Policy Brief Toward Sustainable Financing for Immunization Coverage in Lao PDR Key Messages Despite robust economic growth and sig- Spending on routine immunization in Lao nificant improvement in infant and child DPR has increased considerably from less mortality rates as well as a reduction of than US$4.3 million in 2010 to US$24.8 vaccine-preventable diseases, Lao PDR still million in 2016 and is expected to increase has one of the highest levels of child mor- further as the country expands coverage tality in Southeast Asia. Inequities are also and introduces new vaccines (HPV and ro- pronounced, with disparities in child health tavirus). To date, the increased spending outcomes across socioeconomic groups, by has largely been made possible due to fund- ethnicity, geographic location, and educa- ing from Gavi, the Vaccine Alliance, which tional level of mothers. supported more than half (52 percent) of financing for new and underused vaccines There has been a steady improvement in in the country between 2010 and 2014, and immunization coverage since 2010. Accord- also is providing support for health systems ing to the latest available WHO-UNICEF strengthening (HSS). However, in 2017, Lao estimates, immunization coverage rates in- PDR entered the final phase of Gavi sup- creased for DTP3 from 74 percent in 2010 port, known as the Accelerated Transition, to 82 percent in 2016; and the coverage of and will fully transition from Gavi support in single measles vaccination at nine months 20222. Thus, the share and scope of domes- increased from 64 percent in 2010 to 76 tically financed immunization expenditure percent in 2016. will need to increase significantly over the next five years. However, wide inequities remain in im- munization coverage across economic, As in many other countries, priority pro- urban-rural, geographic, and ethnic di- grams such as the Expanded Program on mensions. The immunization coverage for Immunization (EPI) have set up their own the poor is less than one-half that of the structures and program functions to ensure richest income group (MoH and Lao Sta- coverage and quality of services in a con- tistics Bureau, 2012). There is a high drop- text of health system weaknesses. While out rate for immunization, especially in such earmarked structures may be neces- rural areas with predominantly ethnic sary at the introduction of a new program minority populations. Coverage of routine and when the general health systems are immunizations1 ranges from a low of 21.1 less then optimally developed, such struc- percent in Phongsaly province to a high of tures are justified only for specific purposes. 79.0 percent in Xayabury province. For example, campaigns to increase cov- 1 BCG, Polio (1/2/3), DTP, HepB, HiB, Measles (one dose). 2 Countries enter the final phase of Gavi support once they have exceeded a GNI per capita of US$1,580 on average over the previous three years. 2 LAO PDR: Toward Sustainable Financing for Immunization Coverage erage of Polio or Measles vaccination are which has historically been low, will become necessary to ensure high enough coverage particularly important. Specifically on im- to protect the population from public health munization, Lao PDR has begun the process outbreaks, but other program functions such of transitioning from Gavi support. From an as M&E, Financial Management and Supervi- external financing perspective, a major chal- sion, when set up separately, lead to ineffi- lenge for Lao PDR is to continue expanding ciencies and duplications and create parallel the content and service coverage for key systems for financing and service delivery health programs such as immunization that over the long term. have been traditionally financed externally while maintaining quality and coverage. A As Lao PDR prepares to transition from Least managed transition is vital for financial and Developed Country (LDC) status by 2020 to programmatic sustainability as external become an upper-middle-income country funding reduces. Mainstreaming of vertical by 2030, it also expects to face declining program structures into one coordinated external financing more generally, and from health system would reduce the duplica- bilateral donors in particular. At the same tion of program elements such as program time, the country is trying to move toward management, outreach, supply chain man- covering the entire population with a basic agement, financial flow, supervision and package of health services. Thus, the need management information systems, thereby to increase domestic financing for health, increasing efficiency and sustainability. LAO PDR: Toward Sustainable Financing for Immunization Coverage 3 In moving forward, several possibilities to streamline and sustain the immunization pro- gram in relation to strengthening the overall health system were identified through this immunization assessment and are recommended as priority areas for action both at sys- tem and program levels: • Ensure adequate and sustainable financing for immunization within the context of sustainable financing for UHC. • Increase efficiencies by mainstreaming the separate EPI