Provider perspectives on constraints in providing maternal, neonatal and child health services in the Lao People’s democratic republic: a qualitative study

Abstract

BackgroundTo reduce its high maternal and neonatal mortality rate and meet Millennium Development Goals four and five, Lao PDR has adopted a national ‘Strategy and Planning Framework of Implementation of Maternal, Neonatal and Child Health Services’. This paper reports on implementation constraints identified in three demonstration sites.MethodsThe objectives of this paper are to analyse health worker perceptions of the implementation of the strategy and constraints faced during implementation. A qualitative design was used with interviews conducted at health facilities in three demonstration provinces. Data were collected through key interviews with provincial/district hospital providers (n = 27), health centre staff (n = 8) and village health volunteers (n = 10). Data was analysed informed by Hanson et al’s health system constraint framework.ResultsIn each of the demonstration sites, the Maternal, Neonatal and Child Health program was generally well-understood and the different activities were being implemented. Perceived implementation constraints related mainly to a mix of supply and demand factors. Supply-side constraints related to inadequate human resources, poor remuneration, weak technical guidance, minimal supervision and limited equipment. Demand-side constraints related mainly to cost, limited access to transport, cultural practices and language. Other constraints related to broader strategic management and cross-sectoral contextual constraints. Contextual constraints included low levels of limited education, women’s position in society and poor transport and communications networks. These factors influenced the implementation process and if not addressed, may reduce the effectiveness of the policy and scale-up.ConclusionThe Lao PDR has a well-defined Maternal, Neonatal and Child Health program. Analysis of the constraints experienced by service providers in implementing the program however, is essential for scaling-up the initiative. To achieve effective implementation and scale-up a number of concurrent interventions are needed to address identified constraints. More research is needed to identify the optimal combination of interventions to improve these constraints. The broader contextual characteristics require longer-term, cross-sectoral action.

Implementation of free maternal and child healthcare policies: assessment of influence of context and institutional capacity of health facilities in South-east Nigeria

“…Also, equipment donated by development partners enabled health facilities to offer free services. However, buildings are dilapidated, health facilities lack public utilities and functional ambulances to support referrals, equipment is stacked and not tailored to the scope of services provided by facilities, which are consistent with findings of several studies [18,24,36]. Equally, the study found that donation of seed stock for the drug revolving fund and subsequent procurement through the central medical stores improved availability of quality-assured drugs in health facilities.…”

“…Similarly, shortage of appropriate qualified health workers, worse in remote areas, constrained provision of maternal, neonatal and child health services in the Lao People’s Democratic Republic and three African countries, where health workers had preference for urban posts [19,36]. Though presence of SURE-P staff improved the availability of health workers, postings and transfers of health workers to less busy or urban health facilities limit responsiveness of health facilities and contribute to declining quality of care.…”

“…Use of service charters to curb informal payments to service providers [9], active health facility committees (HFCs) including financial management [10–12], timely payment of providers [13], regular and uninterrupted drug supply [13], availability of clear guidelines on use of user fee replacement grants [14], an effective staff sanction framework, which reduces health worker absenteeism [15], have enabled health facilities to effectively implement free healthcare policies. In contrast, barriers to health facilities implementing free healthcare policies include weak decentralization [10,16–18]; poor supervision and monitoring [19,20]; weak referral systems [17]; absence of written implementation guidelines [14,21]; shortage of staff and inconsistent recording and reporting [10,20]; low social accountability and community involvement [9,22–24]; delayed payment of providers [12,21,25]; lack of adequate drug stock [17,18,24,26–31]; mistrust between providers and patients [19,32–34]; absenteeism [10,15,20]; poorly motivated health workers [18,24]; lack of financial incentives [35]; preference for urban postings [19,36]; funding inadequacy in health facilities [16]; inadequate physical infrastructure [18,24,36]; unavailability of guidelines for use of user fee replacement fund [37] and unclear procedures for targeting beneficiaries [3]. …”

Provider perspectives on the enabling environment required for skilled birth attendance: a qualitative study in western Nepal

“…The Chodzaza & Bultemeier 2010;Sychareun et al 2013). In our study, the SBA training, the supply of drugs, and support from community members and health managers were nominated as strengths of the enabling environment by all SBAs.…”

Recovering disrupted social capital: insights from Lao PDR rural villagers’ perceptions of local leadership

“…This study reanalyzed the data used by Ngan and colleagues [16] and Sychareun and colleagues [17]. The former study focused on the utilization of maternal health care services, and the latter examined constraints experienced by service providers when providing maternal and child health services.…”