Out-of-Pocket Spending on Families and Barriers to Use ofChild and Child Health Services inand the Pacific

Republic on Maternal and Maternal Health in Asia the Lao People’s Democratic Impact of Out-of-Pocket Expenditures

Impact of Out-of-Pocket Expenditures on Families and Barriers to Use of Maternal and Child Health Services in the Lao People’s Democratic Republic
Evidence from the Lao Expenditure and Consumption Survey 2007–2008
COUNTRY BRIEF

1

Summary
• Limited progress has been made in the past decade in reducing the high levels of maternal and child deaths in the Lao People’s Democratic Republic (Lao PDR). Women and children are inadequately covered by basic healthcare services. • The use of medical services is also very low in the country, compared with other countries in the region. • In 2007, there were large inequalities in the use of healthcare services. Rich families and those living in urban areas were almost twice as likely as poor families and those living in the countryside to seek medical treatment. • This inequality in healthcare use exists mainly because (i) the poor are less likely than the rich to recognize that they are ill, and (ii) the poor are less likely than the rich to pursue treatment even when they know they are sick. • Difficulty of access to medical facilities and the cost of treatment are the main reasons why treatment is not sought. • The use of inpatient care, where the problems of physical access and the cost barriers are greater, is much more unequal than the use of outpatient care. Nonpoor families use inpatient care twice as much as poor families, both for children and adults. • Most healthcare visits for both children and adults involve self-medication, with medicines the families themselves purchased. • As hospitals rely on user fees, 89% of child admissions result in financial costs to households. Admission costs are higher on average at public hospitals than at private clinics, indicating that the cost barriers to care in public services are quite high. • The share of out-of-pocket medical spending in total household spending is still not high, however, and financially impoverishing spending is modest, because of the low use of healthcare services in the Lao PDR compared with other countries. • To improve the use of maternal and child health services, the Lao PDR must provide better physical access to the services and lower the financial barriers to access.

Background
The Lao People’s Democratic Republic (the Lao PDR) has made progress in the past decade toward achieving the health related Millennium Development Goals (MDGs), but health outcomes remain among the worst in Asia and the Pacific. The maternal mortality ratio, at about 580, is the second highest in Asia, and is two to four times higher than that of the country’s immediate neighbors (WHO, UNICEF UNFPA, and World Bank 2010). , Basic, effective maternal and child health interventions are still beyond the reach of large segments of the population. The rate of skilled attendance at birth is one of the five lowest in the world (UNICEF 2012), and reported rates of use of public facilities (0.2 curative care contacts per capita per year) are also among the lowest. Progress in expanding service coverage has likewise been limited. Skilled birth attendance, for example, fell from 21% in 2000 to only 20% in 2006, while the percentage of children seeking care for possible pneumonia declined from 36% to 32% during the same period (UNICEF 2000, 2008). According to national health accounts estimates prepared by the World Health Organization (WHO) (WHO 2012), out-of-pocket spending by households accounts for 51% of financing for the 2

health sector. Government spending as a share of gross domestic product in 2010 is the lowest in the region, at 1.5%, compared with 2.9% in Thailand, 2.7% in the People’s Republic of China, 2.6% in Viet Nam, and 2.1% in Cambodia, and has not increased in real terms in the past decade. Donors make major contributions to overall public sector spending, but their funding fluctuates from year to year, causing difficulties in financial management. The government health system covers most of the population and is supplemented by both nongovernmental organization and private providers. The government health infrastructure is limited and concentrated in urban areas. Ratios of hospital beds, doctors, and nurses to population are also among the lowest in the world (OECD 2010). Government healthcare services are underused and private healthcare, although expanding, is limited. Overall rates of use of modern medical care in the Lao PDR are therefore very low. Healthcare services used to be funded fully by the government and were officially provided free of charge at government health facilities, but in 1996 the government introduced user fees. The low budgetary resources made available for government health services have since led to a high reliance on user fee revenues by the facilities. Although the government has set up a number of insurance and safety net

Impact of Out-of-Pocket Expenditures on Families and Barriers to Use of Maternal and Child Health Services in the Lao People’s Democratic Republic

% reporting any sickness in past 30 days

schemes to protect patients from these charges, the schemes have had limited coverage so far. Officially mandated fee exemptions for the poor have been implemented only partially, benefiting less than 10% of patients (Thome and Pholsena 2009). The heavy reliance on out-of-pocket expenditure is likely to be a significant barrier to access to essential maternal and child healthcare services in the Lao PDR.