structures (likewise also for any other vertically managed programs) such as: (i) integrate EPI data as part of the national Health Information Management System (DHIS2); (ii) harmonize financial flow and management reporting and align it with the gov- ernment’s financial management information system; (iii) mainstream supply chain management; (iv) implement fully integrated outreach steadily through integration/mainstreaming of EPI and MCH services; and (v) merge existing supervisory guidelines for MCH and EPI and provide integrated supervision in order to eliminate unnecessary duplication and increase efficiency. • Improve coverage and increase equity of access to basic services such as immu- nization, through: (i) focused support (financial and technical) to districts with less than average service coverage; (ii) ensure adequate MCH home records at every service delivery level to cover the annual cohort of children to be immu- nized; (iii) conduct operations research to identify the most effective and effi- cient mix of facility-based and outreach services; and (iv) undertake a study to understand basic demand-side service constraints. Objective of the Policy Brief This brief draws from the World Bank re- arching objective of the report is to in- port, Managing Transitions: Reaching form the development of short-term and the Vulnerable while Pursuing UHC in Lao longer-term health financing strategies PDR (World Bank, 2017b) which includes and reforms aimed at sustaining progress an in-depth assessment of the immuniza- towards UHC. This policy brief aims to iden- tion program. The diagnostic assessment tify key bottlenecks for service delivery and protocol identified critical constraints and sustainability challenges of essential health opportunities facing the health financing services using immunization services as a system in the context of UHC. The over- tracer. LAO PDR: Toward Sustainable Financing for Immunization Coverage 5 Background Lao PDR has enjoyed robust economic and Whooping Cough from rank 18 to rank 34. growth supported by the resource sector and continued domestic and foreign direct Despite these improvements, the coun- investment in recent years. By 2011, the try has the highest child mortality level country had reached the status of a lower- in Southeast Asia and the national av- middle-income country. GNI per capita and erage conceals high levels of disparities GDP per capita have continued to increase in child mortality across socioeconomic and reached US$2,353 and US$2,150 re- groups, by ethnicity, provinces, and edu- spectively as of 2016. Strong economic cational level of mothers. Each year, an growth has been accompanied by a signifi- estimated 16,000 children die in Lao PDR cant decline in poverty rates. The national before reaching their fifth birthday. The poverty rate declined from 33.5 percent in majority of these deaths occur among the 2002 to 23.2 percent in 2012. The country poor and disadvantaged populations and is making good progress toward attaining are due to just a few preventable and treat- the Eighth National Socio-Economic Devel- able conditions. There is thus a need to un- opment Plan (NSEDP) outcomes to ensure derstand the causes of unjust disparities Lao PDR graduates from Least Developed and urgently tackle the barriers to equity of Country status by 2020. The country is also access to basic health services. addressing the unfinished agenda of the Millennium Development Goals (MDGs), and delivering early progress on the Sustainable Development Goals (SDGs), including UHC. Between 2000 and 2015, Lao PDR re- corded a significant decline in infant and under-five mortality rates. The infant mortality rate decreased from 83 in 2000 to 51 in 2015, while the child (under-five) mortality rate dropped from 118 to 67. Sub- stantial progress has been made in the re- duction of vaccine-preventable diseases. The share in the disease burden of, for ex- ample, Measles, Tetanus, and Whooping Cough, decreased from 9.60 percent, 2.72 percent, and 0.97 percent to 0.24 percent, 0.10 percent, and 0.54 percent respectively between 1990 and 2016. Measles fell from rank 3 in causes of death and disability to rank 74; Tetanus from rank 8 to rank 99; 6 LAO PDR: Toward Sustainable Financing for Immunization Coverage Immunization Coverage Lao PDR provides the standard “routine” nation (due to multi-injections per visit), and immunizations (DTP3, BCG, TT2, OPV, the higher cost of both vaccines and service HepB, HiB) and, since 2001, six additional delivery. antigens (Pentavalent, PCV, IPV, MR, JE, Seasonal Influenza campaign, and HPV There has been a steady improvement in demo). Furthermore, the introduction of immunization coverage since 2010 but HPV and rotavirus vaccine is currently be- coverage still lies below that of countries ing planned for 2018/19 by the National at similar income levels. According to the Immunization Program (NIP). While this latest available data (WHO and UNICEF, will address the high disease burden, the 2017a), immunization coverage rates in- affordability and challenges must also be creased steadily for DTP3 from 74 percent