RESEARCH Open Access

Challenges for strengthening the healthworkforce in the Lao People’s DemocraticRepublic: perspectives from keystakeholdersYi Qian1,2,3, Fei Yan1,2* , Wei Wang1, Shayna Clancy4, Kongsap Akkhavong5, Manithong Vonglokham5,Somphou Outhensackda5 and Truls Østbye4,6,7

Abstract

Background: The Lao People’s Democratic Republic is facing a critical shortage and maldistribution of healthworkers. Strengthening of the health workforce has been adopted as one of the five priorities of the NationalHealth Sector Strategy (2013–2025). This study aims to identify, explore, and better understand the key challengesfor strengthening the Laotian health workforce.

Methods: This study applied exploratory and descriptive qualitative methods and adapted a working life-spanframework. Twenty-three key stakeholders with particular insights into the current situation of the health workforcewere purposively recruited for in-depth interviews. Important policy documents were also collected from keyinformants during the interviews. Thematic analysis was employed for the textual data using MAXQDA 10.

Results: The overarching problem is that there is a perceived severe shortage of skilled health workers (doctors,nurses, and midwives) and lab technicians, especially in primary health facilities and rural areas. Key informants alsoidentified five problems: insufficient production of health workers both in quantity and quality, a limited nationalbudget to recruit enough health staff and provide sufficient and equitable salaries and incentives, limitedmanagement capacity, poor recruitment for work in rural areas, and lack of well-designed continuing educationprograms for professional development. These problems are interrelated, both in how the issues arise and in theeffect they have on one another.

Conclusions: To improve the distribution of health workers in rural areas, strategies for increasing production andstrengthening retention should be well integrated for better effectiveness. It is also essential to take the Laotian-specificcontext into consideration during intervention development and implementation. Furthermore, the governmentshould acknowledge the inadequate health management capacity and invest to improve human resourcemanagement capacity at all levels. Finally, assessment of interventions for health workforce strengthening should bedeveloped as early as possible to learn from the experiences and lessons in the Lao People’s Democratic Republic.

Keywords: Health workforce, Lao People’s Democratic Republic, Qualitative research

* Correspondence: fyan@shmu.edu.cn; fyan2720@gmail.com1Department of Social Medicine, School of Public Health, Fudan University,138 Yi Xue Yuan Road, Shanghai 200032, People’s Republic of China2Fudan Global Health Institute, Fudan University, Shanghai 200032, People’sRepublic of ChinaFull list of author information is available at the end of the article

© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Qian et al. Human Resources for Health (2016) 14:72 DOI 10.1186/s12960-016-0167-y

BackgroundHuman resources for health: a global pictureOptimal health cannot be achieved without a healthworkforce, since health personnel represent the humanlinkage connecting health knowledge to health action[1–3]. The health workforce is at the heart of all healthsystems and plays a key role in improving health servicesand achieving health goals [1–3]. However, the globalhealth workforce is in a severe crisis. It has been esti-mated that the global deficit of skilled health workers(doctors, nurses, and midwives) has increased from 2.4million in 2006 to 7.2 million in 2012 and is expected toreach to 12.9 million by 2035 [1, 3]. Moreover, unevendistribution across the globe and within countries isanother big challenge [1, 3]. The countries who suffergreater burden of disease and require more sufficienthealth staff usually have more severe shortage of healthworkers. Within countries, the inequitable distributionof health workers is also evident between urban andrural areas. Furthermore, there is evidence indicatingthat the global health workforce is aging [3]. It is there-fore important to rethink the models of education,deployment, and remuneration of the health workforceand start a new global agenda relating to human re-sources for health development to reinforce the healthworkforce based on better evidence and practices.

The health workforce in the Lao People’s DemocraticRepublicThe Lao People’s Democratic Republic is one of 57countries having a critical shortage of health workers.The country only had 14 189 health workers in 2012[1, 4, 5]. Of those health workers, 59% were femaleand 16% were from minority groups [4]. Between2005 and 2012, the average number of skilled healthworkers per 1000 population was 0.2 physicians and0.8 nursing and midwifery personnel [5]. This numberwas far below the minimum threshold of 2.28 skilledhealth workers per 1000 population recommended byWHO [1]. Medical doctors, nurses, and midwives withmiddle and high levels of education only accounted forless than 30% of total health workers [4]. There is there-fore a critical shortage of well-trained health workers,especially the qualified medical staff.Health workers in the Lao People’s Democratic Republic

are distributed unevenly among different provinces.Between 2009 and 2010, the capital had the highest num-ber of health workers per 1000 population, 4.2 for all typesof health workers, twice the number of health personnelper 1000 population at the national level during the sameperiod [4]. Moreover, maldistribution of health workersalso exists among different health facility types (centralhospitals, regional hospitals, provincial hospitals, districthospitals, and village health centers), with most being

employed in district hospitals and provincial hospitals [6].Few health workers take positions in village health centers,which are mostly located in remote, mountainous, andhard-to-reach areas [4].Additionally, reports indicate that the overall capacity

of health workers in the Lao People’s Democratic Re-public has limited competence due to poor quality ofmedical training and limited incentives including lowsalaries and lack of opportunities for professional devel-opment, which also affect the performance of healthstaff [5, 6].These human resource constraints in the Lao People’s

Democratic Republic are similar to those in many otherdeveloping and developed countries. Australia has moredoctors and registered nurses working in metropolitanareas than in remote areas; thus, the Australian govern-ment launched the “More Doctors, Better Services” strat-egy in 2000 to address the shortage of health personnel inrural regions [7]. In China, health workers are distributedunevenly, not only between rural and urban locations, butalso among the regions [8]. Thailand is also experiencinginternal migration of skilled health professionals fromrural to urban areas and from the public to the privatesector, posing a new challenge to healthcare [9].