Figure 1: Illness Reporting in the Lao People’s Democratic Republic and Other Asian Countries, Recent Years
45 40 35 30 25 20 15 10 5 0
Pakistan All Lao PDR Children Cambodia PNG Bangladesh Timor-Leste

Data Source
This policy brief presents findings from analysis of the Lao Expenditure and Consumption Survey 2007–2008 (LECS4) (Lao Statistics Bureau 2008). This national survey of 8,296 households (48,021 individuals) collects data on household consumption and living standards, and includes a module on healthcare use and spending. Using the detailed household consumption section of the survey, this policy brief groups the population into equal quintiles of consumption per adult equivalent, as a measure of relative living standards and socioeconomic grouping. The health module can be used to examine inequalities in access to care by mothers and children (defined here as less than 5 years of age), and some aspects of spending. But the small size of the survey sample, as well as the lack of questions about the pregnancy status of women, means that only spending and use patterns in the case of sick children can be assessed. Further, the expenditure question in the health module was not well designed. It asks only about expenditures resulting from inpatient treatment, and not about those from outpatient treatment.

Lao PDR = Lao People’s Democratic Republic, PNG = Papua New Guinea, PRC = People’s Republic of China Sources: Authors’ analysis of LECS4 data set and analyses of Asian Development Bank technical assistance project.

In the LECS4, the proportion of those reporting illness increases with income, both among adults and children (Figure 2). Illness reporting is more likely for individuals (11.5%) and children (13.3%) in the richest quintile than for those in the poorest quintile (9.8% and 10.3%, respectively). No similar variations in reporting are seen with increasing education, suggesting that financial barriers have a greater influence on the ability to recognize illness. Figure 2: Illness Reporting in the Lao People’s Democratic Republic, by Socioeconomic Status, 2007−2008
14
% reporting any sickness in past 30 days

Perception of Illness and Treatment Seeking
Ill individuals must first realize they are sick before they look for healthcare. LECS4 asked whether individuals had been sick in the previous four weeks. In total, 10.1% of all individuals and 10.9% of children below 5 years were reported to have been sick. However, the self-reporting of illness in a survey is an unreliable indicator of the real level or distribution of illness within the population, as it depends critically on the ability of individuals to recognize and respond to the symptoms of illness. This is apparent when a comparison is made of the levels of reported illness in the past 30 days in the Lao PDR and other Asian countries with comparable or better health status (Figure 1). Self-reported illness is also an unreliable measure of differences in health status within a population. The people of the Lao PDR are less likely than those in most other countries in the region to report illness, especially when it comes to illness in children. This suggests that the failure to recognize illness is an important factor behind the low use of healthcare services in the Lao PDR.

12 10 8 6 4 2 0
Poorest All Q2 Children Q3 Quintile Q4 Richest

Q = quintile Lao PDR = Lao People’s Democratic Republic Source: Authors’ analysis of LECS4 data set.

3

Figure 3: Use of Healthcare Services in the Lao People’s Democratic Republic and Other Asian Countries, Recent Years
100 90
% of individuals sick in past 30 days obtaining medical treatments

80 70 60 50 40

(5%, 4%). Overall distance to facilities and high costs are more important to the poor and those living in rural areas, especially rural areas without roads, than to the nonpoor and those living in urban areas (Figure 4). The survey responses do not vary much with other characteristics such as education. Figure 4: Barriers to Treatment of Illness in the Lao People’s Democratic Republic, 2007−2008
100 90
Reasons for not taking treatment (%)

14 3 25

23 4 27

20 6 19

19 5 21

14 27 10

20 5 18

20 3 20

30 20 10 0
Lao PDR All Timor-Leste Children Cambodia Bangladesh Pakistan

80 70 60 50 40 30 20 10 0

10 5 36

Lao PDR = Lao People’s Democratic Republic Sources: Authors’ analysis of LECS4 data set and analyses of Asian Development Bank technical assistance project.