considered. Additional vaccines will present in 2010 to 82 percent in 2016; and for mea- a challenge due to the lengthy vaccination sles from 64 percent in 2010 to 76 percent schedule, issues in supply-chain manage- in 2016 (Figure 1). However, compared to ment, more diversified target population, other countries at similar income levels, potentially higher reluctance against vacci- coverage is much lower. Figure 1: Measles Immunization Coverage (2010 versus 2016) Source: Reproduced from World Bank 2017a (based on, WHO and UNICEF, 2017). Note: x axis in log scale. LAO PDR: Toward Sustainable Financing for Immunization Coverage 7 Economic, urban-rural, geographic and of children who do not complete the full vac- ethnicity-related inequalities in immuni- cination schedule, especially in rural areas zation coverage rates are widespread. The with predominantly ethnic minority popu- wide differences apply to income groups lations. There are also wide differences be- where the immunization coverage for the tween provinces in immunization coverage. poor is less than one-half that of the rich- The coverage rate ranges from 21.1 percent est income group (MoH and Lao Statistics in Phongsaly province to a high of 79.0 per- Bureau, 2012). There is a high dropout rate cent in Xayabury province (Figure 2). Figure 2: Routine Immunization Coverage by Province (2011-12) (%) Source: MoH and Lao Statistics Bureau, 2012. Note: Xaysombourn was only established as a separate province in November 2013; EPI data from the area now covered under Xaysombourn is included above under Vientiane and Xiengkhuang provinces. Accurate reporting of immunization cover- immunization. Based on evidence from all age is a challenge in Laos and there is wide sources (home-based vaccination cards, variability across data sources. Survey health facility records and caretaker recall), data from the 2015 National Immunization the coverage was 81.4 percent for the third Survey shows that, of the 5,981 children dose of Pentavalent vaccine (including DTP/ between 12 and 23 months surveyed, 91 HepB/HiB), while 63 percent were fully im- percent had received at least one routine munized with the required antigens for that vaccination, but only 29.7 percent of these age-group and 9 percent had not received children had valid documentation for their any vaccination. 8 LAO PDR: Toward Sustainable Financing for Immunization Coverage Immunization Service Delivery Immunization services are provided at all health service levels–at provincial and dis- trict hospitals as well as health centers, through a mix of fixed site and outreach ser- vices that depend on the distance of the com- munity from a health facility. Facility-based immunization services are provided to vil- lages located 5 km or less from a facility and are part of the integrated MCH ser- vices, which means that immunization services are delivered at the same time as other interventions. Villages further from the health center (5-10 kilometers or more than one hour) are provided immunization through outreach services that are provid- ed by health center staff once every three months. Immunization outreach services While immunization outreach has often account for about 58 percent of the first been provided as a vertical service, efforts and 86 percent of the second measles vac- have increased to provide additional MCH, cine. Due to the geography of the country, a family planning and nutrition services dur- large number of villages can only be reached ing such outreach. Such integrated out- through outreach and, in several cases, reach for provision of a package of multiple health staff have to walk to the villages and health services including immunization is stay overnight in order to cover all children currently being rolled out. The full package within the target area. This is especially of services now includes ANC, PNC, family problematic for health centers that do not planning and child-growth monitoring, in have a functioning cold chain since the staff addition to (i) immunization for all children first have to travel to the district health of- aged under two years; (ii) Tetanus Toxoid fice to collect the vaccines and then to vil- immunization for women aged 15-45; (iii) lages which may be a full day’s travel from iron-folic acid tablets for pregnant women the health center. On return, they again and postpartum women; (iv) deworming have to travel to the district heath office to and Vitamin A supplementation twice per return unused vaccines which have by then year; and (v) health education. Growth mon- been kept in a cold box for two to three days. itoring and promotion is added for facilities This places an additional time constraint on with sufficient number of health staff and the already limited number of staff avail- capacities. able at the health centers. LAO PDR: Toward Sustainable Financing for Immunization Coverage 9 Bottlenecks to Improving Outreach Service Delivery A rapid field assessment conducted by the World Bank highlighted key bottlenecks re- lated to mainstreaming immunization out- reach both at system and program levels. The main findings from the rapid