ຂ້າພະເຈາ, , ຈະປະຕິບັດເພື່ອຮັບ ປະກັນຄວາມລັບ
ຂອງຂມູນ ທີ່ຂ້າພະເຈາໄດ້ຮັບ. ວັນທີ:
ນັກຄນຄວ້າ
ສາມາດສອບຖາມລາຍລະອຽດ ກ່ຽວກັບການຄນຄວ້າ, ທ່ານ ສຈ Daniel Reinharz ໂທລະສັບ