The health system in the Lao People’s Democratic RepublicThe health system in the Lao People’s Democratic Re-public operates at three administrative levels: central(Ministry of Health, MOH); provincial (provincial healthoffices, PHOs); and district level (district health offices,DHOs) [4, 6, 10]. The Laotian health system has beendecentralized, and some planning and budgeting respon-sibility have been devolved to the provincial and districtlevels, but there is evidence that health management andleadership capacity at the provincial and district levels islimited [4–6]. The health-related expenditures from thegovernment are also modest, and the health system sig-nificantly relies on external funding from donors [6, 11].The government only allocated 2.6% of total expendi-tures to the health sector in 2012 [12]. Healthcare in theLao People’s Democratic Republic is predominatelydelivered by public healthcare providers, at four levels oforganization: hospitals at the central level manageddirectly by the MOH, hospitals at the provincial levelmanaged by the PHOs, hospitals at the district levelmanaged by the DHOs, and providers at the communitylevel (health centers and village drug kits) also managedby the DHOs [4, 10, 13]. There are also a large numberof private pharmacies and clinics, but no private hospi-tals [4]. The uneven distribution of the health workforcegeographically and by facility type has left many primaryhealthcare facilities understaffed and unable to providebasic services [6]. The structure of the healthcare facil-ities is shown in Additional file 1.

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The Lao People’s Democratic Republic is now under the7th National Socio-Economic Plan and utilized the 7thFive-Year National Health Sector Development Plan as aroadmap to achieve the health-related Millennium Devel-opment Goals (MDGs) and improve the life of all Laotians[14]. Under this framework, the National Health SectorStrategy (2013–2025) was approved in 2012 and would beimplemented in three phases, aiming to achieve thehealth-related MDGs by 2015 and universal health cover-age by 2025. Health workforce strengthening is one of thefive priorities for reform [10]. Hence, developing a betterunderstanding of the current health workforce situation inthe Lao People’s Democratic Republic is necessary forachieving the human resources for health target. Previousresearch and reports have mostly included quantitativeinformation on the health workforce in the Lao People’sDemocratic Republic and have not included a comprehen-sive and integrated picture of the health workforce in theLao People’s Democratic Republic. This study aims toidentify, explore, and better understand the key challengesfor strengthening the Laotian health workforce. We alsoprovide recommendations on further health workforcedevelopment in the context of health system reform in theLao People’s Democratic Republic.

MethodsStudy design and frameworkThis study was designed to utilize exploratory anddescriptive qualitative methods as it was the best optionfor achieving the scope of this study [15], mainlythrough the in-depth interviews (IDIs) with key in-formants. These interviews aimed to explore and gainbetter understanding of the problems and challengesfaced by the national healthcare workforce in the LaoPeople’s Democratic Republic.We adapted the “working lifespan of entry-workforce-

exit” framework from the World Health Report 2006,which focuses on “three stages”: (1) when people enterthe workforce (entry stage), (2) when they are part of theworkforce (workforce stage), and (3) when they exitfrom the workforce (exit stage) [1] (see Fig. 1). In theentry stage, there are three central aspects of interest:

planning, education, and recruitment. The workforce stageassesses the following aspects: supervision, compensation,systems supports, lifelong learning, and performance.Finally, migration, career choice, health and safety, andretirement are the four key aspects in the exit stage; theseare also the influencing factors of workforce attrition.

Sampling of key informantsKey stakeholders with particular insights into the currenthealth workforce situation were recruited through a pur-posive sampling strategy [15]. The sampling strategy hadtaken into account the accessibility, convenience, andavailability of the key informants.Study sites in both urban and rural areas and with differ-

ent levels of economic conditions were selected. Two prov-inces were first selected: the Vientiane capital and theVientiane province. The Vientiane capital is an urban re-gion, and the Vientiane province is a rural region. Theformer is more economically developed than the latter. TheXaythany district in the Vientiane capital and the Hinheubdistrict and Vangvieng district in the Vientiane provincewere then selected for recruitment of key informants.Three categories of key informants were recruited for

this study: policy makers, administrative staff, and med-ical staff. The policy makers in positions for nationalhealth workforce planning and management were se-lected from the MOH. The administrative staff involvedin human resources for health management was enlistedfrom three levels: (1) administrative staff from the cen-tral level (MOH and National Institute of Public Health,NIOPH), (2) administrative staff from the provincial ordistrict level, (3) administrative staff from a variety ofhealth facilities (type A and type B district hospital andhealth centers). Medical staff with different experiencesin provision of healthcare were also recruited. Thesampling process is showed in more detail in Fig. 2.