58 46

55

55

58 40

57

57

This gradient in reported illness is not consistent with other evidence indicating that ill health among children is higher in rural areas, in cases where mothers have less education, and in the central part of the Lao PDR (State Planning Committee and National Statistical Center 2000). A reduced responsiveness to illness could be one reason for the inadequate use of healthcare by poorer families. Being sick does not automatically lead to seeking medical treatment. In many countries the poor when sick are less likely to obtain treatment than the rich. Medical treatment is defined here as consisting of visits to government or private medical providers, but excluding the self-purchase of medicines from pharmacies, revolving drug funds, etc. This definition is similar to the definition used in comparable surveys in other countries in the region. The overall rate of use of medical care by those reporting sick in the Lao PDR (20.5% overall, and 16.8% in children) is quite low compared with the rate of use in other countries, where typically 60%–90% of those who are reported as sick obtain medical treatment (Figure 3). There are also inequalities in the use of medical care during periods of illness. The poor in the Lao PDR are less likely to be taken for treatment when sick than the nonpoor (12.8% of sick children in the poorest quintile versus 21.5% in the richest quintile). People in the rural areas are also significantly less likely to be taken for treatment (19.1% of all sick individuals and 15.4% of sick children) than those living in urban areas (24.0% of all sick individuals and 20.7% of sick children). Excluding cases where the illness is not considered serious enough to require treatment (84% overall and 88% in children), the three main reasons why sick persons do not seek treatment are the difficulty of access to treatment (55%, 51%), the high cost of treatment (21%, 25%), and the poor quality of treatment 4

Poorest

Q2

Q3 Quintile

Q4

Richest Urban

Rural Sector

Rural without roads

No cure possible Too expensive

Not good quality Difficult to get to

Q = quintile Lao PDR = Lao People’s Democratic Republic Source: Authors’ analysis of LECS4 data set.

Lack of physical access to treatment emerges as the major factor behind inadequate and unequal use of healthcare when mothers and children are sick in the Lao PDR. Cost of care is another consideration. A reinforcing factor is low responsiveness to illness in the population as a whole.

Use of Health Services
The combination of reduced awareness of illness and reduced likelihood of seeking treatment among the poor results in a large inequality in overall rates of use of medical treatment. Sick children and adults in the richest quintile use outpatient medical care more than thrice (3.2 times) as much as those in the poorest quintile. Use of health services also varies by age: it is higher among young children than among young adults, and increases among older adults (Figure 5). In 2007–2008, infants accounted for 3.4% of all reported outpatient medical treatment, and children (<5 years), for 12.5%. The use of maternal health services could not be estimated, as the LECS4 did not ask respondents to give the reasons for visiting a medical provider.

Impact of Out-of-Pocket Expenditures on Families and Barriers to Use of Maternal and Child Health Services in the Lao People’s Democratic Republic

Figure 5: Use of Outpatient Medical Treatment in the Lao People’s Democratic Republic, by Age Group, 2007−2008
4.0 3.5
% of individuals sick and seeking treatment in the past 30 days

3.4

3.3

3.0 2.5 2.0 1.5 1.0 0.5 0.0 0 1–4 5–9 10–17 18–44 45–64 65+
Age group (years)

2.3 1.6 1.1 0.7

1.6

However, medical providers are not the main source of healthcare in the Lao PDR. Healthcare visits are made primarily to purchase medicines, and most involve self-medication. Other studies reveal that private pharmacies and revolving drug funds are the principal sources of such medicines (Svhakhang et al. 2008). The self purchase of medicines occurs 1.6 times more often than the use of any medical provider. In any given month, 6.7% of individuals (6.6% of children) purchase medicines, and 64.9% of these purchases (61.9% among children) involve self medication. Rates vary little by income level, but are highest (71.5%) in rural villages without access to roads (59.9% in urban areas, 63.3% in rural with roads). Inpatient service use in the Lao PDR, about 2% a year, is one of the lowest in Asia (WHO 2011; OECD 2010). It is also highly unequal, with the richest quintile more than twice as likely as the poorest, and urban residents 1.3 times more likely than rural residents, to use such care. Inequalities in the case of children are similar (Figure 7). Figure 7: Use of Inpatient Medical Care in the Lao People’s Democratic Republic, by Socioeconomic Status and Sector, 2007–2008
0.025
Inpatient admissions per capita per year