assess- ment include: limited understanding of the guidelines for microplanning of integrated MCH and immunization services; different incentives for conducting outreach for im- munization and MCH; and considerable var- iations in how these payments are managed across provinces and districts. These findings support other studies in Lao PDR indicating poor service delivery readi- ness. According to one survey,3 99 percent A UNICEF-supported equity and bottleneck of the facilities surveyed were providing analysis carried out in 2013 and 2014 found routine immunization, but only 49 percent that the “bottlenecks to equity of service had the required medicines and supplies access” ranged from purely economic issues available for immunization and no facilities to psychological and faith-based barriers fulfilled all requirements (staff and guide- in both the demand and supply of services. lines, equipment, medicines and commodi- The factors contributing to vaccination re- ties) for immunization. sistance included: local culture of not using modern medicine; fear of side-effects; no A small study (Mobasser et al., 2016)4 found knowledge about the benefits of immuni- that outcome measures of immunization zation; being away from home during the (and growth monitoring) were significantly agricultural season; and not being informed predicted by distance to the nearest health or being informed too late about immuniza- center or hospital, mothers’ contact with tion activities. Deeper insights into the is- health professionals (both antenatal and sues confronting underserved populations during childbirth), and ethnic group mem- requires qualitative research as a tool to bership. The strongest individual predictor expose and share with others the undercur- was, however, the possession of the immu- rents of not just the health-seeking behav- nization card, which is often found to be out ior of communities but also the health pro- of stock at the health facility level. viders’ cross-cultural communication skills. 3 MoH, 2014. Laos Service Availability and Readiness Survey 2014. 4 The study was carried out in collaboration with the Swiss Red Cross in the rural districts of Luang Prabang province and collected information on the influence of a number of family factors, including whether fami- lies owned a yellow card. 10 LAO PDR: Toward Sustainable Financing for Immunization Coverage Immunization Financing in Lao PDR Overall spending on routine immunization while the actual government immunization has increased significantly from less than spending share was 5.2 percent of total US$5 million annually in the 2007-13 pe- government expenditure on health. The cost riod to US$24.8 million in 2016 (Figure 3). of vaccines (US$11.4 million) accounted for This corresponds to 12.4 percent of total 45 percent of total expenditure on routine government expenditure on health in 2016, immunization in 2016. Figure 3: Overall Expenditure for Routine Immunization (2006–16) Source: WHO and UNICEF, 2017b. The most important feature is the remark- ture, the spending on vaccines itself has in- able increase in expenditure since 2014 creased more than fourfold between 2013 compared to the preceding years, both in and 2016, mostly due to the introduction terms of total immunization expenditure of new vaccines (such as the Pneumococcal and in expenditure financed domestically. vaccine in June 2014). The share of expendi- Between 37 and 48 percent of the total im- ture on vaccines financed domestically also munization expenditure was financed by the went up, showing an increase from under Government of Lao PDR (GoL) during 2014- 10 percent in previous years to 12, 23 and 16 (up from an average of around 7 percent 24 percent in 2014, 2015, and 2016 respec- in earlier years). Within the total expendi- tively. LAO PDR: Toward Sustainable Financing for Immunization Coverage 11 The immunization program has been tion program in Lao PDR during 2016-20 is largely dependent on funding from exter- projected to be US$90.5 million–fluctuat- nal sources accounting for 76 percent of ing around US$18 million annually (this ex- the total spending on immunization in Lao cludes operational costs of HPV operational PDR over the period 2010-14. The largest cost and all costs of the Rotavirus vaccine). share of this (22 percent of total spending Most of the increase in annual costs over between 2010 and 2014 and 29 percent of the projection period compared to the base- external spending) was provided by Gavi. line year (2014, US$16.3 million) is explained Other development partners include US by the intended scale-up of immunization CDC, UNICEF and WHO. For the 2016-20 coverage rates. Over the whole projection period, the World Bank, in partnership with period there is expected to be a funding gap the Government of Australia and ADB will of around US$38 million (42 percent of the provide additional resources which can be total resource need) with a projected annual used for operational costs. Spending is ex- funding gap between projected resource pected to increase further in coming years, needs and expected funding fluctuating be- driven mainly