WHO COUNTRY COOPERATION STRATEGY 2014-2019 LESOTHOapps.who.int/iris/bitstream/10665/246297/1/ccs_lso_en.pdf · WHO COUNTRY COOPERATION STRATEGY 2014-2019 ... WHO Country Cooperation

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W H O C O U N T R Y O F F I C E L E S O T H O

WHO COUNTRY COOPERATION STRATEGY

2014-2019

LESOTHO

COOPERATION STRATEGY - Lesotho 2 - Final.indd 1 2015/07/09 1:46 AM

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AFRO Library Cataloguing-in-Publication Data

WHO Country Cooperation Strategy 2014-2019 Lesotho

1. Health planning2. Health plan Implementation3. Health Priorities 4. International cooperationI. World Health Organization. Regional Office for Africa

ISBN: 978 92 9 023207 0 (NLM Classification: WA 540 HE8)

© WHO Regional Office for Africa, 2014

Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. Copies of this publication may be obtained from the Library, WHO Regional Office for Africa, P.O. Box 6, Brazzaville, Republic of Congo (Tel: +47 241 39100; Fax: +47 241 39507; E-mail: [email protected]). Requests for permission to reproduce or translate this publication, whether for sale or for non-commercial distribution, should be sent to the same address.

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

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All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization or its Regional Office for Africa be liable for damages arising from its use.

The conceptual designs were done in AFRO and laid out and Printed in Lesotho



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CONTENTS:

CONTENTSACRONYMS………………………………………………………………………...v

PREFACE…………………………………………………………………………..ix

ACKNOWLEDGEMENTS…………………………………………………..…….xi

EXECUTIVE SUMMARY…………………………………………………………xiii

SECTION 1: INTRODUCTION ………………………………………..……..…1

SECTION 2: COUNTRY HEALTH AND DEVELOPMENT CHALLENGES .........................................................................3

2.1 Geography ………….......................................................…………….............32.2 Demographic Profile and Characteristics of Population ……………................32.3 Politics and Governance Structure ……...…………………………….........…....42.4 Socioeconomic Status ………..........................................................................52.5 Social Determinants of Health ..……………………….........................…..........62.6 Health Status of the Population .………………………..………..............…......82.7 National Response to Overcoming Health Challenges …………….....….…...112.8 Health Systems and Services ………...................................................…......15

SECTION 3: DEVELOPMENT COOPERATION AND PARTNERSHIPS ....17

3.1 Aid Environment in the Country ………........………………………................. 173.2 Coordination and Aid Effectiveness int he Country ……………….…............ 183.3 UN Reforms Status and UNDAF Process ……..............………….........…… 19


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SECTION 4: REVIEW OF WHO COOPERATION OVER CCS2G .............. 21

4.1 Support from Headquarters and AFRO .......……..……………....................... 224.2 WHO responses to changing country needs ........……………....................... 224.3 Other Partners .......……..……………............................................................. 234.4 Achievements of CCS2G .......……..……......................………....................... 244.5 Challenges in Implementation of CCS2G …..…..............………….........…… 27

SECTION 5: STRATEGIC AGENDA FOR WHO COOPERATION.............. 31

5.1 Validation of CCS strategic agenda with National Policy ……....................... 415.2 Validating CCS strategic agends with UNDAF/LUMDAF ........……............... 415.3 Validating CCS strategic agenda with WHO Global and Regional Priorities . 41

SECTION 6: IMPLEMENTING STRATEGIC AGENDA: IMPLICATIONS FOR WHO..................................................... 43

6.1 Nature and Level of Support Needed from WHO Regional Office and Headquarters .......……..……………............................................. 436.2 Appropriate competences and skills required to implement CCS3G ........…. 44

SECTION 7: MONITORING AND EVALUATION ........................................ 47

REFERENCES ........................................................................................... 49

ANNEX:Annex A: CCS Development Process .....................................……....................... 55Annex B: Health Development Support 2010/11 to 2012/13 ................................. 55Annex C: SWOT Analysis .......................................................……........................ 56Annex D: Comparison of CCS3G and Health Sector Priorities ..…........................ 57Annex E: LUNDAP Outcomes Compared to CCS3G Priorities ............................. 58Annex F: Validating the CCS Strategic Agenda with WHO Global Priorities ......... 58Annex G: Validating the CCS Strategic Agenda with WHO Regional Priorities ..... 59



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SECTION 4: REVIEW OF WHO COOPERATION OVER CCS2G .............. 21

4.1 Support from Headquarters and AFRO .......……..……………....................... 224.2 WHO responses to changing country needs ........……………....................... 224.3 Other Partners .......……..……………............................................................. 234.4 Achievements of CCS2G .......……..……......................………....................... 244.5 Challenges in Implementation of CCS2G …..…..............………….........…… 27

SECTION 5: STRATEGIC AGENDA FOR WHO COOPERATION.............. 31

5.1 Validation of CCS strategic agenda with National Policy ……....................... 415.2 Validating CCS strategic agends with UNDAF/LUMDAF ........……............... 415.3 Validating CCS strategic agenda with WHO Global and Regional Priorities . 41

SECTION 6: IMPLEMENTING STRATEGIC AGENDA: IMPLICATIONS FOR WHO..................................................... 43

6.1 Nature and Level of Support Needed from WHO Regional Office and Headquarters .......……..……………............................................. 436.2 Appropriate competences and skills required to implement CCS3G ........…. 44

SECTION 7: MONITORING AND EVALUATION ........................................ 47

REFERENCES ........................................................................................... 49

ANNEX:Annex A: CCS Development Process .....................................……....................... 55Annex B: Health Development Support 2010/11 to 2012/13 ................................. 55Annex C: SWOT Analysis .......................................................……........................ 56Annex D: Comparison of CCS3G and Health Sector Priorities ..…........................ 57Annex E: LUNDAP Outcomes Compared to CCS3G Priorities ............................. 58Annex F: Validating the CCS Strategic Agenda with WHO Global Priorities ......... 58Annex G: Validating the CCS Strategic Agenda with WHO Regional Priorities ..... 59

ACRONYMS:

ADAAL Anti-Drug and Alcohol Association of Lesotho

ADB African Development Bank

AFP Acute Flaccid Paralysis

AFRO Regional Office for Africa (WHO)