Lao PDR = Lao People’s Democratic Republic Source: Authors’ analysis of LECS4 data set.

When individuals seek outpatient medical care, they do so mostly from public providers. Public hospitals and health centers account for 54% of all outpatient visits, and for 50% of child visits (Figure 6). However, use patterns differ more significantly between urban and rural residents, than between income groups. Rural residents use public health centers more than urban residents, while urban residents make more use of central hospitals, suggesting that physical access and transport barriers are the major determinants of use. Private clinics, doctors, and nurses account for 34% of all outpatient care use (37% among children), and a higher share of such use among the nonpoor. Figure 6: Outpatient Medical Care for Children in the Lao People’s Democratic Republic, 2007−2008
100 90
% of children seeking care by provider

0.020

0.015

0.010

0.005

28

7 2 35

6 1

4 3 39

5

13 6

80 70 60 50 40 30 20 10 0 10
Poorest

0.000
Poorest Q2 Children Q3 Quintile All Q = quintile Lao PDR = Lao People’s Democratic Republic Source: Authors’ analysis of LECS4 data set. Q4 Richest Urban Rural Sector

35

21 10 15

55 8 2 38 41 40 34 22 3
Q2 Q3 Quintile

60

27

9 3 22 41

Cost of Hospital Admission
The LECS4 design severely limits the analysis of costs of healthcare visits, as only costs associated with inpatient admissions, and not those incurred in outpatient visits or the purchase of medicines, are elicited. With hospital admissions, respondents are asked to provide the combined costs involved in each hospital stay, as well as the costs of transport to the hospital. Almost all inpatient visits (99.6% overall, and 100% where children are concerned) incur treatment costs, and most visits (87.9% overall, and 77.7% for children) also entail travel costs. Treatment 5

32

6
Q4 Richest

15
Urban

5
Rural

Sector Traditional Public health centers Central hospitals

Other Private doctors, nurses, clinics Other public hospitals Q = quintile Lao PDR = Lao People’s Democratic Republic Source: Authors’ analysis of LECS4 data set.

costs for each hospital admission average KN1,199,332 (KN671,037 for children) and travel costs KN200,214 (KN 105,981 for children).1 These costs vary considerably by type of provider: admissions are most expensive at central hospitals and at treatment facilities abroad. The costs for children are similar, although somewhat lower (Figure 8). Admission costs are generally higher at public hospitals than at private clinics, although the data do not permit accounting for differences in case mix and treatment. The average cost of an admission for a child, including transport, at a public hospital (KN600,604) is more than the household’s total weekly consumption for 87.5% of the people of the Lao PDR. Overall travel costs are relatively small, suggesting that most of the people avail themselves of medical care only if it is easily accessible. Figure 8: Hospital Admission Costs in the Lao People’s Democratic Republic, by Healthcare Provider, 2007–2008
4,000 3,500
Average cost associated with visit to provider ( KN ‘000)

household spending, is used. Unfortunately, because expenditures are not disaggregated by household member, healthcare spending by specific individual characteristics or for mothers and children cannot be analyzed. According to LECS4, annual out-ofpocket spending on medical care in 2007−2008 amounted to KN81,953 per capita, equivalent to a low (by regional standards) 1.7% of total household expenditures (Figure 9). Figure 9: Share of Out-of-Pocket Medical Spending in Household Budgets in Regional Countries, Recent Years
India Viet Nam Bangladesh Cambodia PRC Australia Nepal Kyrgyz Republic Sri Lanka Philippines Indonesia Lao PDR Thailand Malaysia Maldives Fiji Timor-Leste 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0
Out-of-pocket spending as a % of total household expenditure Lao PDR = Lao People’s Democratic Republic, PRC = People’s Republic of China Sources: Authors’ analysis of LECS4 data set, analyses of Asian Development Bank technical assistance project, van Doorslaer et al. 2007 and forthcoming estimates by Equitap research network for Fiji and Maldives.

