TECHNICAL ASSISTANCE COMPLETION REPORT

Division: SESS
TA No., Country and Name Amount Approved: $500,000
TA 7058-LAO: Piloting Community e-Centers for Better Health Revised Amount: - Not Applicable
Executing Agency Source of Funding: Republic Amount Undisbursed: Amount Utilized:
ADB of Korea e-Asia and $ 19,454.50 $ 480,545.50
Knowledge Partnership Fund
TA Approval TA Signing Fielding of First Consultant TA Completion Date
Date: Date: Original: 31 Aug 2009 Actual: 30 Apr 2010
29/01/ 2008 11/02/2008 02/07/2008 Account Closing Date
Original: 31 Aug 2009 Actual: 31 Aug 2010
Description
1
The TA was intended to demonstrate how the use of e-centers in rural health facilities could improve the skills of health staff
and promote health in rural communities. The Government rural health network of district hospitals health centers (HCs), and
Village Health Workers (VHWs) is expected to deliver health services to a small and scattered population. While support
systems are in place, communication problems, especially during the rainy season, result in health staff and VHW working in
relative isolation. Many paper-based health publications are available at the central level but it is difficult to distribute them
effectively in rural areas. Making such information available electronically to local level health personnel is an inexpensive
means to improve their capacity and a priority.
th
The National Growth and Poverty Reduction Strategy and the 6 National Socio-economic Development Plan (2006-2010)
promotes the development of information communications technology (ICT) to improve public service delivery, reduce the
isolation of remote and poor areas, and carry out training through distance learning. One planned initiative is the development of
a broadband network to deliver public services from the province to the district and to the village administration office. The
ADB's Country Strategy and Program (2007-2011) for Lao PDR supports the Government's efforts to enhance the access and
quality of maternal and child health care by expanding the low-cost network of village health care volunteers and trained health
workers. The e-center pilot complements this effort. ADB's Greater Mekong Subregion Regional Communicable Disease Control
2
Project has already produced a substantial amount of health education training materials, including audio-visual tools.
Expected Impact, Outcome and Outputs
The expected impact was improved health in rural communities. The expected outcome was improved quality and utilization of
HC staff and VHWs, and increased use of ICT services. The intended outputs were (i) 16 health facilities in two provinces
provided with ICT services, (ii) appropriate e-health content and services produced and used including three interactive training
CD-ROMs on maternal and child health and nutrition, control of communicable diseases, and basic village health worker skills,
(iii) staff skills enhanced in basic care, use of ICT and basic e-center maintenance, and (iv) outcome of e-centers assessed and
shared including lessons and cost implications. The TA design was relevant especially given the remote conditions of the
country. The delivery of e-government and distance learning remains Government's priority and health remains a significant
area of ADB engagement in Lao PDR. The TA was innovative, the first of its kind in the country, and was implemented as
designed.
Delivery of Inputs and Conduct of Activities: The TA was adequately formulated with regard to stakeholder participation and
ownership. None of the stakeholders had experience with the technical aspects of the TA. The terms of reference were well
formulated. All consulting services were engaged in accordance with the TA paper although a minor change in scope was
required to allow the ICT firm an additional $17,000 to provide refresher training. The consultants delivered high quality products
and their performance was satisfactory. ADB staff input was intensive and high quality. There were four review missions and
frequent videoconferences, emails, and phone calls. The performance of both ADB and the IAs was satisfactory.
TA preparation underestimated (i) the cost of producing the training CD-ROMS, (ii) the technical capacity of the staff of the
National Agency for Science and Technology (NAST), (iii) the demand for training by the Provincial Science and Technology
Office, district hospital and HC staff, and (iv) the time required for NAST and MOH to make decisions about the e-center system
specifications and utilization guidelines. Although the TA was extended by four months, the time available for piloting the system
was reduced from the planned 12 months to 6 months.
Evaluation of Outputs and Achievement of Outcome
Output 1. E-center networks developed. Sixteen health facilities were provided with ICT services. As HC staff lived near the
HCs, they were willing to extend use to the general community beyond working hours.
Output 2. Health information developed. Good quality e-health content and services were produced and used. A project
website has been developed that provides a wide range of newly developed health material in Lao language. The budget was
sufficient for only two training CD-ROMs as the development cost was significantly higher than expected. This shortcoming was
offset by translating the VHW CD-ROM into three additional languages: the ethnic minority languages of Hmong, Khmou, and
Lao Tung. During the final monitoring survey, discussions with VHWs and district hospital and HC staff revealed a genuine

1
The TA paper states: "E-centers are an outlet for providing the general public with affordable access using information and
communication technology, such as the internet, email, computer training, distance learning, online services, and other
services and information beneficial to the community."
2
ADB 2005: ADB's Greater Mekong Subregion Regional Communicable Disease Control Project, Manila (CAM $9 million, Lao
PDR $6 million, VIE $16 million, 21 November 2005, Asian Development Fund)
interest in the CD-ROM training. The Government appreciated the quality of the materials. The VHW CD-ROM has also been
used by some VHWs for community training. Training material from the project website has been transferred to CDs and
distributed to the HCs. The pilot demonstrated the usefulness of CD-ROMs as an effective method for distance learning.
Output 3. Local ICT capacity built. Staff skills in basic health care, ICT use, and basic e-center maintenance were enhanced.
The 50% training targets for VHWs and district hospital and HC staff were exceeded. A total of 80 district hospital and HC staff
and 216 VHWs attended the basic e-health education and computer courses. Many participants attended all the training offered.