AGOA African Growth and Opportunities Act

AJR Annual Joint Review

ART Anti-Retroviral Treatment

BCC Behaviour Change Communication

BNP Basotho National Party

BUMC Boston University Management Consultants

CBL Central Bank of Lesotho

CCS Country Corporation Strategy

CCS2G CCS Second Generation

CCS3G CCS Third Generation

CD Communicable Diseases

CHAL Christian Health Association of Lesotho

CV Curriculum Vitae

DG Director-General of WHO

DHHS Director General of Health Services

DHMT District Health Management Team

DHPS Department of Health Planning and Statistics

DHS Demographic and Health Survey

DMA Disaster Management Authority

DQS Data Quality Self-Assessment

DVDMT District Vaccine Data Management Tool

EMR Electronic Medical Records

EPI Expanded Program on Immunization

EPDMS Electronic Performance Management Development System

EU European Union

FCTC Framework Convention on Tobacco Control


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FIND Foundation for Innovative New Diagnostics

GAVI Global Alliance for Vaccines and Immunizations

GOL Government of Lesotho

GPW General Program of Work

HDI Human Development Index

HHA Harmonization for Health in Africa

HIV & AIDS Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome

HMIS Health Management Information System

HPV Human Papilloma Virus

HQ Head Quarters of WHO

HRH Human Resources for Health

HSA Health Service Area

HSR Health Sector Reforms

HSS Health Systems Strengthening

HTAP HIV and AIDS Technical Assistance Program

HTC HIV Testing and Counselling

ICD10 International Coding of Diseases 10th Revision

ICT Information and Communication Technology

ICU Intensive Care Unit

IDSR Integrated Disease Surveillance and Response

IEC Information, Education and Communication

IHM International Health Measurement

IMR Infant Mortality Rate

IST Intercountry Support Team

KNCV Royal Netherlands TB Foundation

LBTS Lesotho Blood Transfusion Services

LDC Least Developed Countries

LPPA Lesotho Planned Parenthood Association

LRCS Lesotho Red Cross Society

LUNDAP Lesotho United Nations Development Assistance Plan

M & E Monitoring and Evaluation

MAF MDG Acceleration Framework

MCC Millennium Challenge Corporation

MDG Millennium Development Goals



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MDR-TB Multi-Drug-Resistant TB

MMR Maternal Mortality Ratio

MOF Ministry of Finance

MOH Ministry of Health

MTSP Medium Term Strategic Plan

NAC National AIDS Commission

NCD Non-communicable Diseases

NGO Nongovernmental Organization

NHPSP National Health Policy, Strategies and Plans

NNICU Neonatal Intensive Care Unit

NORAD Norwegian Agency for Development Cooperation

NSDP National Strategic Development Plan

PAU Projects Accounting Unit

PBF Performance Based Financing

PEPFAR President’s Emergency Plan for AIDS Relief

PHC Primary Health Care

PIH Partners in Health

PITCT Provider Initiated Counselling and Testing

PMNCH Partnership on Maternal Newborn and Child Health

PMTCT Prevention of Mother to Child Transmission

PNC Post Natal Clinic

POA Plan of Action

PPP Public Private Partnerships

PRSP Poverty Reduction Strategy Paper

PSI Population Services International

PWD People Living with Disability

QMMH Queen ‘Mamohato Memorial Hospital

RB Regular Budget

RED Reaching Every District

SACU Southern Africa Customs Union

SADC Southern African Development Community

SHI Social Health Insurance

SIA Supplementary Immunization Activity

SWAP Sector-Wide Approach


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SWOT Strengths, Weaknesses, Opportunities and Threats

TA Technical Assistance

TB Tuberculosis

TSR Treatment Success Rate

TWR Total Fertility Rate

UN United Nations

UNDAF United Nations Development Assistance Framework

UNDRMT UN Nations Disaster Risk Management Team

UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

US United States

USG United States Government

VF Voluntary Contribution Fund

WCO WHO Country Office

WFP World Food Programme

WHA World Health Assembly

WHO World Health Organization

WR WHO Representative

XDR-TB Extensively Drug Resistant TB



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PREFACE:

The WHO Third Generation Country Cooperation Strategy (CCS) crystallizes the major reform agenda adopted by the World Health Assembly with a view to strengthen WHO capacity and make its deliverables more responsive to country needs. It reflects the WHO Twelfth General Programme of Work at country level, it aims at achieving greater relevance of WHO’s technical cooperation with Member States and focuses on identification of priorities and efficiency measures in the implementation of WHO Programme Budget. It takes into consideration the role of different partners including non-state actors in providing support to Governments and communities.

The Third Generation CCS draws on lessons from the implementation of the first and second generation CCS, the country focus strategy (policies, plans, strategies and priorities), and the United Nations Development Assistance Framework (UNDAF). The CCSs are also in line with the global health context and the move towards Universal Health Coverage, integrating the principles of alignment, harmonization and effectiveness, as formulated in the Rome (2003), Paris (2005), Accra (2008), and Busan (2011) declarations on Aid Effectiveness. Also taken into account are the principles underlying the “Harmonization for Health in Africa” (HHA) and the “International Health Partnership Plus” (IHP+) initiatives, reflecting the policy of decentralization and enhancing the decision-making capacity of Governments to improve the quality of public health programmes and interventions.

The document has been developed in a consultative manner with key health stakeholders in the country and highlights the expectations of the work of the WHO secretariat. In line with the renewed country focus strategy, the CCS is to be used to communicate WHO’s involvement in the country; formulate the WHO country workplan; advocate, mobilise resources and coordinate with partners; and shape the health dimension of the UNDAF and other health partnership platforms in the country.


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I commend the efficient and effective leadership role played by the Government in the conduct of this important exercise of developing the CCS. I also request the entire WHO staff, particularly WHO Country Representative to double their efforts to ensure effective implementation of the programmatic orientations of this document for improved health outcomes which contribute to health and development in Africa.

Dr Matshidiso Moeti WHO Regional Director for Africa



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ACKNOWLEDGEMENTS:

This Country Cooperation Strategy document is the product of a collaborative effort between the different levels of the WHO, the Ministry of Health and partners. We would like to express our appreciation to all who played a supportive role during the preparation of this document.


