This short report describes how the USAID Health Care Improvement Project (HCI) is working with the Ministry of Health and Sports’ National Tuberculosis (TB) Control Program in Bolivia to strengthen the quality of TB services in La Paz, Cochabama and Santa Cruz provinces. USAID began to address Bolivia’s TB epidemic in 2006 when it asked the Quality Assurance Project (QAP), HCI's predecessor project, to work with the Gestión y Calidad en Salud (GCS) bilateral project to implement a collaborative improvement project aimed at improving TB services.

This report describes an improvement activity in El Alto, Bolivia, designed to improve treatment compliance among TB patients by assuring a full dedicated treatment course. This was achieved by organizing medicines in a box reserved for each patients and by improving logistical management of medications at the health network level. This report is also available in Spanish.

Este informe corto describe una mejora ejecutada en Cochabamba, Bolivia, para reducir el número de muestras de saliva que son inútiles para diagnosticar la tuberculosis a través de cambios al proceso de solicitar muestras de esputo y otras técnicas para ayudar a los pacientes a producir una buena muestra de esputo. El informe está disponible también en inglés.

Con el fin de identificar oportunidades y necesidades de apoyo a las redes municipales de salud para mejorar el Programa Nacional de Control de la Tuberculosis (PNCT) de Bolivia, el Proyecto Gestión y Calidad en Salud en asocio con el Proyecto de Garantía de la Calidad (Quality Assurance Project, QAP), decidieron realizar un diagnóstico rápido de la situación del PNCT en dieciséis municipios priorizados de los Departamentos de La Paz, Cochabamba y Santa Cruz. Los datos para el diagnóstico fueron recopilados entre noviembre 2006 y enero 2007. Los hallazgos sirvieron para desarrollar intervenciones de mejora que fueron implementados por medio de un colaborativo de mejoramiento iniciado en 2007 en los mismos municipios.

In an attempt to address high maternal mortality and morbidity in Latin America and the Caribbean, the United States Agency for International Development (USAID) began the Latin America and Caribbean Regional Initiative to Reduce Maternal Mortality (LAMM) in 1996. Recognizing that existing USAID-supported programs already address family planning, prenatal care, and clean delivery strategies to reduce maternal mortality, LAMM targets essential obstetric care at the first level of referral facilities. Bolivia, Ecuador, and Honduras were sites for the development and pilot testing of essential obstetric care (EOC) interventions. Under LAMM, the Quality Assurance Project (QAP) is responsible for supporting process redesign and quality improvement teams as they address weak components in the EOC system. QAP conducted a baseline assessment of the quality of care and compliance with EOC standards at the facility level in a selected area of each country in 1998. The QAP LAMM team developed a set of 21 indicators to measure quality of care and how each system was functioning. Data on the indicators were collected through the review of patient medical records and other facility records, structured observation of deliveries, and a questionnaire completed by healthcare professionals. The assessments indicate that adequate infrastructure to provide EOC exists in all three study areas. However, deficits were documented in the capacity of these facilities to deliver quality EOC services. Inadequate supplies and equipment, lack of trained personnel, and failure to comply with quality standards all limit the functional access to EOC. The assessments also suggest that low utilization of the study facilities is an important barrier to the delivery of EOC in all three countries. Over a third of the staff surveyed reported never having been trained in the management of obstetrical emergencies. With respect to the performance of clinical EOC tasks, the assessments found that time intervals between recordings of fetal heart rate failed to meet international standards. Asepsis was routinely practiced during delivery in all three countries, while the administration of hemoglobin tests to patients whose admitting diagnosis suggested the possibility of hemorrhage varied widely among the three countries. The assessments also examined whether basic tasks were recorded in patients' medical records, and many tasks appeared unrecorded. The assessment results suggest that a variety of interventions will be required to increase awareness of and compliance with performance standards. Such interventions could include effectively disseminating and communicating standards, in-service training, job aids, increased supervision and monitoring, and assuring availability of supplies and equipment through process redesign and quality improvement. The LAMM initiative contemplates repeating assessments in 2001 to evaluate the effectiveness of its efforts. The adequacy of the 21 indicators to reliably measure the initiative's achievements should be reviewed, and efforts should be made to better standardize data collection instruments and sampling methods. Some of the original indicators may be hard to interpret as gauges of progress, and there may be other indicators that should be introduced. A new set of nine indicators, including five of the original ones, has been introduced by LAMM for routine quality monitoring. These indicators should be considered for future facility assessments. (excerpt)