by the higher share in domes- tween US$7 million and US$8 million. The tically financed vaccine procurement, the largest share of the required resources is ex- increased routine operational costs due to pected to be financed by GoL. The cofinanc- the expansion of coverage and services in ing requirement for Gavi vaccines is expect- remote areas and for underserved popula- ed to increase from US$750,000 in 2018 to tions, and the additional two new vaccines US$1.3 million in 2019 and to US$2.1 million planned from 2018/19. in 2020.5 The GoL now pays for vaccines, injection The combined cofinancing requirements supplies, personnel salaries, transporta- for Gavi vaccines and those for the Global tion, maintenance and overheads, and Fund over the next three years will amount program management. The GoL began fi- to US$8.7 million required from GoL; this is nancing vaccines in 2012, and it has rapidly expected to increase further thereafter. increased its vaccine financing share (tra- When combined with other cost pressures ditional and cofinancing of new Gavi-sup- from within the health sector and beyond, ported vaccines) from about US$125,000 in this phase of transition requires careful 2012 to over US$1.1 million in 2015-16 (Gavi planning to ensure sustainable domestic re- Vaccine Alliance, 2015). Vaccines were pro- sources for externally financed programs in- cured with financial support from the Japan cluding immunization during the transition International Cooperation Agency (JICA) period and beyond. Given the need to plan until 2007 and then by UNICEF and LuxDev. carefully and ensure sustainable financing for UHC in the context of transitions, it is According to the cost projection under- important that the assumptions made in taken in the Lao PDR’s Comprehensive the cMYP process and the projections for Multi-Year Plan (cMYP) for Immunization, resource requirements are accurate and up- 2016-20, the total costs of the immuniza- dated as necessary. 5 The estimated cofinancing requirement for Gavi does not include the additional cofinancing requirement associated with introduction of new vaccines, except HPV routine vaccination, that are under considera- tion. 12 LAO PDR: Toward Sustainable Financing for Immunization Coverage Key Policy Recommendations The immunization program in Lao PDR fac- (iii) introduction or expansion of ear- es two immediate challenges: (i) to ensure marked consumption and income tax- adequate financing for the immunization es, including social health insurance. program within the context of declining Pros and cons as well as viability of external funding; and (ii) to reduce inequi- policy options to increase fiscal space ties in access to immunization and ensure need to be carefully analyzed. high coverage in all parts of the country and • Understand existing bottlenecks in across socioeconomic sections of society. It increasing public financing for health. is, therefore, necessary to mainstream as Efficiency in health spending can be many aspects of NIP as possible, so as to one of the most important factors for reduce operational costs while retaining a realizing fiscal space for health. focus on quality and equity of access. Through this immunization assessment, the Key recommendations toward ensuring following areas were identified for improving adequate and sustainable financing for the efficiency by mainstreaming EPI activities: immunization program include: • Harmonize financial management re- • Ensure adequate financing for the porting for EPI and align it with the immunization program in the broad- government financial management er context of sustainable financing information system. for UHC. Policy options to increase • Fully integrate EPI data into the na- domestic financing to replace exter- tional Health Information Manage- nal sources should not be considered ment System (DHIS2) and discon- program by program, but need to be tinue separate recording at facilities. assessed comprehensively as domes- This will decrease the workload in the tic resource mobilization for UHC. field while providing quality data for • Assess fiscal space for UHC and program management. The DHIS2 evaluate viable policy options to in- is increasingly providing robust data crease public financing for health in from all provinces. EPI data is already an efficient, equitable and sustain- included in DHIS2, while the EPI pro- able manner. Increases in public fi- gram continues to use their separate nancing, or “fiscal space” for health recording system. This causes double can potentially be realized through: work at the facility level. Integration (i) sustained economic growth and will also solve the issue of different increases in general government rev- reporting dates leading to differences enues; (ii) greater prioritization given in numbers reported between the two to health in government budgets; and, systems. LAO PDR: Toward Sustainable Financing for Immunization Coverage 13 • Mainstream supply chain manage- The following areas were identified to in- ment, including the supply of EPI com- crease coverage and reduce inequities: modities into one integrated supply chain