To address these inequities, Bolivia embarked on the process of decentralizing health services in the mid-1990s. The national government established a universal insurance package for basic health services to be delivered at the municipal level. In January 2003, this insurance program was expanded to cover health services for pregnant women and children under five.

The introduction of health insurance has improved equity and access to health care. However, it has also greatly increased the responsibilities of municipalities. From 2002-2003, MSH worked with selected Bolivian mayors and local health officials to help them cost out health services and provide sound financial controls. MSH also developed a tool to establish reimbursement formulas and systems to collect the national funds to cover the cost of insuring their residents.

Concurrently, M&L is working to enhance the financial viability of NGOs and health providers. M&L;s technical assistance is supported by the United States Agency for International Development (USAID).

Summary of Work

In collaboration with Chemonics, M&L adapted its Cost Revenue Analysis Tool (CORE) to aid Bolivia's municipalities in the decentralization process, particularly to better manage the health system.

M&L has also provided technical assistance (TA) to three client organizations in Bolivia:

• PROSALUD, Bolivia's largest health NGO with 32 health facilities (30 health centers and 2 clinics) covering a population of approximately 500,000.
   
• COMBASE, a faith-based NGO in Cochabamba with a small hospital and five small clinics.
   
• PROCOSI, a health NGO network with 36 members
   

At COMBASE, PROSALUD, and others, M&L is employing both on-site TA as well as online electronic support for business planning and leadership development.

PROSALUD

PROSALUD provides high-quality health care nationwide through a network of clinics. When the organization first developed a network of sustainable outpatient clinics for lower- and middle-income patients in the areas surrounding the city of Santa Cruz, MSH provided technical assistance in management. Expansion and growth, however, brought new organizational challenges. In collaboration with M&L, PROSALUD developed a new institutional strategy, an administrative and financial management model, and updated its organizational structure and human resources management systems.

M&L is working with PROSALUD to implement specific aspects of the newly designed management model, specifically an integrated health information system; new financial system; and manuals and operations documents for human resources management. M&L and PROSALUD developed a model for the Annual Operational Plan linked to the budget which, this year, will be linked to PROSALUD's financial system.

COMBASE

In 2001, USAID/Bolivia identified COMBASE to receive technical assistance from M&L. M&L was also charged with implementing a continuous process of leadership and management development to build COMBASE's organizational capacity, with the goal of achieving financial sustainability.

M&L initiated its technical assistance program with the application of two participatory assessment approaches: the Management and Organizational Sustainability Tool (MOST) and the Cost Revenue Analysis Tool (CORE). The assessments showed that poor leadership, deficiencies in management systems, cash shortages, and debts were affecting the performance, financial stability, and sustainability of the organization. An action plan was developed to:

• Modernize the programmatic and financial information systems;
   
• Design new human resources, administrative, and financial management systems;
   
• Improve overall organizational performance, including annual planning.
   

PROCOSI - Business Planning Program

The Business Planning Program (BPP) is a comprehensive blended-learning program, which uses face-to-face and electronic methods to help organizations build expertise in business planning. This innovative program covers such areas as capturing and packaging breakthrough ideas, identifying target markets and marketing strategies, and determining the best complement of staff to develop ideas. The BPP also helps NGOs navigate the financial aspects of a business plan—projecting both social and financial return on investment. The tools, techniques, and worksheets supplied during this learning experience serve to simplify the complexities of the business plan, while helping participants to balance their enthusiasm with facts.

Results

M&L's adapted CORE tool has been used to strengthen the financial management capacity of selected Bolivian municipalities to aid in the decentralization process. The tool was applied and evaluated in Pando (a group of nine Bolivian municipalities) in 2003. However, as the program was approaching its end, the Bolivian government changed the national insurance program for the second time in less than a year. In response, M&L was able to adjust the tool before the small project ended.

PROSALUD

M&L has worked closely with PROSALUD to develop a new management model to modernize and decentralize the organization. The model included redefining the roles, responsibilities, and functions of each level of the organization; reviewing and updating all of the management systems; revising job descriptions; and redesigning the organizational structure. M&L has also prepared PROSALUD for the implementation process with training sessions and the development of implementation plans.

COMBASE

After three years of technical assistance from M&L:

• COMBASE is no longer in debt;
   
• Overall cost recovery rate has been steadily increasing;
   
• Four clinics have a recovery rate greater than 100%.
   

COMBASE's information system has been modernized and is functioning in all locations. The system database integrates client information, clinical information, and financial information, providing the management team with up-to-date and reliable information so that it can make informed decisions. Financial statements are now ready on a consistent monthly schedule.

New administrative, financial, and human resource management processes are being developed and implemented in the hospital and all five clinics. Manuals have been developed for each system and staff is being trained.

COMBASE is now actively engaged in annual planning, monitoring of spending, and searching for new funding sources.

PROCOSI - Business Planning Program

After completing the BPP, PROCOSI became M&L's Program Partner, and is now able to deliver the BPP to clients within Bolivia and Latin America.

PROCOSI has been asked to deliver a modified version of the course to health managers responsible for the delivery of FP and other RH services in 20 municipalities with the idea of extending the program to all 350 municipalities in the country. PROCOSI will provide all mentoring, monitoring, and follow-up coaching during the course.