Data collectionThe fieldwork was conducted over 3 weeks in theLao People’s Democratic Republic. The first 1-weekperiod was used by the Lao People’s Democratic Re-public, Chinese, and US research team members to

Fig. 1 The working life-span of entry-workforce-exit framework. Note: adapted from [1]

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prepare for fieldwork and conduct a pilot interview.The last 2 weeks (November, 2014) were utilized forkey informant interviews.Four topic guides for different types of key informants

(policy makers and administrative staff from the centrallevel, administrative staff from the provincial or districtlevel, administrative staff from health facilities, and med-ical staff ) were used to facilitate the interviews. Thetopic guides were designed to cover the key aspectsincluded in the working life-span framework. The mainpoints for probing for the interviews are presented inAdditional file 2. Furthermore, the important policydocuments over and beyond those that the researchershad already identified from the literature review werealso collected from key informants during interviews.IDIs were conducted by the primary researcher in English

and Lao with a research assistant fluent in both English andLao and with experience in public health research. Anactive interpreter model was applied during the interviews:the researcher facilitated the IDIs in English, and theresearch assistant translated and summarized the keyresponses from participants to the primary researcher toallow her to ask additional questions [16]. The key inform-ant interviews were terminated when there was no newinformation forthcoming, most of which lasted 1.5 to 2 h.The final sample size was reached by saturation of informa-tion [17, 18]. Most of the interviews were recorded using adigital voice recorder, and field notes were taken during theinterviews (two interviews were done without recordingbut with detailed field notes).There was a total of 23 key informants interviewed. A

broad range of policy makers and administrative staff wereinterviewed. The different key informants are presented in

Table 1. The Health Personnel Development Strategy by2020 and Handbook of Health Professions and Educa-tional Programs were key policy documents gathered.

Data analysisA thematic analysis was employed for the textual datacollected using MAXQDA 10 [15]. The recordings weretranscribed verbatim in English and then double-checkedby a research assistant for accuracy of transcriptions. Thethemes were developed mainly based on the guidingframework and also generated from the topic guides andthe textual data of the IDIs. Information from policydocuments and IDIs were all segmented by themes. Theanalysis process was inductive: themes were identified,coded, classified, and recoded, with the data becomingthemes. The themes and codes were revised and refinedcontinuously and integrated providing new insights.

Data quality assuranceThe research team had attended the training on qualitativeresearch and had experiences of qualitative fieldwork. Tri-angulation was applied to explore the issues from differentsources: policy makers, administrative staff, and medical

Fig. 2 Selection of key informants. HC health center, KIs key informants

Table 1 Key informants interviewed

Policy makers Administrative staff Medical staff

Central level 7 – –

Provincial level – 5 –

District level – 3 –

Hospital – 2 –

Health center – 4 2

Subtotal 7 14 2

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staff. Moreover, key informants had various backgrounds,characteristics, and experiences reflecting a broad range ofperspectives. Furthermore, open-ended question guideswere used to capture the range and depth of the perspec-tives. Interviews were conducted until no new informationwas elicited. During the interviews, the replies werevalidated with the respondents to ensure that the mainissues have been captured. The methods and process ofdata collection and analysis were written up, helping toincrease the transparency of this study.

Ethical considerationsEthical approval was obtained from the Ethics Committeeof the School of Public Health of Fudan University (Refer-ence number: IRB#2014-09-0532). The consent forms inLao with explicit explanation of the study, confidentiality,privacy, and anonymity were provided to all participantsbefore the interviews. Participation in the study was volun-tary and confidentiality was assured. Participants agreed totake part in the study and signed the informed consentforms. Additionally, permission for recording was alsoobtained from all participants before the IDIs. All paperdata and digital data were appropriately stored under lockor were password protected.

ResultsCurrent stock and demand for health workers: severeshortage of skilled health personnelThe key informants from the Health Personnel Depart-ment of the MOH stated that there were two main typesof health workers in the Lao People’s DemocraticRepublic: civil servant health workers and contracthealth workers. The civil servant health worker holds anofficial position in the public health sector and receivesa stable salary, whereas the contract health staff has noofficial position and no salary.Most key informants reported the biggest problem to be

the severe shortage in health workers, especially in ruraland remote areas. The greatest deficits were for skilledhealth personnel and laboratory technicians. Furthermore,most highly qualified health personnel worked at central-

and provincial-level health facilities, not at the primaryhealth level. Key informants attributed the shortage to theinsufficient budget at the national levels for civil servantpositions and poor attraction to work in health centersand rural areas.

…one thing is they want to put the bachelors,bachelor graduates in health centers, but there is nobachelor, there are only medical assistants, so theyhave to put the medical assistants to work in thehealth centers, that is the problem. (IDI 1)

Personal incentives: insufficient and inequitableMost of the key informants reported that the incen-tives provided to health workers were insufficientand inequitable across different types of health staff.The salary level of civil servant health workersmainly depended on their “rank,” which was deter-mined by the Ministry of Finance according to theireducation background and working experiences. Thisimplied that civil servant health workers of the samerank would receive similar salaries no matter whichtype of facility they work in. Retired civil servanthealth workers receive around 60–70% of their ori-ginal salary monthly.Besides rank-based salary, many key informants con-

sidered that the other financial incentives were notequitable across different types of civil servant healthworkers (see Fig. 3). Medical staff in hospitals could alsogain financial incentives from other sources, includingbonus payments for on-call hours, working with hazard-ous substances, and consultation services. The latter twotypes of bonus payments were contingent on hospitalfunds and were not stable and reliable sources ofincome. The health workers in health centers could onlyget bonus payments for on-call hours, consultationservices, and per-diem payments for outreach services.One administrative staff reported that some health cen-ter staff could earn extra income by working part timein private pharmacies or clinics.

