We conducted 24 semistructured interviews with people from different groups, including the government, UN agencies, NGOs, and civil society organizations. The participants were mostly women (16 out 28). Their average age was 47, with a range from 32 to 61. Three participants worked at the central level in the healthcare system, 5 worked at the provincial level, 5 worked at the district level, and 3 worked at health centers (or small hospitals). Three participants worked for UN agencies, and 2 worked for NGOs. One was a consultant, and 2 were active members of civil society associations. Twenty-two were interviewed in the Lao language (Table 1).
Table 1
Basic characteristics of participants in the interviews
Number of participants | | 24 |
Female | | 16 |
Age | mean (min–max) | 47 (32–61) |
Organization | Healthcare institution at central level | 3 |
| Healthcare institution at provincial level | 5 |
| Healthcare institution at district level | 5 |
| Health center (small hospitals) | 3 |
| UN agency | 3 |
| NGOs | 2 |
| Consultant | 1 |
| Civil society Association | 2 |
Languages of interview | Lao | 22 |
| English | 1 |
| French | 1 |
The following sections present the state of power sharing between government levels that emerges from the data analysis. This is followed by a description of the institutionalized factors (structure and the interpretive schemes) that shape the sharing of power underlying the fight against malnutrition.
Power sharing between government levels in the health sector
In Lao PDR, the national government and the Politburo have primary authority. Provincial governments have some decision-making authority and financial and management responsibilities for political, economic, sociocultural, and human affairs; natural resources, the environment, and other resources; and national and local defense and security, and foreign affairs, as assigned by the government. However, provincial administration is directly under the supervision of the central government in accordance with the principle of democratic centralism, which formally defines the governance structure of communist-party-led countries (12, 13). In real life, there is a power play between the national and provincial governments that relies on a complex basis of power that only partially reflects the sharing of power defined in the constitution (12, 40). However, it is important to note that the Communist Party of Lao PDR has the leadership of the political system at all levels of government (41, 42).
The political decentralization structure of Lao PDR is also reflected in its healthcare system. The Ministry of Health (MOH) oversees the healthcare system, but it is shared between three levels of governance: central, provincial, and district (43).
The MOH is responsible for the public health system in the country, including hospitals, preventive and curative medicine national centers, and medical colleges and health science universities. It also formulates health plans, develops and implements public policies, and manages financial, human, and material resources in the public system. Moreover, the MOH is the main interlocutor of any international cooperation project. (43).
Provincial health offices (PHOs), which are under the control of the MOH, are responsible for providing advice on health affairs and allocating and monitoring the health services budget. They are also responsible for health audits of district hospitals and health centers(43, 44).
The district health offices (DHOs), which are under the control of the PHOs, supervise prevention and curative services offered in district hospitals and health centers. They are also responsible for village health volunteers (VHVs) and other village-based healthcare providers, who are the link between the village and the formal healthcare system (43).
At the local level, primary health care facilities can benefit from local resources, such as the contribution of these village-based health care providers and human resources from the Party's mass organizations (44).
The private sector in Lao PDR also plays a role in healthcare, providing an increasingly important part of primary health care at the community level (43, 45).
Regarding financing, we note that the care budget for public services is mainly based on MOH allocated funds and user fees collected at the point of service. The budget allocation from the central government to the provincial governments is primarily based on the number of personnel authorized by the central government to work in the public health facilities. This number is determined by the Ministry of Home Affairs in consultation with the MOH and the provincial health offices (PHOs). The provinces and districts are then responsible for hiring these professionals based on employment guidelines issued by the MOH. One notes that this assistance is not considered a resource during budget preparation (43, 45).
The government also supports activities that must be linked to the five-year plans for health and the Government’s National Socio-Economic Development Plan (NSEDP), the five-year NSEDP and the long-term National Growth and Poverty Eradication Strategy (NGPES) (43, 46). PHAs can influence the writing of these policies (43, 46).
Power sharing between government levels and nutrition programs in Lao PDR
The MoH has the ultimate responsibility for nutrition programs. However, at lower levels of governance, which are under the control of the central government, provinces must put in place governance structures for nutrition programs. The roles and interactions between these institutions are formally defined in government documents (6, 47).
It is up to the provincial government to ensure that centrally defined programs, such as vertical nutrition programs, are implemented. Provinces are supposed to have autonomy in managing the centrally allocated budget for nutrition, and they can plan activities they believe are the most promising to help them reach nutrition indicator targets. Provinces are expected to fund nutrition programs from their health budgets without mobilizing other sources to finance activities (6, 7).
