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
Mémoire
Ashken N’doh Sanogo
Sous la direction de :
Daniel Reinharz – Directeur de recherche
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.
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.
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
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
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
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
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
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.
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.
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.
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
1HSS 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
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.
5MNCH 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.
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.
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
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).
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
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.
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
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
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.
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
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.
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).
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
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)
(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
these women might not know when to consult when a need to see a health professional is warranted.
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)
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.
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.
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
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.
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
(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.
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.
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.
« 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
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
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
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.