Fig. 3 Summary of income structures for different types of health workers in the Lao People’s Democratic Republic

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The public health workers and health administrativestaff only got rank-based salary and per diem. Thecontract health workers only received payments foron-call hours and per diem work. Due to the incon-sistency of work hours, most of them need to rely ontheir family to survive.

Because they are local people, living in that village,that means that the health center is located in thatvillage, it is very near to his house, so even theirsalary is not high, but they are not in a farmingsituation, because their parents are there, whentheir salary is not sufficient, they can go to theparents, so the parents will give them (food…),so they will not die. (IDI 2)

In addition to financial incentives, the health workerswho were evaluated as “outstanding” in performance ap-praisals were provided with upgraded rank, participationin medical or degree training, and enrollment in medicalconferences as additional non-financial incentives.Furthermore, their payments may be delayed by

months and most participants considered this as a mainconcern. The payments would be delayed due to inad-equate governmental management ability and compli-cated processes for fundraising and appropriations. Thehealth workers would often rely on their families forliving expenses during unpaid periods.

we (health center) get from the district, and thedistrict gets from provincial health department, andthe provincial health department gets from provincialfinancial department. The payment is delayed, we getonly up to the October payment, so from Novemberuntil now, we did not get paid. (IDI 7 conducted inMarch, implying the staff didn’t receive payments for4 months)

Performance of health workers: perceived conscientiousand dedicatedMost key informants thought the health workers, espe-cially those in health centers, were conscientious anddedicated to their work, even during the unpaid periods.Furthermore, community members were perceived to besatisfied with the health services and have developedgood relationships with health workers.

And our staff are devoted to the villages, althoughwe don’t get anything [salary and incentives], westill go for the outreach activities, and the villagersalso like us, when we are working in the villages,even though we don’t get any support from thedistrict health office, the villagers would providefood to us. (IDI 3)

The two most important factors related to perform-ance were locality and staff assignment. Due to easierliving conditions and support from family, local staffmight perform better than non-local staff. The MOHmay assign a health worker to a less desirable area, evenif they are not qualified for that position out of necessitydue to the shortage of skilled health professionals. Inaddition, several participants mentioned other factorsthat impact performance including salary level, healthinsurance, housing conditions, and personal reputation.

Locality, is most important factor, they are close totheir family, they can help their family, they are livingin the village where the health center is located, sothey can go to the health center easily. (IDI 8)

Performance appraisal: lack of standardizedmeasurements and influences on health workersAccording to the discourse of policy makers, perform-ance appraisal was implemented at two levels: the insti-tutional level and the health staff level. The performanceappraisals of health facilities were conducted usingstandard checklists by external upper-level health ad-ministrative departments, mainly covering management,financial, and technical aspects. However, there was alack of consistent and detailed knowledge on the evalu-ation checklists. The performance appraisal reports werealso unavailable for us to review.One problem reported by some policy makers was

there was no standardized method of evaluating healthstaff; thus, health facilities were left to create their ownevaluation systems covering different aspects. One dis-trict hospital followed the evaluation system created byan international organization and adopted several di-mensions including clinical skills, interpersonal rela-tionship both with colleagues and patients, attendance,compliance with professional regulations, and attitude.Some health centers used the feedback from thecommunity, and some did not have any performanceappraisal at all.Most key informants indicated that performance

appraisal produced limited influences on health workers.Although there is a chance that employees may move upin rank sooner than the standard 2 years, this is only forthose deemed outstanding and it is uncommon. Ratherthan being terminated, poorly performing staff wererequired to reflect on their performance and weretrained on how to adjust their actions in the future. Poorperformance had few and only minor repercussions.

… normally every two years, you would be promotedone sub-rank, your sub-rank would be increased byone, but if your performance is outstanding, you havenever done any mistakes, the hospital would propose

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to the provincial health department, and then to theMOH, to upgrade your sub-rank of one, so instead ofwaiting for two years, you do it only one year, you getit only one year. (IDI 6)…so you ask about the impacts of the evaluation:there is no penalty the staff, we don’t fine the staff,once you are doing wrong, we would call that staff totell what you have been doing, that is the first stage,and the second stage is that, if the staff member needto write down what he had done wrong, then he mustpromise that he would not do it again, and he wouldchange his behavior, his performance; and if it is thethird stage, in two years, we would upgrade the rank,he would not be upgraded, but so far, there is nohealth work at stage 2 or 3, only stage 1. Andsometimes, the staff moves away to anotherdepartment, but it is very rare. (IDI 8)