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ExECUTIvE SUMMARY:

The Country Cooperation Strategy (CCS) is the key guiding tool providing strategic direction for WHO and intensifying its interventions in the country. The first CCS in Lesotho was operational from 2004 to 2007, followed by the second CCS 2008-2013. Development of the new CCS to cover 2014–2019 comes at an opportune time when the National Health Plan has just been concluded and the sector strategic plan is in its finalization stage. The development process for this CCS involved documentation review, and both internal and external consultations which, were mainly in the form of structured qualitative interviews.

Lesotho is a small mountainous country which is completely landlocked by the Republic of South Africa. The country’s population is estimated at 1.8 million with gender distribution of 51.3% females and 48.7 % males. Life expectancy is estimated at 41.2 years, i.e. 39.7 years for males and 42.9 years for females; this signifies a decline of ten years, in relation to the 1996 census, due partly to the HIV/AIDS pandemic. The Lesotho Government is a constitutional monarchy with the King’s functions predominantly being ceremonial. The country practices democratic governance, with a prime minister as head of government with full executive authority.

Lesotho is classified as a Least Developed Country (LDC) with an estimated income per capita of $1,000 and an annual economic growth rate of 4.4%. The economic development of Lesotho has historically relied on remittances from Basotho employed in South Africa, where employment declined in recent years. The textiles and clothing manufacturing sub-sector has over the years absorbed the greater part of employees, but employment declined by 10.4% in 2011 due to economic recession, which resulted in the closure of some firms. The 2008 Labour Force Survey Report records a 25% unemployment rate, although the majority (71%) of the employed are found in the informal sector where the practice of in-kind payments is common. Livestock and major crop production levels fell over the years, resulting in a situation where the country produced only 30.0% of its food requirements.

The country boasts of a high literacy rate, with an estimated 85% of the population aged 15 years and above considered as literate. Female literacy (94.5%) in Lesotho remains higher than male literacy. The Demographic and Health Survey (DHS) of 2009 indicated that 80% of the population has access to improved sources of water, while 24% has improved sanitation facilities.


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HIV and AIDS remains the major health challenge with an estimated national prevalence of 23%. The ART coverage is at a low level of 51%. Lesotho is reported to be one of the fifteen countries with the highest per capita TB cases. On the other hand, the Treatment Success Rate (TSR) of 74% falls short of the target of 85%. Treatment of Multi-Drug Resistant Tuberculosis (MDR-TB) is donor-dependent, and the situation is worsening, as shown by monthly enrolment for treatment. The prevalence of tobacco use is put at 39.3% among the youth, while alcohol drinking is reported at 31%. Diabetes prevalence is also reported at 4% and cancer accounts for 4% of deaths. Trauma is the second main reason for male admissions in hospitals due to HIV and AIDS.

The government and its partners are engaged in a number of initiatives to promote healthy living and to create awareness. The newly introduced guidelines on Option B+ are implemented for prevention of Mother-to-Child Transmission. In line with the MOH broad plan on integrated service, ‘Family Health Days’ are also implemented. The number of facilities providing PMTCT has increased from 191 in 2010 to 203 in 2012 and PMTCT coverage is 52%. A 70% HIV sero-prevalence rate has been reported in April 2013 among TB patients. Access to PAP smear services has been availed in all hospitals and Lesotho Planned Parenthood Association (LPPA) clinics for early detection of cervical cancer. Human Papilloma Virus (HPV) vaccine for prevention of cervical cancer was also introduced. While immunization is known to be one of the most successful and cost-effective public health investments that can save children’s lives, immunization coverage is, on the average 60%, which is far less than the target of 80%.

Since the advent of decentralization, health service delivery has been entrusted to ten administrative districts of the country. There are two major health service providers, namely the Government of Lesotho (GOL) and the Christian Health Association of Lesotho (CHAL). The MOH has been able to allocate 14.8% of total government budget to the health sector; this is close to the Abuja declaration target of 15%.

Lesotho enjoys financial support from a number of health development partners towards both budget support and specific sector priorities. For the year 2012/2013, donor support constituted 25% of MOH capital budget. There is a Health Partners’ Forum which sets a platform for health development partners to share their areas of support to minimize or eliminate duplication of efforts. The Annual Joint Review (AJR) was introduced as a common monitoring mechanism for the Health Sector Review (HSR) and



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was inaugurated in 2003. The UN embarked on ‘Delivering as One’ as a strategy that provides an opportunity, not only to improve efficiency of the UN programme, but also to strive for greater impact of its efforts in supporting the National Strategic Development Plan (NSDP). Although there is limited knowledge of the CCS2G content within the MOH, the CCS2G priorities were broad enough to align with the ministry’s priorities. Some achievements have been noted regarding implementation of the CCS2G, with the pinnacle being completion of the National Health Policy (NHP) and drafting of the strategic plan. These achievements were made thanks to support from both WHO Regional Office and Headquarters. Financial and human resources within the MOH and the WHO Country Office (WCO) are the main challenges facing implementation of the CCS.

Determination of the strategic direction for WHO is based on the country’s key health challenges, priorities, WHO priorities at global and regional level, Lesotho United Nations Development Assistance Plan (LUNDAP) outcomes and feedback from the consultations which have provided an overview of the perceived comparative advantages of WHO. Five strategic priorities identified for 2014–2019 include: (i) Strengthening the prevention and control of TB, HIV & AIDS and other communicable diseases; (ii) strengthening maternal and child health services; (iii) prevention and control of non-communicable diseases; (iv) health systems strengthening and; (v) addressing the sociocultural and environmental determinants of health. These are entirely aligned to the priorities of WHO at all levels, the NHPSP and the LUNDAP. Implementation of these will benefit from continued support from WHO Regional Office and the Headquarters.


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SECTION 1:

INTRODUCTION

The Country Cooperation Strategy (CCS) is the key guiding tool which provides the strategic direction of WHO’s work in the country. It gives a high-level indication of WHO country support towards country specific health priorities in an attempt to assist the country to meet its own health agenda. To achieve this, the CCS aligns itself to the National Health Policy, Strategies and Plans (NHPSP). It creates an opportunity for the WHO country work to be harmonized with that of other players in the sector such as United Nations (UN) agencies and other health development partners.

The first CCS in Lesotho was operational from 2004 to 2007. This was followed by the second generation CCS (CCS2G 2008–2013) which expired at the end of December 2013. It is therefore essential that the third generation (CCS3G 2014–2019) be developed. This comes at an opportune time when the NHP has just been concluded and the sector strategic plan is in the finalization stage. The CCS2G had five (5) strategic areas as follows:

• Strengthening the control of HIV/AIDS and TB;• Strengthening family and community health, including sexual and

reproductive health;• Enhancing capacity for the prevention and control of major

communicable and non-communicable diseases;• Strengthening health system capacities and performance;• Fostering health sector partnerships, advocacy and equity.