TA Outcome. The performance indicator for the TA outcome was a 25% increase in the utilization of health facilities and VHWs
by communities, and a 50% increase in computer literate staff in the health facilities. The 50% increase in computer literate staff
was met. In the district hospitals the number of staff using computers increased from 55 to 90 while the number using email
increased from 4 to 19. At the health center level, no staff used a computer or sent email prior to the project. After
implementation, 16 of 19 staff were using the computer and sending email. However, an increase in the utilization of health
facilities could not be confirmed because of the short piloting period.
The TA was effective in achieving its outputs and outcomes, to the extent that the outcome could be measured. The short pilot
period was sufficient to indicate that computer literacy had been achieved but not whether it had an impact on utilization rates of
health services. In hindsight, impact on utilization rates of the district hospitals, HCs and VHWs was not a robust indicator for a
range of reasons: (i) utilization rates could increase because of improved recording, (ii) utilization rates can fluctuate with the
rate of illness; (iii) three months of data is not sufficient to demonstrate change. Testing the knowledge of hospital and HC staff
and VHWs could have provided a proxy measure for improved health care. The TA's main value, however, is in the lessons
learned about establishing rural e-centers even if the project outcomes could not be fully demonstrated.
The TA was less efficient. The collaboration between NAST, a technical agency, and MOH, a service delivery agency, was an
important element of the pilot. However the two implementing agencies had not previously collaborated at the central and
provincial level, which resulted in delays and reduced the time available for implementation. Running the pilot in one province
may have decreased travel costs, increased coverage of clustered HCs, and provided more insights into how the hospitals and
HCs could use ICT to improve service delivery. The level of client satisfaction was high, especially at the local level. At the
national level, the government was pleased with the result of the pilot and the learning materials produced.
Overall Assessment and Rating:
The overall assessment of the TA is partly successful. It was relevant, effective, less efficient, but may not be sustainable as an
internet linked e-community health system. Operating costs are high and, until the Lao PDR government completes its
broadband roll-out, the service cost to district hospitals and HCs for all but basic email becomes prohibitive. Thirteen of 16 e-
centers were out of ink on the last monitoring visit. Policies on e-charges were put into place late in the trial and have not been
evaluated for sustainability. Until the cost of internet use decreases, policies on use are needed to prevent the monthly internet
allocation being consumed by a long download of a health training video. One solution is to open the e-center to other, non-
health activities such as distance learning, entertainment or other public or private services. The costs of maintenance can then
be shared. It should be noted, however, that the project was innovative and valuable as a pilot in terms of the lessons learned.
These should be documented to serve as a reference for all agencies planning to introduce e-based systems for beneficiaries in
remote areas.
Major Lessons:
(i) The keenness and ability to learn is immense, especially among district hospital and HC staff, as they have the least access
to knowledge. The pilot has demonstrated that even the HC staff (mostly over age 40) and the VHWs are able to master simple
uses of the computer to use interactive CD-ROMs.
(ii) Keep the design and specifications simple. The capacity to maintain the equipment and troubleshoot is limited
(iii) Develop IT policies first before rolling out the system including who is allowed to use the internet and for what purpose, and
by limiting printer use.
(iv) Until the cost of the internet decreases significantly, it is better to download and disseminate materials of interest to the
district hospitals and HCs using CDs or other inexpensive forms of storage rather than through web streaming.
(v) The consultants prepared excellent final reports which should be analyzed for the lessons learned from this pilot regarding
system architecture and system development, training, usage, and dissemination of training material.
Recommendations and Follow-Up Actions
(i) SESS should prepare a knowledge product, based on the consultants’ reports, on lessons learned in establishing community
e-centers in a low internet capacity environment.
(ii) In the next fiscal year, NAST and MOH should review the continued use of ICT by the district hospitals and HCs. What has
happened to the system since the TA was completed? Has coverage expanded? Was support and maintenance provided?
Have allocations been made in the government budget for district hospital and HC internet use and consumables?
(iii) NAST and MOH should test VHW retention of the lessons from the VHW CD-ROM as a measure of training effectiveness.

Prepared by: Wendy Duncan Designation: Principal Education Specialist

In preparing any country program or strategy, financing any project, or by making any designation of or reference to a
particular territory or geographic area in this document, the Asian Development Bank does not intend to make any judgments
as to the legal or other status of any territory or area.