Education and continuing education: completelyestablished but disconnected from health workforcedemandThe “Handbook of health professions and educationalprograms” indicates that the Lao People’s DemocraticRepublic has developed a complicated health professioneducational system, covering detailed core competencies,curriculum structure, and career options for each cat-egory [19]. The education system was designed to trainfour main classifications of staff including medical anddental staff, nursing and midwifery, and paramedicalstaff, as well as managerial and support staff [19]. Theformer three categories had five levels of education: lowlevel, middle level, high level, bachelor level, and post-graduate level [19]. The duration of programs variedamong disciplines from 2 to 6 years [19]. The policymakers reflected that the annual number of graduates inall categories was around 2000, from 10 health educationinstitutes (1 medical university, 5 health professionalcolleges, and 4 health schools).One problem mentioned by several policy makers was

that the training of low-level health workers has beendiscontinued since the government planned to improvethe education level of the health workforce by no longerproducing low-level health workers. Meanwhile, theexisting low-level health staff were required to upgradeeducation levels through continuing education courses.However, some current low-level health staff had diffi-culties in upgrading because they were elderly.Some of the education programs were provided to

current health workers as long-term continuing educa-tion programs but in shorter duration than the directentry programs. The short-term continuing educationprograms were conducted at four levels: health facility,district, provincial, and central levels. The programs atthe health facility level consisted of on-site training with

varied frequencies among facilities. The district-, provin-cial-, and central-level programs were held in the formof centralized training covering different topics. Someinternational organizations also provided trainings orfunding to support training programs. In addition, healthstaff would be sent to upper-level health facilities orother countries for long-term training, mostly dependingon scholarship opportunities. Most of the participantsheld positive perceptions on these programs and desiredmore training to improve knowledge and skills.In terms of continuing education, some key informants

reflected that attending continuing education programswere not obligatory for health staffs to maintain theirlicense. The service need of health facilities and theavailability of funding to support the training are the keyinfluencing factors. Participation in continuing educationprograms were occasionally offered to outstandinghealth staff as incentives.The main concern of most interviewees on medical

education was the disconnect between medical educa-tion and health workforce demand. The medical educa-tion programs were not based on the actual demand,and the students in health disciplines were trained inless relevant disciplines. Furthermore, health educationfacilities and teachers were lacking, and the studentseven did not have sufficient opportunities to conductclinical practices. Therefore, the medical educationprograms were limited in quality and insufficient to traincompetent health workers.

…so you accept 30 persons without planning, you justtrain and train without goal, what are you going touse these people to do, you don’t train according toyour need, what is why… (IDI 2)

Recruitment and hiring: highly competitive for limitedpositionsBoth the policy makers and administrative staff reportedthat there were two types of patterns to recruit healthworkers: top-down from the MOH and bottom-up fromwithin the health facilities. The top-down recruitmentincluded health staff who were sent from the MOH tohealth facilities. The procedure for top-down recruit-ment was to make an announcement, hold exams andinterviews for candidates, rank and recruit the eligiblecandidates based on available civil servant positions, andassign positions. The candidates were required to passan exam from the Ministry of Home Affairs and anexam from the MOH to work in the health sectors.Many participants said that locality was the key factorfor the MOH to allocate health workers to specifichealth facilities. Although the MOH considered thepreferences of candidates, they preferred to send thegraduates back to the health facilities in their home

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regions. The assignment of positions was mostly decidedby district health offices. Most of the top-down recruitedhealth personnel had civil servant positions.Bottom-up recruitment occurs when candidates who

could not obtain a civil servant position through theMOH apply directly to health facilities for contractpositions. Then the health facilities can apply for a civilservant position from the MOH for this staff, but thisprocess could take several years while the staff work in acontract position. Most medical graduates would applythrough the top-down system because they could dir-ectly receive the civil servant position with salary fromthe MOH rather than applying through the bottom-uppattern to get contract positions without salaries.Some administrative staff reflected that only about half

of the medical graduates could obtain civil servant em-ployment through the MOH and the rest usually becamecontract health staff in health facilities because thecurrent available civil servant positions are insufficientto absorb those already trained.

Mobility of health workers (attraction, retention, andloss): low attractiveness but good retention in primaryhealth facilities and rural areasMost key informants mentioned that many health pro-fessionals preferred to work in health facilities of thecentral or provincial levels rather than the primaryhealth facilities such as health centers or health facilitiesin rural areas. The low attractiveness of working in pri-mary health facilities and rural areas was a big concern.The reasons for this included the following: no housingsupplied to non-local health staff, poor living conditions,inconvenience in commuting because of the poor trans-portation system, and the lack of confidence to practicealone without supervision in rural areas. One participantshared that many new graduates felt challenged andunprepared to take positions in rural areas because theywere supposed to deal with all medical conditions inde-pendently, including very complicated medical cases.The health workers who were willing to take the posi-tions in rural areas were mainly because they were fromthe local, and they could gain the civil servant positionsthere.

… this is the experiences when we collected data inVientiane province, they don’t believe in themselvesto work in the rural area, because the new graduates,you need to “wear many hats” in the rural area, “I ama medical doctor, I am not a surgeon, I am not apediatrician”, but when you are posted in a healthcenter, when the patient comes, you can’t say no, Ican’t do with that”, you have to be able to…evenoperate on the patient, that is why they are notconfident… (IDI 11)

Most interviewees agreed that the general retention ofhealth workers was good, including the health workersin rural areas. Health workers who had local familiesand had developed good relationships with patients andlocal communities were more likely to stay in theirpositions. Some health workers regarded the stability ofcareer and the reputation in society as important forretention. Moving with family was the primary reasonfor health staff to change their jobs. One MOH staffrecommended providing bonuses and supportive super-vision in medical practices to rural health workers tobetter support them working in remote areas.