The development process1 of this CCS involved consultations and extensive review of documents relating to global, regional and country-specific health issues to facilitate alignment. Consultations were in the form of structured qualitative interviews to enable open and detailed feedback. These began with internal stakeholders who are mainly WCO staff to establish the office’s view on the implementation of the CCS2G and for the team to share their thoughts towards the strategic agenda of the next CCS. Further consultations

1 Annex A provides details.


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were undertaken with the Ministry of Health (MOH) staff, mainly counterparts of WHO technical team. Some UN agencies, health development partners and representation of church-based organizations were also consulted to establish their opinion about WHO and its contribution to achieving the country’s health objectives, and to get guidance on the areas of focus for the next CCS, based on their thoughts around the comparative advantages of WHO. The people consulted individually constituted the review team, whose collective contribution will be obtained during the validation process of this document.

Internal consultations had limitations as some technical staff members were either fairly new in the organization or were unfamiliar with the CCS formulation process, and therefore were not able to provide much opinion about the CCS under review.

To implement the CCS, WHO agrees with MOH on two yearly plans and budget, the Biennial Plan of Action (POA), with the aim of providing a clear detailed analysis of the areas of implementation in the respective two years. The first POA for implementation of the CCS2G in Lesotho covered 2008–2009 followed by 2010–2011 and then 2012–2013. WCO Lesotho has, on average, a budget of US$ 5.0 million every 2 years and this can be exceeded based on local resource mobilization efforts.

The Policy of WHO is guided by its member states through the annual World Health Assembly (WHA). The WHO Global Agenda priorities are then articulated by the General Programme of Work (GPW) in recognition of the global health status and challenges. The 2014–2019 Global Health Agenda as articulated by the 12th GPW identified six (6) leadership priority areas which countries are expected to draw their priorities from in developing their CCSs.

Lesotho is a member of the 47 countries in the WHO African Region whose ministers of health contextualize and adapt the WHA priorities to their region.

This document is composed of six sections. The first section has defined the CCS development process and WHO Policy Framework. The second section provides an overview of the status of health and development in the country and the challenges thereof. Section three analyses the role played by health development partners and coordination mechanisms. The fourth section reviews WHO cooperation in Lesotho with specific focus on the life-cycle of the CCS2G. The fifth section highlights the proposed agenda for this CCS, followed by section six which captures the implications for WHO in implementing the CCS.





SECTION 2:

COUNTRY HEALTH AND DEVELOPMENT CHALLENGES

2.1 Geography The Kingdom of Lesotho (former Basutoland) is a small2 mountainous country which is completely landlocked by the Republic of South Africa. It is made up mostly of highlands which rise to nearly 3,500 meters in the Drakensburg Mountains. About one quarter of the country has altitudes of between 1,500 and 2,000 metres. The highland area is where many of the villages are hard to reach. The country is divided into four (4) ecological zones, namely Highlands (Mountains), Foothills, Lowlands and Senqu River Valley. The mountainous topography of the country presents difficult terrain and arable land is limited. The rural highlands are less developed and winters are severe with heavy snowfalls that often cut off the population from access to basic social services such as health.

2.2 Geographicprofileandcharacteristics ofpopulation

According to the 2006 Lesotho population census, the country has a population of 1880 661, with gender distribution of 51.3% and 48.7% females and males respectively. The total population of three (3)3 of the ten districts is more than half of the country’s population. These are inclusive of the capital city, Maseru, which is the most populous with 22.9% of the population. The rural areas of the country continue to have the highest percentage4 of the

2 30,355km2 of area

3 Leribe, Berea and Maseru

4 76% of the population


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population, although there has been a decline over the years. The annual growth rate of the population was 0.1% during the inter-census period of 1996 to 2006, which marks a significant decline5 compared to previous inter-census periods.

Age distribution, as estimated in 2012, is as follows: Age groups 0–14 years constituted 33.5%, 15–64 years, 61.1% while 65 years and over made up only 5.4% (Lesotho Country Profile, KPMG Proprietary Services 2012 and CIA World Factbook). Estimates of the census of 2006 put overall life expectancy at 41.2 years for the population, while for males and females these were 39.7 years and 42.9 years respectively. This is a significant decline of about 10 years, compared to the 1996 census figures. This decline in life expectancy is attributed to the high mortality rate resulting from HIV and AIDS. The Total Fertility Rate (TFR) was also reported as one of the lowest in sub-Saharan Africa at 3.3 children per woman.

An estimated 99.7% of the people of Lesotho identify as Basotho. The main language is Sesotho and it is the first official and administrative language. English is the second official and administrative language. Other languages used by the minority of the population include Ndebele, Xhosa and Zulu.

2.3 PoliticsandgovernancestructureThe Lesotho Government is a constitutional monarchy with the King’s functions predominantly being ceremonial, with no executive or legislative powers. The monarch is hereditary. The country is governed by a bicameral parliament consisting of a senate and an elected national assembly. The prime minister is the head of government with executive authority.

Lesotho is a democratic country that allows a multi-party political system following its independence from the British in 1966. During the same period, the country was also renamed the Kingdom of Lesotho from Basutoland. The first party to rule the country was Basotho National Party (BNP) and the country experienced a lot of political instability relating to elections over the years, including military coups. The last violent demonstrations against election results were those of the 1998 post-elections, which prompted a brief but bloody intervention by the combined South Africa and Botswana military forces under the auspices of the Southern African Development Community (SADC). The country became relatively stable after the 2002 elections.

5 2.6% (1976 – 1986) , 1.5% (1986 – 1996)





The latest elections of 2012 were inconclusive as they saw no party winning an absolute majority to form government. This resulted in formation of the first three-party coalition government which is currently ruling.

For administrative purposes, Lesotho is divided into 10 districts: Berea, Butha-Buthe, Leribe, Mafeteng, Maseru, Mohale’s Hoek, Mokhotlong, Thaba-Tseka, Qacha’s Nek and Quthing. The constitution provides for an independent judicial system. The judiciary is made up of the Court of Appeal, the High Court, Magistrate’s Courts, and traditional courts that exist predominately in rural areas. There is no trial by jury, rather, judges make rulings alone, or, in the case of criminal trials, with two other judges as observers. The constitution also protects basic civil liberties, including freedom of speech, association, and the press; freedom of peaceful assembly; and freedom of religion.