To structure the partnership and coordination between actors and sectors involved in vertical programs, the government put in place a Nutrition Center and gave it the responsibility to coordinate the multisectoral activities susceptible to improving nutrition indicators. The Nutrition Center is recognized by all respondents as the place where expertise in the field of nutrition in the country can be found. Therefore, it has the legitimacy to encourage collaboration between complementary actors. The Nutrition Center hosts the National Nutrition Secretariat, which formally assumes the responsibility to coordinate actors in different organizations and at different levels, both internal and external. It also has the responsibility to raise funds for nutrition activities and to recruit external expertise when needed (6, 7).
The Secretariat is complemented with nutrition coordination bodies, called Nutrition Committees, which are found at the different levels: national, provincial, and district levels. Nutrition Committees are formal multisectoral coordination structures involving actors from different sectors and organizations concerned with the fight against malnutrition in Lao PDR (6). The Nutrition Committees are under the formal responsibility of the National Nutrition Committee that was created in 2013. This Committee is chaired by a Deputy Prime Minister. This central-level responsibility gives the central government the power to impose its program not only to the lower levels but also among the sectors concerned (6, 7).
One notes that the fight against malnutrition in Lao PDR is not solely addressed by vertical programs supported by the Nutrition Center. It also relies on primary health care (PHC), which is supervised by the MOH. It must provide preventive and curative nutrition-related services in health centers and through outreach activities (44, 48). PHC programs and approaches can receive financial and expert support from external donors, mainly United Nations agencies and NGOs (49, 50). However, this support must be approved by the central government.
Structure, power sharing and the fight against malnutrition in Lao PDR
The data show that the structure underlying the distribution of power in the field of nutrition is based on 5 fundamental elements: 1) the existence of a public policy; 2) the availability of human resources; 3) the source of financing the fight against malnutrition; 5) the key role of mass organizations of the Party; and 6) communication tools that mitigate traditional hierarchical constraints.
The following sections present the state of decentralization of the health care system that emerges from the data analysis. It will be followed by a description of the structure and the interpretive schemes that shape the offer of services framed in a defined decentralization state (Fig. 1)
A national nutrition public policy
The fight against malnutrition in Lao PDR is primarily based on a public policy, the National Nutrition Policy (NNP). which was enacted in 2008. This policy provides the legal framework for mobilizing and coordinating actors with resources that can contribute to improving nutrition indicators, regardless of their sector. The policy is operationalized through formal strategic plans developed by the Ministry of Health. These official documents define the responsibilities for the fight against malnutrition among the different levels of government in the country. They encourage lower-level governments to take action to mobilize resources that are considered necessary to meet nutrition targets (6, 7, 47). The structural institutional basis of the NNP requires the fight against malnutrition to take place within a largely centralized system, in which decisions are primarily made by national institutions involved in nutrition.
Availability of human resources
Lao PDR is still lagging behind its neighbors in terms of the quality of its public education system. Many documents highlight that the training provided in public teaching institutions does not meet international standards, particularly in the fields of healthcare, and especially in remote regions (43, 45, 51). Most qualified and experienced expertise is located at the central level. Local government and health center levels outside cities often lack resources and trained staff to provide high-quality nutrition services. This factor obviously limits the effectiveness of local governments in managing nutrition programs.
The lack of human resources is compounded by a high turnover rate. While any change in work position at the district level could formally be influenced by the central government, as it is the latter who funds the position (46, 51), respondents state that the decision is generally made independently at the district level. Turnover weakens the capacity to coordinate the numerous actors involved. Moreover, according to nearly all respondents, this high turnover of personnel drains a considerable part of the local budget, as it leads to staff training and per diem spending.
All efforts to address these issues are led by the central government. The main initiative in this area is the National Strategy and Action Plan for Integrated Services on Reproductive, Maternal, Newborn and Child Health (RMNCH), which was implemented in 2009 and revised in 2015. The RMNCH’s objective was to promote the integration of scarce existing services to ensure that resources are available at the local level throughout the country to respond to nutrition and vaccination needs. This policy forces provincial and district authorities to achieve economies of scale in the use of their human resources (49, 52).
The lack of human resources is a major factor that has led the structure of the fight against malnutrition to be under the responsibility of institutions located at the central level.