Insufficient financial support for the health workforce andfor health facilitiesMost key informants stated that the main financial supportfor operation of health facilities came from the government,including costs of health personnel salaries, on-call pay-ments, infrastructure, and basic medical equipment. Thefunding for outreach services in health centers came mainlyfrom the district government. In addition, some inter-national organizations or companies fund health facilitiesfor outreach services or specific health promotion events.The funding for outreach services or health promotionevents was allocated quarterly and required health centersto submit plans including their budget.

…before, we got the budget from two sources, onewas the district health office, the other from the LaoLuxemburg Development Organization, this is incollaboration between Lao government and Luxemburggovernment, they provide the funds quarterly,depending on the activities of health centers, sowhen you have activities, you write down your plans,then you submit your plans to the Lao-LuxemburgDevelopment Organization, when they check andapprove, so they provide the funding supportaccording to the activities. But currently we getfrom one source, the district health office. (IDI 3)

Most key informants considered the insufficient budgetfor the health workforce to be a problem. The governmentcould not afford sufficient civil servant positions to hire themedical graduates, and the salary and incentives providedto current health workers were insufficient. Simultaneously,most directors of health facilities stated that the financialsupport from the government was also insufficient, so thisbecame a key constraint for health facilities to providehealth services with a limited budget. Health centers coulduse the profits from sale of medications or from chargingpatients for services to pay for utilities or incentives tohealth workers. However, the usage of profits more than 1million kip (≈120 US dollars) per month required theapproval from the district health office.

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One administrative staff member reported that therewas poor integration between external funding frominternational organizations or companies and the gov-ernment, which led to the funding not being spentwisely. The external funding from international organi-zations or companies and government funding werespent on similar activities without coordination so theyduplicated efforts, indicating the poor capacity of fund-ing management.

…the World Bank provided the money for the perdiem, for food, accommodation if they stayedovernight in the community for outreach work, andtransportation means fuel to the outreach team, andthe outreach team would ask them to integrate withthe routine of the government, that was the districtplan to go every 3 months, that means 4 times a year,in order to cover the immunization and the VitaminA supplementation, and the MCH. But instead ofdoing so, the government didn’t put the moneytogether to run outreach activity services and worldbank went this time, so the government went againusing the governmental money for the same, and theycame back, the next week, they would go with otherfunding, you see… (IDI 7)

DiscussionThe interrelationships among the problemsThe key aspects explored in the IDIs provide a pictureof the current status of the health workforce in theLao People’s Democratic Republic and reflects theproblems of the health workforce using the workinglife-span framework. The perceived overarching prob-lem is that there is a severe deficit of skilled healthworkers (doctors, nurses, and midwives) and lab tech-nicians, especially in primary health facilities and ruralareas. This deficiency is related to five main problemsdiscussed by the key informants. First, the productionof health workers is insufficient both in quantity andquality. Second, the national budget is inadequate torecruit enough health workers and provide sufficientand equitable salaries and incentives to them and thepayment is often delayed. Third, the health workforcemanagement is weak, and this lack of capacity is amajor barrier to support the health workforce. Fourth,while rural areas have good health workforce reten-tion, especially among the health workers of local ori-gin, these areas are not attractive to most outsiders.Last but not least, there is a lack of well-developedcontinuing education programs for professional devel-opment. These problems are interrelated, both in howthe issues arise and in the effect they have on oneanother. (The five main problems are marked in redboxes in Fig. 4.)

There are two possible reasons for the insufficient pro-duction of health staff both in quantity and quality. As aconsequence of inadequate capacity in health workforcemanagement, no appropriate assessment is adopted inhealth workforce planning to reflect the real demand forhealth workers. Thus, the medical education programsare not based on the real demand, and most of them areinadequate to produce health workers with adequateknowledge and skills. This is especially true for thosewho are to practice in rural areas where health workersare required to deal with all medical conditions inde-pendently. Meanwhile, the available number of healtheducation facilities and teachers is insufficient to traincompetent health workers, but this situation is disre-garded during the recruitment of new students.The MOH has limited budget to recruit all new gradu-

ates as civil servant health workers and to supply suffi-cient salary and incentives. As a result of this, almost halfof new graduates are forced to work as contract healthworkers who receive low and unstable payment. Addition-ally, salaries and incentives are often delayed for monthsbecause of the inadequate capacity in financial manage-ment and complicated processes for fundraising and ap-propriations. The insufficient and delayed payment forceshealth personnel to depend on their families; therefore, lo-cality becomes a significant factor in attraction and reten-tion, especially in rural areas.There are four potential reasons for the low attraction

of working in primary health facilities and rural areas.There is no housing supplied to non-local health staff,poor living conditions, and inconvenient commutingbecause of the poor transportation system. Furthermore,the health workers may lack confidence to practice alonewithout supervision in rural areas.In addition, the current performance appraisal system

does not notably encourage health personnel to improvetheir performance and filter out poorly performing staff.