The legal system is based on English common law and Roman-Dutch law with judicial review of legislative acts in High Court and Court of Appeal. (Lesotho Judiciary, available on www.justice.gov.ls).

2.4 Socio-economicstatus

Lesotho is classified as one of the Least Developed Countries (LDC) with an estimated income per capita of $1 000 and an annual economic growth rate of 4.4%. The economic development of Lesotho has historically relied on remittances from Basotho employed in South Africa, customs duties from the Southern Africa Customs Union (SACU), and export revenue for the majority of government revenue. However, the government has recently strengthened its tax system to reduce dependency on customs duties.

As the world got into economic recession, Lesotho got affected too. Lesotho became eligible for trade benefits under the Africa Growth and Opportunities Act (AGOA) in 2000 and resumed exporting to the United States under the same in 2001, with its textiles and clothing manufacturing sub-sector growing substantially. However, the global economic crisis and the related slump in consumer demand in the United States (US) resulted in the sub-sector registering negative growth rates from 2007 to 2009 and recovered only in 2010. It was estimated to have registered a lower growth rate of 4.4% in 2011 compared with 6.4% in 2010. The bulk of the products are exported to the USA, therefore the slow recovery of the latter’s economy and the associated low consumer demand resulted in a decline in orders for Lesotho’s manufactured textiles, consequently, production had to be reduced and some manufacturing firms had to close down operations in 2011.


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The textiles and clothing manufacturing sub-sector dominates Lesotho’s manufacturing industry and makes a substantial contribution to employment and economic growth in Lesotho. This industry has had the majority of employees in the country. However, employment in the textiles sector dropped by 10.4% in 2011 due to the aforementioned closure. Similarly, employment in the public sector and South African mining industry dropped by 0.1% and 0.3% respectively. (The Central Bank of Lesotho (CBL) Annual report of 2006) The 2008 Labour Force Survey Report records a 25% unemployment rate, although the majority (71%) of those employed are in the informal sector, where in-kind payments are common.

The findings of the 2009/2010 Agricultural Census indicate that agriculture production, particularly production of major crops and livestock, fell quite significantly in 2009/2010, compared to the two previous census years. The drop in production over the years resulted in a situation where Lesotho produced only 30.0% of its food requirements and the deficit had to be imported. Food aid played a significant role in closing the gap. There are a number of factors constraining agricultural production in Lesotho, such as limited availability of arable land. The largest share of the population resides in rural areas, with the majority relying heavily on agriculture for their livelihoods. A decline in agricultural production therefore means aggravation of the poverty challenge. (CBL Economic Review, December, 2011, No.137 available at: www.centralbank.org.ls/publication).

2.5 Socialdeterminantsofhealth

2.5.1 Socio-economic

In 2010, Lesotho ranked 141 out of 169 countries on the Human Development Index (HDI), based on a value of 0.467. Despite the per capita of $1,000, Lesotho’s poverty head count was put at 54%, according to the 2002/03 national household income survey.

2.5.2 Socio-cultural

The DHS of 2009 indicates that 94% of children of primary school age (age 6-12 years) attended primary school. Of this total, 92% were boys and 97% girls. There seemed to be a strong positive relationship between household





economic status and schooling. In 2012, KPMG also indicated that Lesotho boasts high literacy levels, with an estimated 85% of the population aged 15 years and older considered as literate. Female literacy (94.5%) in Lesotho remains higher than the male literacy rate.

2.5.3 Environmental

The 2009 DHS indicated that 80% of the population has access to improved sources of water, with variation in the rural and urban areas, though the latter is more advantaged. In general, 25% of households take no longer than 30 minutes to get water from a supply source, while 23% have water in their home. A programme of water quality surveillance that looks into the structural integrity of drinking water facilities and the bacteriological quality of potable water is in place within the Ministry of Health. The programme is, however, not operating optimally to influence positive change management including maintenance of drinking water supplies. Information generated is not adequately used to predict potential hotspots for waterborne diseases.

Good household sanitation contributes to low infant mortality as it encourages improved hygiene. The 2009 DHS found 24% of the population with improved sanitation facilities, which mainly relate to availability and use of a toilet by family members only, with the facility ensuring that there is no human contact with waste.

While the country has no system for monitoring indoor and outdoor pollution, it is noted that 73% of households use cooking fuel that potentially results in air pollution (DHS 2009). The air pollution challenge is compounded by, among others, an increasing use of motor vehicles, emissions from industrial works and burning of wastes.

Waste management remains a challenge that needs to be addressed, especially in urban areas and in health-care facilities across the country. Lesotho has no formally licensed landfill sites and all waste is disposed at unlicensed and/or informal dump sites (MCA-Lesotho, 2010). Some of the waste disposed in these dump sites include ash from facilities for treating health-care risk waste.

The country’s capacity to monitor all aspects of food safety still remains limited. There is need to strengthen this capacity, taking into consideration the serious public health risks posed by the consumption of unsafe food.


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Table 1: Key socio-economic and demographic indicators

Indicators Value

Population size (De jure) 2006 1 880 661

Gender distribution (Females) 51.3%

Gender distribution (Males) 48.7%

Annual population growth 0.1%

Life expectancy at birth 42.2years

Total fertility rate 3.3 births

Literacy level (2012) 85%

Income per capita $1 000

Annual economic growth rate 4.4%

Unemployment rate (2008) 25%

Human Development Index(HDI) 141 out 169

Poverty head count (2002/03) 54%

Sources: Census 2006, KPMG 2012, Labour Force Survey Report 2008, National Income Survey 2002/03

2.6 Healthstatusofthepopulation

2.6.1 Maternal and child health

Lesotho health sector is faced with a number of challenges as indicated by the high maternal mortality ratio which increased from 762 per 100 000 in 2004, to 1155 per 100 000 live births in 2009. The life-time risk of maternal death is estimated at 1:32, implying that one out of 32 women in Lesotho will die of pregnancy and childbirth-related conditions though there has been an increase in the number of skilled birth attendance from 55% to 61% (DHS 2004, 2009). Maternal deaths due to pregnancy, childbirth and postpartum complications, are on the increase, indicating low quality of maternal services, coupled with high staff turnover.

