Developing a hospital quality improvement initiative in Lesotho.

PURPOSE: Hospital-based quality improvement (QI) programs are becoming increasingly common in developing countries as a sustainable method of strengthening health systems. The aim of this paper is to present the results and lessons learned from a QI program in a large, rural, district hospital in Lesotho, Southern Africa. DESIGN/METHODOLOGY/APPROACH: Over a 15-month period, a locally-relevant, hospital-wide QI program was developed and implemented. The QI program consisted of: planning meetings with district and hospitals staff; creation of multi-disciplinary QI teams; establishment of a QI steering committee; design and implementation of a locally appropriate QI curriculum; and monthly consultation from technical advisers. Initial QI programming was developed in three distinct areas: maternity care, out-patient care, and referral systems. FINDINGS: Partogram documentation in the maternity department increased by 78 percent, waiting time for critically ill patients in the out-patient department was reduced by 84 percent, and emergency referral times were reduced by 58 percent. ORIGINALITY/VALUE: The design and early implementation of QI programs should focus on easily achievable, locally-relevant improvement projects. It was found that early successes helped to fuel further QI gains and the authors believe that the work building sustainable QI skill sets within hospital staff could be useful in the future when attempting to tackle larger national-level quality of care indicators. The findings add to the existing evidence suggesting that an increased use of locally-relevant quality improvement programming could help strengthen health care systems in low resource settings.

Good governance and budget reform in Lesotho Public Hospitals: performance, root causes and reality.

Lesotho has been implementing financial management reforms, including performance-based budgeting (PBB) since 2005 in an effort to increase accountability, transparency and effectiveness in governance, yet little is known about how these efforts are affecting the health sector. Supported by several development partners and $24 million in external resources, the PBB reform is intended to strengthen government capacity to manage aid funds directly and to target assistance to pressing social priorities. This study designed and tested a methodology for measuring implementation progress for PBB reform in the hospital sector in Lesotho. We found that despite some efforts on the national level to promote and support reform implementation, staff at the hospital level were largely unaware of the purpose of the reform and had made almost no progress in transforming institutions and systems to fully realize reform goals. Problems can be traced to a complex reform design, inadequate personnel and capacity to implement, professional boundaries between financial and clinical personnel and weak leadership. The Lesotho reform experience suggests that less complex designs for budget reform, better adapted to the context and realities of health sectors in developing countries, may be needed to improve governance. It also highlights the importance of measuring reform implementation at the sectoral level.

Social responsibility, international development, and institutional commitment: lessons from the Boston University experience.

Boston University (BU) has a long history of a strong social mission and commitment to service. In August 2003, BU made an institutional commitment to work with the country of Lesotho to tackle the human capital implications of the HIV/AIDS epidemic. Surrounded by South Africa, and with a population of two million, Lesotho, a stable democracy, suffers the world's third-highest adult HIV prevalence rate of about 24%. The initiation of the program required a substantial initial institutional investment without any promise of payback. This allowed BU to begin work in Lesotho while searching for additional funds. The government of Lesotho and BU agreed to focus on preserving the lives of Lesotho's citizens, building the capacity of the country's workforce, and maximizing the efficiency of Lesotho's existing systems and resources. Initial activities were modest, beginning with workshops on problem solving, then the launch of a primary care clinic that offered HIV/AIDS treatment services at the nation's only teacher training college. With support from the W.K. Kellogg Foundation, the main focus is now on strengthening district-level primary care services, including the initiation of a family medicine residency training program in cooperation with the University of the Free State in Bloemfontein. The initial commitment has developed into a mutual partnership, with benefits to country and university alike. By combining the expertise from various schools and departments to focus on a single country, a university can significantly advance international development, strengthen its service mission, enrich teaching, and provide new opportunities for research.

The new cell culture smallpox vaccine should be offered to the general population.

A series of major factors must be weighed in deciding whether or not, and to what extent, a particular country should consider pre-exposure vaccination for smallpox. These include the risk of a bioterrorist attack using smallpox, the risk of secondary spread from another country, the risks and benefits of vaccination, the effectivenes s of vaccination pre- and post-exposure, the prevalence of immunocompromised persons, the capacity of the medical care delivery system and the wealth of a nation. We review here the issues and variables relevant for policy making, propose a framework for country-specific decision making and suggest the World Health Organization has a key role to play, particularly with regard to lower-income countries. In doing so, we support the proposition.