Source of financing the fight against malnutrition
Lao PDR has a centralized budgeting and funding procedure for its health care public system. Nearly all funding for healthcare activities comes from the central government. Provinces have limited ability to generate their own resources that can be used to tailor the fight against malnutrition to regional specificities.
This system has been a source of discontent. Many respondents at the peripheral level reported that budget transfers from the central government to lower administrative levels are often delayed, especially in remote areas. There are also delays due to the lengthy budget negotiation process.
The irregular flow of funds is partially offset by the availability of external funding, such as from NGOs (6, 7). All respondents agree that the presence of NGOs at a local level gives more autonomy to professionals involved in nutrition programs. This is because NGOs provide funding and motivation to those who provide services to the communities. However, activities by external actors must be approved by the central government. Additionally, projects are typically implemented in villages and districts considered to be priority settings for public health interventions by the provincial and/or district authorities.
Most importantly, all respondents agree that the involvement of external donors and actors is essential for enabling deconcentration in Lao PDR. External donors provide the support needed to adjust nutrition programs to the specific needs of local populations. This ensures that programs are more effective and relevant to the people they serve.
Key role of mass organizations of the Party
In Lao PDR, mass organizations of the Party, such as the Lao Women's Union (LWU) and the Lao Youth Union (LYU), are almost always involved in any social or health program implemented in the community. The members of the mass organizations designated to collaborate with public health professionals are typically from the communities where the programs are implemented. This is formally seen as a way to ensure that the programs are relevant to the needs of the community and that the messages are communicated in a way that is understandable and relatable. They are also responsible for passing on information about the programs to the Party hierarchy and for promoting Party propaganda. This ensures that the programs are aligned with the goals of the Party. The involvement of mass organizations in nutrition programs is particularly important, as there is often a lack of professionals in this field. Mass organizations can help to fill this gap by providing manpower and mobilizing the community to support the programs. There is nearly no nutrition program without the involvement of the LWU (6, 43, 53). It is expressed in the following quotation:
“…there are the Party grassroot members in the meeting (nutrition committee meeting at the district level), who we invited to join us, as well as the standing and district party committee who divide the responsibility for guiding each population group, whoever is responsible for our target group, we would take them to the field, as well as the mass organization, especially the Lao Front for National Development as a main actor to discuss this, secondly is the Women Union that we can’t forget them, we would take them going to the field with us.” said by participant from district level (Luangnamtha_04)
However, mass organizations are not public health organizations. They lack public health expertise. Their contribution is often limited to transmitting educational messages drafted, under central government control, by those in charge of programs in the communities.
The influence of mass organizations in combating malnutrition reinforces the concentration of leadership and power at the central level.
Communication tools that mitigate traditional hierarchical constraints
Lao PDR is a sparsely populated country that lives on a large area (equivalent to that of the United Kingdom). Weak infrastructure and the impact of the rainy season on the ability to drive on unpaved roads make communication between different administrative levels difficult (46, 54). The popularity of rapid and efficient new communication devices, such as online platforms, is therefore not surprising.
According to most respondents, the use of social networks has been the major changing factor in the functioning of health programs in a system that involves various levels of government. Social networks, such as Facebook or WhatsApp, have become the preferred way to communicate in the world of nutrition, as almost everyone has a smartphone and is connected to the internet. New technologies are increasingly important in directly connecting actors across different levels of government. They are replacing the need for paperwork communication and have opened up new opportunities for less formal communication. Nevertheless, the use of social media tends to respect hierarchical lines inside the government apparatus. Communication through new technologies therefore still respect the bureaucratic line of command. It is expressed in the following quotation:
“In the groups, there are staffs (DHO staffs) and department level (PHO staffs) together... If the department (PHO staffs) isn’t in the group, they will send the responsible staffs to join the group. So, we always exchange (information) with each other. Whenever the central level (staffs) send messages in the group, everyone always responds. They couldn’t act like they haven’t seen it (messages), because we have the responsibilities for our work, and they also have their responsibilities. If they don’t answer, it means that they haven’t followed up (on the work)” said by participant from central level (Central_01)
However, formal communication with and among external donors and NGOs still does not make good use of social media. According to respondents, the formality that characterizes collaborations involving external actors has not changed much. Social media are used but do not replace formal meetings and paperwork bureaucratic processes.