3,000 2,500 2,000 1,500 1,000 500
All All All All All Children Children Children Children Children All Children

0

Figure 10: Out-of-Pocket Medical Spending in the Lao People’s Democratic Republic, by Socioeconomic Status and Sector, 2007–2008
300 250 200 150 121 100 66 50 9 0
Poorest Q2 Q3 Quintile Q4 Richest Urban Rural Sector

Treatment

Transport

Lao PDR = Lao People’s Democratic Republic Source: Authors’ analysis of LECS4 data set.

Average costs of admission are higher for the nonpoor than for the poor, but are only 28% more for the richest than the poorest quintile. As incomes vary much more between them, these costs are a greater burden for the poor than the nonpoor, consistent with the finding that the poor are more likely to report cost as a factor behind their nonuse of medical treatment. This indicates that government spending on hospitals and other social protection schemes has been ineffective or insufficient to make inpatient treatment more affordable to the poor, mothers and children.

Out-of-pocket health spending per capita per year (KN ‘000)

Hospital or clinic abroad

Central hospital

Regional Provincial hospital or district hospital

Public health center

Private health clinic

275

66

22

38

Out-of-Pocket Spending on Healthcare
The LECS4 health module cannot be used to analyze the distribution of healthcare spending, as it asks only about inpatient costs. To analyze the levels of household health expenditures, the household expenditure section of the survey, which asks about all
1

Q = quintile Source: Authors’ analysis of LECS4 data set.

Exchange rate at the end of 2007: $1 = KN9,632.

However, there are large disparities between income groups in spending. Overall, the richest quintile spends 31 times more per capita than the poorest quintile (Figure 10). Spending also increases with income as a share of total household budgets and as a share of nonfood spending (Figure 11). Overall spending on healthcare

6

Impact of Out-of-Pocket Expenditures on Families and Barriers to Use of Maternal and Child Health Services in the Lao People’s Democratic Republic

is so concentrated in nonpoor households that the poorest quintile accounts for only 2% of such medical expenditure, reflecting lower incomes and ability to pay. In contrast, the richest quintile accounts for two thirds of overall healthcare spending (Figure 12). Figure 11: Share of Out-of-Pocket Medical Spending in Household Budgets and Nonfood Expenditure by Socioeconomic Status in the Lao PDR, 2007–2008
Out-of-pocket health spending as a % of total HHE and a % of nonfood expenditure

any given month in 2007−08, 0.5% of people in the Lao PDR were pushed below the $1 international poverty line2 as a result of household medical spending (Figure 13). The frequency of catastrophic health expenditures is also relatively low, whichever definition is used (Figure 14). In any given month in 2007–2008, 3.8% of the people of the Lao PDR had to allocate more than 10% of their total household budget, and 3.6% had to allocate more than 40% of their monthly nonfood expenditures, to medical treatment costs. The relatively low financial impact Figure 13: Incidence of Impoverishment Resulting from Out-of-Pocket Medical Spending by Households in Regional Countries, Recent Years
Pakistan India Bangladesh PRC Nepal Viet Nam Indonesia Maldives Philippines Lao PDR Sri Lanka PNG Thailand Timor-Leste Malaysia Kyrgyz Republic Fiji 0.0 1.0 2.0 3.0 4.0 5.0
% of population falling below the international povery line of $1.08 (1993 PPP) per day Lao PDR = Lao People’s Democratic Republic, PNG = Papua New Guinea, PRC = People’s Republic of China Sources: Authors’ analysis of LECS4 data set, analyses of Asian Development Bank technical assistance project, and forthcoming estimates by Equitap research network.