Priorities to strengthen the health workforceTailored and integrated interventions to address unevendistribution of health workersUneven distribution between urban and rural regionsshould remain a policy priority for improving the healthworkforce in the Lao People’s Democratic Republic sincethe shortage of qualified health personnel in remote andrural areas can hinder a large proportion of the popula-tion access to health services and lead to disparities inhealth outcomes between those in rural and urban areas[20, 21]. Many countries have a similar maldistributionproblem and emphasize the training of more rural healthworkers. However, experiences from other countriesshow that production of more medical staff is insuffi-cient to improve the distribution of health personnel. InNepal, new medical schools were opened to increase the

Qian et al. Human Resources for Health (2016) 14:72 Page 9 of 13

supply of rural health workers, but this leads to overpro-duction and emigration of medical students [21]. Chinalaunched a rural doctors project to improve the staffing ofrural health centers in 2010, providing candidates with ascholarship package including free tuition, room, and livingexpenses but requiring them to serve 6 years at their localhealth center. However, there was a high turnover rateamong the graduates in this program, who were stillattracted to work in upper-level health facilities in urbanlocations [22]. The Indonesian government implemented acompulsory services project to increase the health workersin rural areas, which found that female candidates were lesslikely to be prepared to serve in remote areas even if theywere paid double the salary of health staff working in urbanareas [23, 24]. These suggest that increased productionshould be combined with retention strategies.The Lao People’s Democratic Republic has its own

specific characteristics and determinants, which shouldbe taken into consideration for HRH strategy develop-ment to ensure that the choice of interventions istailored to the local context. As discussed earlier, it isnot so attractive to work in rural regions but there is stilla fairly good retention of health workers in these re-gions. Therefore, it may be practical to admit morestudents with rural backgrounds because personal originis a key factor both in attraction and retention for theseworkers in rural regions. In addition to the factors onlow attraction identified in this study, it has also beenhighlighted in previous reports that new graduates of

health-related disciplines prefer to work in upper-levelhospitals in cities rather than in health centers in rurallocations because they have more part-time job op-portunities there to complement the low salaries fromgovernment employment [6, 10].Interventions providing extra incentives in rural areas

are another possible strategy to encourage non-localhealth workers to practice in rural regions. Further-more, the government might also consider the adoptionof clinical rotations in rural areas while the students arestill in school. Revision of curricula that reflect ruralhealth issues would help students to develop the confi-dence to practice in rural locations and to be familiarwith the medical problems in rural areas. For currentrural health workers, concerns about maintenance ofknowledge and skills should also be considered becausesuch skills might regress due to shortage of supervisionand relative isolated practicing environment. Therefore,continuing education programs should be developed forhealth personnel in rural regions. It is likely more effect-ive to implement a well-designed integration of inter-ventions including both short-term and long-term onesrather than introduce interventions in an uncoordinatedand ad hoc fashion.

Improving the health management capacity at the sub-national levelsThe inadequate health management capacity especiallyat the sub-national levels explored in this study is also

Fig. 4 Interrelationships among key problems in the health workforce in the Lao People’s Democratic Republic. Note: skilled health workers:including doctors, nurses, and midwives; PHC primary healthcare

Qian et al. Human Resources for Health (2016) 14:72 Page 10 of 13

important since implementation of health workforceinterventions relies strongly on competent human re-source management [20]. One possible reason for weakhealth management capacity at the sub-national levels inthe Lao People’s Democratic Republic could be that themajority of provincial and district health managers aremedical doctors without appropriate management train-ing [10]. Another important reason reported was thedecentralization of the health system had happenedfaster than local management capacity building. Re-lated to this, there is also a lack of support from thecentral level, i.e., there were no guidelines providedon how to plan and budget at the sub-national levelfor provincial and district managers for many yearsafter the health system was decentralized [6]. There-fore, resources need to be invested for improvinghuman resource management capacity at all levels. Inrural areas, supervision capacity for creating a sup-portive working environment to retain health profes-sionals needs to be improved through managementdevelopment initiatives.

Strengthening the evaluation of interventions implementedThe Laotian government has implemented certain inter-ventions to address the problems in the national healthworkforce. The government issued the HRH policy in2006 to provide incentives for attracting and retaininghealth workers in remote areas with specific reference tothe 47 poorest districts [25]. Moreover, the training ofhealth workers was decentralized to the provinces in orderto promote the recruitment and retention of staff closer totheir homes in 2009 [6]. In 2012, the governmentlaunched a new policy which required medical graduatesin medicine, nursing, midwifery, pharmacy, and dentistryto compulsorily serve for 3 years in rural areas before theyget licenses to practice [26]. This policy also provides in-centives to well-performing health staff in rural areas andattracts new graduates to continue their service providingin the rural area after the required service [26]. The gov-ernment plans to gradually increase the number of civilservant positions in health facilities, especially for ruralsites, and provide civil servant positions to the currentcontracted health workers; the number of new positionswould be 4000 in 2013. However, there is so far no moni-toring or evaluation plan in place. Interventions may havedifferent impacts when they are implemented at differentsites, and the implementation of experiences from othercountries into the Lao People’s Democratic Republic maylead to unexpected outcomes. Appropriate monitoringand evaluation should be considered an essential aspectbecause the experiences and lessons generated from theintervention implemented in the Lao People’s DemocraticRepublic could be very valuable.