Respondents agree that new technologies are transforming both formal and informal relationships between levels of governance. However, they cannot say whether, in the near future, these changes could support the functionality of the deconcentration that formally characterizes the health system or another type of power sharing that gives more responsibility to local governments and thus a fight against malnutrition less dependent on a centralized system.
Interpretive schemes influencing the fight against malnutrition in Lao PDR
The data show that the interpretive schemes underlying the distribution of power in the field of nutrition are based on 3 fundamental elements: 1) the understanding of the malnutrition concept; 2) the perception of the role of different levels of government in the fight against malnutrition; and 3) the expected impact of the country's development changes on the distribution of powers in the fight against malnutrition.
Understanding of the malnutrition concept
There is a convergence of thought among the different levels of governance about the causes of malnutrition in Lao PDR and the challenges it poses for the healthcare system. There is also a consensus on the solutions that need to be implemented to this issue. Almost all respondents agreed that multisectoral programs are essential, as the health sector can only address a few of the factors that contribute to malnutrition. Respondents recognize that health sector interventions have little impact if they are implemented in isolation.
Perception of the role of different levels of governance in the fight against malnutrition
There is a relative consensus among the different levels of governance that nutrition interventions should be developed and led by the central level. Every respondent recognizes that the provinces lack resources to address malnutrition on their own and that leadership at the central level is essential. The majority of participants, whether representatives of the national or field organizations, believe that the national level is where real competence and knowledge about how to fight malnutrition can be found. National-level actors tend to perceive district-level actors as lacking adequate training, information, and skills regarding how to promote healthy nutrition. They also emphasize the limited material resources and infrastructure available to effectively implement nutrition programs. However, the majority of participants, including those representing organizations at the provincial or district/village levels, stress the fact that they are not sufficiently considered essential as executors with assets. Indeed, they claim to have a better understanding of the local context and to be able to make available local and community resources, including local health volunteers and mass organizations that can be used to address the specific needs of the community. Given more authority to local governments to develop programs is seen as a way to more effectively address the problem of malnutrition. However, how to do this remains somewhat obscure. None of the participants was able to come up with a realistic proposal for a different division of powers that would better target the specific needs of the people in the districts. In conclusion, there is a convergence between interpretative schemes and the structure of the fight against malnutrition. However, there is still a need to clarify how to give more authority to local governments without compromising the leadership of the central level.
Expected impact of the country's development changes on the distribution of powers in the fight against malnutrition in Lao PDR
Like most developing countries, Lao PDR is experiencing tremendous socioeconomic changes that affect the way in which the formalization of relations between levels of governance is expressed in real life. Lao PDR is a country of small communities whose members tend to know each other well. They find it natural to call or text each other, even using familiar forms (such as calling nonfamily members "sister," "brother," or "parent") to ask and discuss work-related matters outside of working hours or on weekends. Moreover, because social life in Lao PDR revolves around traditional events, such as commemoration dinners, there are many opportunities throughout the month for people who want to communicate with each other to meet outside of their workplace. This dynamic is seen as a major facilitator of emotional connection. It is expressed in the following quotation:
“…we all know each other, it’s convenient, simple and easy to communicate. When we discuss, we understand each other immediately. We all have telephone and WhatsApp numbers; we have many groups to communicate anytime… We know each other well, we can call them (PHO staffs) our sisters…” said by participant from nutrition center (Central_01)
However, the arrival of new technologies has an impact on the foundation of interpersonal relations in Lao PDR. Social media is now ubiquitous, and people are constantly sharing news about each other's lives. This democratization of exchanges has led to a more homogeneous understanding of nutrition problems vertically and horizontally on a regional level.
New technologies are also accelerating decision-making. In the past, people had to wait for formal social meetings to discuss issues. Now, they can exchange information more quickly and easily via platforms such as WhatsApp. This has led to more active nutrition programs, as people are always up-to-date on the latest information and intervention.
WhatsApp is also being used as a tool for knowledge sharing and professional development. People in different groups can compete with each other to share the most innovative ideas and best practices. This has led to a more collaborative and effective approach to fighting malnutrition.
In parallel, the existence of different groups on WhatsApp brings a sense of competition among them. A successful activity can quickly become a model for another actor facing similar challenges. While some people tend to worry that this could lead to the gradual disappearance of social traditions, most people agree that it also facilitates communication between different levels and increases the effectiveness of anti-malnutrition programs. New technologies strengthen the alignment of different interpretative schemes and the alignment between interpretive schemes and the structure of the fight against malnutrition.