7 6 5 4 3 2 1 0
Poorest Q2 Q3 Q4 Richest

Quintile OOP expenditure as % of total household expenditure OOP as % of household nonfood expenditure HHE = household expenditure, Q = quintile Source: Authors’ analysis of LECS4 data set.

Figure 12: Out-of-Pocket Health Spending in the Lao People’s Democratic Republic, by Socioeconomic Status, 2007–2008
2% 6%
Poorest Q2 Q3 Q4 Richest

9% 16% 67%

Figure 14: Incidence of Catastrophic Out-of-Pocket Medical Spending in Regional Countries, Recent Years
Cambodia Viet Nam PRC India Pakistan Nepal Kyrgyz Republic Philippines Indonesia Bangladesh Lao PDR Thailand Sri Lanka Malaysia Maldives Fiji PNG Timor-Leste 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0
% of population spending more than 10% of household budget on health Lao PDR = Lao People’s Democratic Republic, PNG = Papua New Guinea, PRC = People’s Republic of China Sources: Authors’ analysis of LECS4 data set, analyses of Asian Development Bank technical assistance project, and forthcoming estimates by Equitap research network.
2

Q = quintile Source: Authors’ analysis of LECS4 data set.

Financial Impact of Out-of-Pocket Spending on Healthcare
Out-of-pocket financing of healthcare can cause considerable financial hardship to families. This impact can be assessed in two ways: by the number of households pushed below the poverty line by such spending (impoverishing impact), and by the number of households that must devote a large share of their resources to medical treatment (catastrophic impact). Studies show that heavy reliance on out-of-pocket spending in health systems usually results in medical impoverishment and catastrophic spending (van Doorslaer et al 2006; van Doorslaer et al. 2007). The LECS4 reveals levels of impoverishing and catastrophic expenditures that are much lower than those in other countries in the region such as Bangladesh, the People’s Republic of China, and Viet Nam. In

Equivalent to a consumption level of $1.08 (1993 PPP) per day, or KN3,973 per day, in 2007.

7

of healthcare in the Lao PDR does not imply that the healthcare system provides good protection against financial risk. Given the low overall rates of use of medical care in the Lao PDR, this low level of impoverishing expenditures is due more to nonuse of services, the inability of households to pay, and the lack of effective access to non-free alternatives, especially in the rural areas.

Organisation for Economic Co-operation and Development (OECD). 2010. Health at a Glance: Asia/Pacific 2010. Paris. State Planning Committee and National Statistical Center, Lao People’s Democratic Republic (Lao PDR). 2000. Lao National Health Survey. Vientiane, Lao PDR: State Planning Committee and National Statistical Center. Svhakhang L., S. Sengaloundeth, S. Freudenthal, and R. Walhstrom. 2008. Availability of Essential Drugs and Sustainability of Village Revolving Drug Funds in Remote Areas of Lao PDR. In Health and Social Protection: Experiences from Cambodia, [People's Republic of] China and Lao PDR, edited by B. Meessen, X. Pei, B. Criel, and G. Bloom. 23 ed. Antwerp: ITG Press, pp. 519–543. Thome Jean-Marc, and Soulivanh Pholsena. 2009. Lao People’s Democratic Republic: Health Financing Reform and Challenges in Expanding the Current Social Protection Schemes. In United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP), Promoting Sustainable Strategies to Improve Access to Health Care in the Asian and Pacific Region, pp. 71–102. United Nations Children’s Fund (UNICEF). 2012. The State of the World’s Children: Children in an Urban World. New York City. van Doorslaer, E. et al. 2006. Effect of Payments for Health Care on Poverty Estimates in 11 Countries in Asia: An Analysis of Household Survey Data. Lancet. 368 (9544). pp. 1357–1364. van Doorslaer, E. et al. 2007. Catastrophic Payments for Health Care in Asia. Health Economics. 16 (11). pp. 1159–1184. World Health Organization (WHO). 2011. Country Cooperation Strategy for the Lao People’s Democratic Republic 2012–2015. Geneva. ———. 2012. Estimates for NHA Data. http://apps.who.int/nha/database/ DataExplorerRegime.aspx. World Health Organization (WHO) et al. 2010. Trends in Maternal Mortality: 1990 to 2008. Geneva: WHO, UNICEF UNFPA, and World Bank. ,