management system that uses • Conduct operations research to iden- IT for commodity forecasting and tify the most effective mix of facility- management at least down to the dis- based and outreach services. trict level. • Undertake a study on EPI and oth- • Implement a merger of EPI and MCH er basic demand-side service con- services into an integrated outreach straints. service. The EPI has, until recently, • Shift from input-based to perfor- provided separate outreach services mance/results-based planning and every quarter. It has recently been de- financing for greater focus on results. cided to merge EPI and MCH services This shift has been introduced with to form integrated outreach. During co-financing from the Government of field visits it was found that a number Australia through the disbursement of facilities continue to provide sepa- linked indicators (DLIs) under the rate EPI outreach sessions and that World Bank-supported Health Gov- some are only merged with family ernance and Nutrition Development planning services. Effectively imple- Project (HGNDP) which, under the re- menting integrated outreach services cently approved additional financing across the country has the potential includes a specific DLI to incentivize to substantially increase availability increased immunization coverage in of EPI as well as MCH services. the 50 underperforming districts. • More specifically merge the super- This results-based design also cre- visory guide for MCH and EPI to in- ates incentives for higher coverage crease efficiency and save cost. and frequency of integrated outreach • Ensure that adequate MCH home re- services, and to increase non-salary cords to cover the annual cohort of health recurrent expenditure at the vaccinated children are locally avail- district level. The use of performance- able. In the context of integrated out- based financing to strengthen im- reach, studies in Lao PDR (as well as munization and other priority ser- globally) show links between avail- vices could be further strengthened ability of home records for immuniza- with contributions from other donors tion and immunization coverage. This and the government channeling their would be a simple and inexpensive funds through similar disbursement means to increase immunization cov- mechanisms. erage, with the possible external ben- efit of increasing coverage of other MCH services. 14 LAO PDR: Toward Sustainable Financing for Immunization Coverage References Gavi Vaccine Alliance. 2011. Annual Progress Report 2010. Submitted by The Government of Lao People’s Dem- ocratic Republic. ———. 2012. Annual Progress Report 2011. Submitted by The Government of Lao People’s Democratic Republic. ———. 2013. Annual Progress Report 2012. Submitted by The Government of Lao People’s Democratic Republic. ———. 2014. Annual Progress Report 2013. Submitted by The Government of Lao People’s Democratic Republic. ———. 2015. Annual Progress Report 2014. Submitted by The Government of Lao People’s Democratic Republic. Ministry of Health (MoH). 2014. Service Availability and Readiness Assessment Survey Report. Lao PDR. Vien- tiane: MoH. Ministry of Health (MoH) and Lao Statistics Bureau. 2012. Lao Social Indicator Survey (LSIS) 2011-12 (Multiple Indicator Cluster Survey/Demographic and Health Survey). Vientiane: MoH and Lao Statistics Bureau. Mobasser, A., M. Fong, J. Bitzer and J. Measelle. 2016. “Small investment, big returns: examining the effects of having a ‘Yellow Card’ on immunization and growth monitoring of young children in Lao PDR.” Annals of Global Health, 82(3): 394. United Nations Children’s Fund (UNICEF). 2015. Qualitative Research Proposal for Knowledge, Attitude, Per- ceptions, Beliefs and Practices Among the Underserved, Hard to Reach Ethnic Groups in Lao People’s Demo- cratic Republic, 2015. World Bank. 2017a. World Development Indicators Database. http://data.worldbank.org/data-catalog/world-development-indicators World Bank. 2017b. Managing Transitions: Reaching the Vulnerable while Pursuing Universal Health Coverage Vientiane and Washington, DC: World Bank. World Health Organization (WHO) and United Nations Children’s Fund (UNICEF). 2017a. WHO/UNICEF Esti- mates of National Immunization Coverage. http://www.who.int/immunization/monitoring_surveillance/data/en/ ———. 2017b. Joint Reporting Form (JFR). http://www.who.int/immunization/monitoring_surveillance/data/en/ Disclaimer: This note is a product of the staff of the International Bank for Reconstruction and Development/ The World Bank. The findings, interpretations, and conclusions expressed in this document do not necessarily reflect the views of the Executive Directors of The World Bank, the governments they represent or the funding partners (the Government of Australia and Gavi). The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. World Bank Vientiane Lao PDR The World Bank Xieng Ngeun Village, Chao Fa Ngum Road, 1818 H Street, NW Chanthabouly District Washington, D.C. 20433, USA P.O Box: 345 Tel: (202) 4731000 T + 856 21 266 278 Fax: (202) 4776391 M + 856 20 2222 1330 Website: www.worldbank.org F + 856 21 266 299 Website: www.worldbank.org/lao