Strengths and limitationsThis is the first study using qualitative methodology toexplore and better understand the problems related tothe health workforce in the Lao People’s DemocraticRepublic. A range of different key stakeholders withinsights into the health workforce issues in the LaoPeople’s Democratic Republic was included, and theirrich perspectives were captured. Ten topics extractedfrom the working life-span framework were adapted intotopic guides and probed to gather comprehensive infor-mation on the health workforce.Several limitations should be mentioned. Local key

informants from three districts of two provinces wererecruited in this research because of the financial andtime constraints, some information on the localcircumstances may not represent the whole country, butsufficient qualitative information on the national situationof the health workforce was collected from other key in-formants. Additionally, an interpreter was employed dur-ing the in-depth interviews, and it was sometimes difficultfor the interpreter to summarize all participant responses.Most IDIs were audio recorded so that the main responseswere still captured. In addition, questions on monitoringand evaluation from the topic guides created very littlediscussion. It may be more appropriate to use quantita-tive methods to collect evaluation-type data or analyzeexisting data.

ConclusionsThis study has identified the problems and challenges forthe health workforce in the Lao People’s DemocraticRepublic and explored underlying causes and interrela-tionships among the problems. It is necessary to under-stand this situation and the key challenges relating to thehealth workforce in the Lao People’s Democratic Republicbefore implementing new policies and interventions.To improve the distribution of health workers in rural

areas, strategies of increasing production and strength-ening retention should be well integrated for bettereffectiveness. Meanwhile, it is essential to take Laotian-specific context into consideration during interventiondevelopment and implementation. Furthermore, the gov-ernment should acknowledge the inadequate healthmanagement capacity and invest resources to improvehuman resource management capacity at all levels. Inrural areas, the supervision capacity for creating a sup-portive working environment to retain health profes-sionals also needs to be improved through managementdevelopment initiatives. Also, assessment of interven-tions of health workforce strengthening should be devel-oped as early as possible to synthesize the experiencesand lessons in the Lao People’s Democratic Republic.Due to the complexity of this issue, one study is not

sufficient. More quantitative and qualitative studies are

Qian et al. Human Resources for Health (2016) 14:72 Page 11 of 13

required to better and more comprehensively describeand understand the health workforce situation in theLao People’s Democratic Republic. As the Lao People’sDemocratic Republic strives to improve its health work-force, research should also focus on and evaluate theeffectiveness of implemented interventions.

Additional files

Additional file 1: The structure of healthcare facilities in the LaoPeople’s Democratic Republic, 2012. The number of healthcarefacilities at different levels in the Lao People’s Democratic Republicin 2012. (DOCX 12 kb)

Additional file 2: The main points for probing in topic guides. The mainpoints included in the topic guides to cover the key aspects in theworking life-span framework. (DOCX 15 kb)

AbbreviationsDHOs: District health offices; IDI: In-depth interview; MOH: Ministry of Health;NIOPH: National Institute of Public Health (Lao People’s DemocraticRepublic); PHC: Primary healthcare; PHOs: Provincial health offices;WHO: World Health Organization

AcknowledgementsOur most sincere appreciations go to all key informants who participated inthis study. Special thanks go to Prof. Shenglan Tang and Prof. Xu Qian forfacilitating the collaboration between the National Institute of Public Health,Duke Global Health Institute, and Fudan Global Health Institute.

FundingThis study was partly funded by Fudan Global Health Institute and Duke GlobalHealth Institute for study design and data collection. Yi Qian was also supportedby a scholarship from the China Scholarship Council for writing this manuscript.

Availability of data and materialsData sharing not applicable to this article as no datasets were generated oranalyzed during the current study.

Authors’ contributionsYQ was involved in the study design, the recruitment of the key informants,the facilitation of the interviews, analysis of the transcripts, and writing of themanuscript. FY was involved in the study design, participated in thefacilitation of the interviews, and commented on the draft. WW was involvedin the study design, participated in the recruitment of the key informants,and facilitated the interviews. SC supported the analysis of the transcriptsand was involved in the drafting of the manuscript. KA helped to recruit thekey informants, supported the interviews, and commented on themanuscript. MV helped to recruit the key informants, participated in theinterviews, and commented on the manuscript. SO participated in theinterviews as an interpreter and counterchecked the transcripts. TO wasinvolved in the study design and the writing of the manuscript. All authorsread and approved the final manuscript.

Competing interestsThe authors declare that they have no competing interests.

Consent for publicationNot applicable.

Ethics approval and consent to participateEthical approval was obtained from the Ethics Committee of the School ofPublic Health of Fudan University (Reference number: IRB#2014-09-0532). Theparticipation in the study was voluntary, and participants were assured ofconfidentiality. All participants agreed to take part in the study and signedinformed consent forms, and permission for audio recording was obtainedfrom all participants before the IDIs. All paper data and digital data wereappropriately stored under lock or password protected.

Author details1Department of Social Medicine, School of Public Health, Fudan University,138 Yi Xue Yuan Road, Shanghai 200032, People’s Republic of China. 2FudanGlobal Health Institute, Fudan University, Shanghai 200032, People’s Republicof China. 3Key Laboratory of Health Technology Assessment (Ministry ofHealth), Shanghai 200032, People’s Republic of China. 4Department ofCommunity and Family Medicine, Duke University, Durham, NC, UnitedStates of America. 5National Institute of Public Health, Vientiane Capital, LaoPeople’s Democratic Republic. 6Center for Aging Research and Education,Duke-NUS Medical School, Singapore, Singapore. 7Duke Global HealthInstitute, Duke University, Durham, NC, United States of America.

Received: 12 February 2016 Accepted: 19 November 2016

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