Based on the 2010 maternal death report, there were 67 maternal deaths, with obstetric haemorrhage being the leading cause of deaths (31%), followed by complications of hypertension in pregnancy (25%). Pregnancy-related sepsis was 3.3%, while non-pregnancy-related infections were the





third commonest cause (11.7%). Overall, 78.3% of maternal deaths were a result of direct obstetric causes, while indirect causes accounted for 18.4% of deaths. These leading causes of maternal mortality are preventable and can be addressed by low-cost interventions. There has been a steady increase in contraceptive prevalence rate from 35% to 47%, though the country has not reached the 50% target for sub-Saharan Africa.

Infant mortality rate (IMR) is as high as 91 per 1 000 live births; under-five mortality is 117 per 1 000 live births; and child mortality is 28 per 1 000 live births (DHS 2009) are also high.

Recognizing the high burden of maternal and newborn ill-health on the development capacity of individuals, families and communities, there is an urgent need for provision of essential care during pregnancy, of skilled care during childbirth and the immediate postpartum period;, and a few critical interventions for neonates during the first days of life.

2.6.2 HIV and AIDS

The HIV epidemic remains the major health challenge and the most important obstacle to sustainable human and socioeconomic development in the Kingdom of Lesotho. The country has a generalized HIV epidemic and registers the world’s third highest HIV prevalence; and the fifth highest TB-HIV co-infection rates. The annual incidence is still at 2.47% and prevalence at 23%. New infections and prevalence are higher among women than men aged 15-49 years and prevalence is highest at over 40% among people aged 30-39 years. Among young people aged 20-24 years, HIV prevalence is also high, estimated at 16.3%, while 4 000 children below age 14 years continue to be infected with HIV every year.

The country continues to experience a serious health impact of the epidemic. In 2012 about 23 000 adults and 4 000 children were newly infected, and more than 250 000 adults and 37 000 children under the age of 14 years were infected with HIV in 2013. Moreover, pregnant women who were estimated to be with HIV was 14 763; 11, 000 women and men had HIV-TB co-infection.

Though AIDS-related mortality in Lesotho reduced from more than 21 000 in 2001 to less than 10 000 in 2013, only 60% who needed the life-saving ARV medicine were receiving it. AIDS continues to be the highest cause of death and accounted for 20% male, 22% female, and 8% child deaths in hospitals (AJR 2013).


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2.6.2 Tuberculosis

Lesotho has the fifth highest estimated TB incidence in the world, with rates of new TB cases estimated in 2012 at 630 TB patients per 100 000 populations with incidence of sputum smear positive TB estimated at 281 TB cases per 100 000 population. TB notification rates have remained above 400 per 100 000 population.

TB burden remains huge in Lesotho, with prevalence of all types of TB estimated at 424 cases per 100 000 population, and yet the TSR remains low at 74% and contributes to a high TB mortality estimated at 17 deaths per 100 000 annually. The majority of people with the disease who are notified annually are in the young economically productive age group of 24-35 years. This mirrors the HIV age distribution profile, suggesting continuing transmission of infection rather than reactivation of old infection. About 80% of notified TB cases are also HIV positive. Other factors favouring transmission of tuberculosis infection and progression to disease include poverty, overcrowding, poor ventilation, alcoholism and poor nutrition as well as the mining community.

2.6.3 Noncommunicable diseases

Tobacco use is another factor contributing to health risks, with tobacco reportedly killing nearly 6 million people around the world each year. The WHO STEPS survey on chronic disease risk factors was carried out in Lesotho from April to May 2012, and to date, only preliminary results are available. The findings indicated that about 25% of Basotho are currently smoking, with majority being males (48.7%). WHO report on the global tobacco epidemic of 2013 also portrays 39.3% prevalence of tobacco use among the youth in Lesotho.

Overindulgence in toxic substances and unhealthy lifestyles are other health challenges. Alcohol intake in Lesotho is reported at 31% according to the preliminary results of the WHO STEPS survey, with men accounting for the highest proportion. The same study indicated 83.8% of sampled population with raised BP (SBP ≥ 140 and/or DBP ≥ 90 mmHg) who were not on medication. About 42% of people did not exercise regularly, and 92.7% of them ate less than 5 servings of fruit and/or vegetables on average per day. .

Diabetes, one of the costly non-communicable diseases (NCDs), affects people of all ages and is reported to be responsible for 4.5 million deaths in the world in a year. The WHO STEPS survey reported prevalence of 4% in Lesotho. It is among the top ten causes of disability, and can result in





a number of life-threatening complications (AJR 2013/ Partnership, Mental Newborn and Child Health – PMNCH 2013).

The Global Cancer Facts and Figures indicate that there were 7.6 million deaths related to cancer in 2008, the majority of which were in the least developed countries. It is estimated that the burden could be higher due to currently adopted unhealthy lifestyles, such as smoking, physical inactivity, and poor diet to mention a few. The WHO Global Burden of Disease estimates also highlight that cancer accounts for 4% of deaths in Lesotho. Unfortunately no accurate data on the burden is available in Lesotho.

Trauma remains the second main reason for admission of males in hospital, after HIV and AIDS, with resultant death ranging from 3%-6% (AJR 2012). Causes of trauma are mainly head injuries resulting from fights. According to police data, injuries resulting from road traffic accidents are also on the increase, with the burden mainly in the capital city, Maseru. The table below reflects trends in some key health indicators.

Table 2: Trends in health indicators

Indicators 1976 1986 1996 2006 2004 2009 2011

Life Expectancy 51 53 59 41 41.02 41.84 50

IMR/1000 live Births 103 84 74 94 91 91 63

Child Mortality Rate/1000 - 34 34 24 24 28

U5 Mortality Rate/1 000 5 - - 113 113 117 86

MMR/100000 Births - 282 282 939 762 1155 620

Sources: Health Policy 2011 and WHO Health Statistics 2013

2.7 Nationalresponsetoovercoming healthchallenges

In line with global and regional commitments, and in an effort to improve and sustain the quality of life of the Basotho people, the NSDP of Lesotho places halting and reversing the HIV and AIDS epidemic among its population high on its development agenda. The country finances 70% of cost of ARV medicines and will finance 100% of TB medicines, based on the 20% annual incremental contribution from 0% in 2009. Lesotho has mobilized financial and technical support from a number of partners towards achieving its MDG targets for HIV/AIDS and TB. Below is an account of specific initiatives undertaken by the government to address these challenges.