Conclusions
This analysis of the Lao Expenditure and Consumption Survey 2007−2008 reveals significant inequalities in the use of, and access to, basic healthcare services, with travel and cost being the most significant barriers. Overall, out-of- pocket spending on healthcare is low, and so does not lead to a high incidence of financial impoverishment. This is not a positive finding, however, as the low spending is associated with very low use of healthcare services in the Lao PDR. The high costs of obtaining medical treatment discourage poor families from taking their sick children for medical care. Despite government programs, visits to public healthcare facilities typically cost as much as or more than visits to private clinics. To improve access to maternal and child health services and the outcomes of such services, the Lao PDR should focus on expanding the service delivery network in rural areas to give more families ready access to healthcare facilities, and on reducing the costs of obtaining treatment at public facilities.

References
Department of Statistics, Lao People’s Democratic Republic (The Lao PDR), and United Nations Children’s Fund (UNICEF). 2000. Multiple Indicator Cluster Survey 2000: Preliminary Report. Vientiane: National Statistical Center. ———. 2008. Lao PDR Multiple Indicator Cluster Survey 2006: Final Report. Vientiane, Lao PDR: Department of Statistics and UNICEF . Lao Statistics Bureau, Ministry of Planning and Investment. 2008. Lao Expenditure and Consumption Survey 2007−2008. Vientiane.

Suggested citation
Anuranga, C., J. Chandrasiri, R. Wickramasinghe, and R.P Rannan. Eliya. 2012. The Impact of Out-of-Pocket Expenditures on Families and Barriers to Use of Maternal and Child Health Services in the Lao People’s Democratic Republic: Evidence from the Lao Expenditure and Consumption Survey 2007–2008 RETA–6515 Country Brief. Manila: Asian Development Bank.

ADB RETA 6515 Country Brief Series
Poor maternal, neonatal, and child health adversely affects women, families, and economies across the Asia and Pacific region. This burden of illness must be reduced if the Millennium Development Goals (particularly 4 [reduce child mortality] and 5 [improve maternal health]) are to be achieved and improvements made in the health and economic well-being of households and nations. Progress in this regard will require an increased supply of effective healthcare services, as well as demand for such services. This series of country briefs provides evidence from national household surveys on the financial burdens imposed on the poor by private expenditures on public and private healthcare services. Countries can use this information in building awareness within health systems and policy bodies of financial constraints on healthcare, and in designing demand-side interventions to increase the use of maternal, neonatal, and child health services. Summaries of the analysis of household data from Bangladesh, Cambodia, the Lao People’s Democratic Republic, Pakistan, Papua New Guinea, and Timor-Leste, and a summary overview, are included in the series. This country brief was prepared by the Institute for Health Policy in Sri Lanka under an Asian Development Bank (ADB) technical assistance project, Impact of Maternal and Child Health Private Expenditure on Poverty and Inequity (TA–6515 REG). The Institute for Health Policy and authors gratefully acknowledge the funding made possible by ADB that was financed principally by the Government of Australia. Australia is taking a leading role in global and regional action to address maternal and child health. A key part of this is to strengthen the evidence for increased financial support and the most effective investments that governments and donors can make to meet Millennium Development Goals 4 and 5. Australia supported this technical assistance project as a part of this commitment.

About the Asian Development Bank
ADB’s vision is an Asia and Pacific region free of poverty. Its mission is to help its developing member countries reduce poverty and improve the quality of life of their people. Despite the region’s many successes, it remains home to two-thirds of the world’s poor: 1.7 billion people who live on less than $2 a day, with 828 million struggling on less than $1.25 a day. ADB is committed to reducing poverty through inclusive economic growth, environmentally sustainable growth, and regional integration. Based in Manila, ADB is owned by 67 members, including 48 from the region. Its main instruments for helping its developing member countries are policy dialogue, loans, equity investments, guarantees, grants, and technical assistance.

8 Asian Development Bank. Publication Stock No. ©

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