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The national responses to HIV and TB have been based on the NSDP, NHPSP, the country‘s commitment to regional and global HIV/TB resolutions and declarations; as well as the emerging global movement for Universal Health Coverage with essential high impact health interventions and opportunities brought about by developmental and technological innovations, with bearing on the efficient delivery of HIV and TB prevention and control services.

Through the 2008–2012 National TB and Leprosy Plan and 2011-2015 National Strategic plan for HIV and AIDS, the country continued to pursue the attainment of the Millennium Development Goals targets for HIV, AIDS and TB control. A new national TB Strategic Plan 2013-2017 has been developed.

The country has achieved universal health facility coverage with HTC, PMTCT, ART and TB DOTS services, and is scaling up interventions consistent with the Global Health Sector Strategy on HIV/AIDS 2011-2015, as well as the STOP TB Strategy. HIV, AIDS and TB control services are integrated in the Primary Health Care (PHC) system and HIV/AIDS and anti-TB medicines are provided free of charge to all patients, even in the non-state sectors. The government has established partnerships with the Christian Health Association of Lesotho (CHAL) for the management of HIV and TB patients and is seeking to expand the scope to cover other private health-care providers.

The country has adopted the global HIV and TB policies, guidelines and tools for service provision and management, including programme and disease monitoring. HIV sentinel surveillance has been conducted every two years; the last one was in 2011 and the latest for 2013 is in progress. In addition, HIV surveillance was included in the LDHS, and provided useful population-based data in 2004 and 2009. The next one is planned for 2014. However, the true burden of TB is not yet known, as the first national TB prevalence survey is only planned for 2014. The National policy provides for ambulatory treatment of patients and treatment approaches are based on WHO/IUATLD guidelines and recommendations.

HIV and TB diagnostic services have been expanding progressively, with all the public health facilities able to provide rapid testing for HIV and microscopic diagnosis for TB, including an innovative approach (“Riders for Health”) to get laboratory specimens and results to and from health centres. The Government is contributing 70% of funds needed for the purchase of ARV medicines, and has been contributing progressively towards the procurement of first-line anti-TB medicines from the Global Drug Facility, reaching 100% at the beginning of 2014. “Community-Based Support Group and “Community DOT Supporters’ initiatives are being widely implemented to improve treatment adherence.





Lesotho is running both hospital and community-based MDR-TB treatment models. All DR-TB patients are systematically started on TB treatment or both TB and ART for co-infected patients, within a short time of diagnosis. The country has a well-developed laboratory capacity to diagnose MDR-TB, using conventional technologies, and is rolling out new WHO-endorsed rapid molecular tests to aid early diagnosis. All confirmed M/XDR-TB cases are able to access free second-line anti-TB medicines and there have been no waiting lists for treatment.

The following major issues and challenges still remain: True burden of TB in the country is not yet known as no TB disease survey has ever been conducted; Government resource allocation for HIV and TB control activities, including human and financial resources, are not yet commensurate with the size of the disease burden; the ART coverage and TB treatment success rates are still fall far below the 80% and 87% of the global target respectively. This is mainly due to low enrolment of people with HIV in treatment and poor retention into treatment for both people with HIV and TB, attributed to high patient loss to follow-up and death rates; HIV and TB diagnostics are still faced with frequent shortage of HIV test kits and lack of microscopy services at some facilities, as well as low coverage of Gene-Xpert technology due to the challenging geographical terrain of the country.

There are still significant portions of the population without easy access to essential HIV and TB diagnosis and treatment services, due to geographical barriers, especially during rainy and winter seasons. Some health facilities, especially at peripheral level, do not initiate treatment even for laboratory-confirmed susceptible TB cases as well as for children with HIV. A vertical model of DR-TB management is partner-run and driven, with minimal oversight by the NTLP and the general primary health care system. The capacities of designated laboratory to conduct DST for second-line anti-TB medicines and access to culture and DST services by far located and rural health facilities is still a challenge.

There is still limited functional collaborative linkage between the two programmes at central and district policy levels, as well as in the service delivery points/health facilities resulting in low coverage of ART among HIV/TB co-infected patients. Patient monitoring tools for HIV and TB are not linked and there is incomplete and unreliable recording on HIV and TB activities. Infection control at health care facilities remains a challenge and most of them do not have infection control plans.


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Lesotho employs a number of mechanisms to discourage unhealthy habits, and tobacco is recognized as the most preventable cause of non-communicable diseases. World No-Tobacco day is celebrated annually and a number of anti-smoking campaigns are organized in the country. Lesotho ratified the WHO Framework Convention on Tobacco Control (FCTC) in 2005, and the Tobacco bill has been completed. The Anti-Drug and Alcohol Association of Lesotho (ADAAL) which promotes student awareness against substance abuse in high schools is in place. There is also a programme towards prevention of alcohol use implemented with a Norwegian development non-governmental organization.

In order to control high blood pressure and diabetes, health promotion initiatives, through different types of media, have been employed to promote screening of both diseases.

Cancer screening is one of the factors that control the disease burden, therefore, access to PAP smears services has been availed in all the hospitals and LPPA clinics for early detection of cervical cancer. The cervical cancer screening programme was also launched at Senkatana at the beginning of 2013. Unfortunately to date, treatment is not yet provided in the country. As one of the primary prevention approaches, in 2011, the MOH introduced a HPV vaccine towards prevention of cervical cancer. This was piloted in two districts before it was replicated in the remaining eight districts.

In May 2011, Lesotho launched a Decade of Road Safety which included production of educational information on prevention of road traffic accidents.

Immunization is known as one of the most successful and cost-effective public health investments that can save children’s lives. Thus immunization can significantly contribute to achieving the MDG 4 relating to reduction of child mortality, which aims to reduce under-five mortality by two thirds by 2015. Several initiatives were therefore taken to improve immunization coverage. Data Quality Self-Assessment (DQS) was conducted which led to identification of four districts with high numbers of unimmunized children. Reaching Every District (RED) training was conducted in the identified districts. Expanded Programme on Immunization (EPI) recording and reporting tools were reviewed to incorporate new vaccines. The national routine immunization by vaccine showed the immunization coverage to be, on the average, 60%, which is far less than the target of 90%. This is of great concern in perspective of achieving the MDG target on immunization.

The country has a Disaster Management Authority (DMA) in preparedness for emergencies. The Emergency Preparedness and Response (EPR) plan exists but needs to be reviewed. The country also has an Integrated Disease





Surveillance and Response (IDSR) in readiness for outbreaks. There is a multi-sector Business Continuity Plan (BCP), which is not necessarily disease-focused but covers all types of emergencies. It has been completed through coordination by DMA, but is yet to be endorsed. Communication of emergencies needs to improve as it sometimes is delayed. Multisectoral post-disaster needs assessments are undertaken after each disaster to determine the effects and required remedial actions. WHO partakes in health-related assessments.

3.3 UNReformsStatusandUNDAFProcessHistorically, the health service delivery functioned within the Health Service Areas (HSA) which divided the country into 18 zones. Following decentralization, health service delivery is now assigned to ten administrative districts of the country. Each district has at least one hospital. There are two major health service providers namely, the Government of Lesotho (GOL) and the Christian Health Association of Lesotho (CHAL) with ownership of about 60% and 40% of the health institutions respectively. The table below indicates the total number of health facilities by district and ownership.

Table 3: Summary of health facilities by ownership

Proprietor# of

General Hospitals

# of Primary

Hospitals

# of Health Centre

# of Filter

Clinics

Total # of Facilities

GOL 12 0 83 4 99

CHAL 8 0 73 0 81

Red Cross 0 0 4 0 4

Private 1 4 47 0 52

GRAND TOTAL 21 4 207 4 236

Sources: Health facilities list 2013

The new state-of-the-art referral hospital, Queen ‘Mamohato Memorial Hospital (QMMH) has been operational since October 2011, in replacement of the old Queen Elizabeth II Hospital (QE II) through an innovative, ground-breaking Public-Private Partnership (PPP). The hospital comes with advanced equipment and additional services, such as the Intensive Care Unit (ICU) and Neonatal ICU (NNICU), which were previously unavailable in QE II.


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The government is the main financier of the health sector budget, with CHAL also benefiting substantially from government subvention. The government undertook a study to conduct feasibility of a Social Health Insurance (SHI) as another source of funding for health-care services. However, no progress has been made after the study. It is worth mentioning that in the past financial year, the GOL has been able to allocate 14.8% of the total government budget to the health sector; this is close to the Abuja declaration target of 15%. Also per capita spending on health has been increasing over the three years from 2009/10 to 2012/13.

The MOH has institutionalized a Human Resources Information System (HRIS) to track HR information for the health facilities of GOL, CHAL and Lesotho Red Cross Society (LRCS). This system is being used to generate data on current supply of Human Resources for Health (HRH) and to date, there is a total of 2 848 employees within CHAL, GOL, and the LRCS. The donor community finances 11% of the total workforce.





SECTION 3:

DEVELOPMENT COOPERATION AND PARTNERSHIPS

Lesotho enjoys financial support from a number of health development partners towards both budget support and specific sector priorities. For the year 2012/2013, donor support constituted 25% of the MOH capital budget. Lesotho also enjoys proceeds from Global Fund towards HIV and AIDS and TB interventions that support patients who are chronically ill. The Fund also helps to retain human resources of the health sector.

3.1 AidEnvironmentintheCountry Each partner is expected to make financial, technical or any material contributions to the health sector. Health partners are categorized as development, and implementing partners, where development partners provide financial support by channelling funds to the MOH or other agencies that implement directly. Implementing agencies are those that are seen on the ground, at all levels of the health sector, inclusive of district and community, implementing some of the activities directly. WHO is known for its technical support, apart from being a funding agency. Ultimately, all partners support the ministry’s priorities at different levels. The table below shows the areas supported by various health partners categorized as development partners.


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Table 4: Health Development Partners’ areas of support

Areas of Support Development Partner

General Management (Excluding HR) Irish AID, World Bank, Global Fund, EU, MCC,

Decentralization Irish AID, World Bank, MCC

Monitoring and Evaluation, Research and MIS Irish AID, WHO, World Bank, MCC, IHM

Medical Waste Management World Bank, WHO, MCC

Human Resources (Including short term training) Irish AID, WHO, UNICEF, USG, World Bank,BUMC , Kellogg Foundation, ADB, UNFPA, MCC

Curative Health Care (Includes Lab + LBTS) WHO, World Bank, USG, - CDC, Global Fund,MCC, FIND, SolidarMed, KNCV

Communicable Diseases (HIV and AIDS, TB) WHO, Global Fund, USG, Irish AID, CHAI, PIH,GAVI

Disability Services NORAD Social Welfare Services, USG, Global Fund, EU,

Public Health Services WHO, UNICEF, USG, Global Fund, EU

Sources: Interview with Health Planning

The World Bank, EU and ADB are in the process of launching direct budget support for the country. The UN will play an active role in enhancing the capacity of Government to meet the requirements for budget support, and in ensuring that international principles and standards are taken into account in the design and implementation processes.

Annex B indicates the financial support provided by development partners in the past three years, based on the amounts received by the Project Accounting Unit (PAU) during the past three financial years of the CCS2G life. Funding amounts spent directly from partners have not been reflected, and this makes it impossible to undertake proper comparative analysis of partners’ support. It can be noted from the Annex that the partners that provided consistent financial support over the three years are the Irish AID, UNICEF, EU, MCC, the World Bank and PEPFAR.

3.2 CoordinationandAidEffectiveness intheCountryIn an effort to coordinate the high number of health partners, a Partnerships Coordination Code of Conduct was developed and introduced to the MOH partners. It provides guidance on the entry point of partners into the MOH, planning and reporting requirements by partners to the MOH. Not many partners are familiar with the Code of Conduct, and a number of the ministry





departments are also not aware of the document, with the exception of the Department of Health Planning and Statistics (DHPS). The challenge with partners is the frequent turnover of their leadership, leading to loss of institutional memory, which could be one of the reasons the code of conduct is unknown to partners whose organizations have been in the country for some time. One of the challenges experienced in implementing the code of conduct was the entry point into the MOH, which is identified as the DHPS, while with respect to implementation, it was often the office of the Director General of Health Services (DGHS).

There is a Health Development Partners Forum co-chaired by the WHO and PEPFAR. The forum sets a platform for health partners to share their areas of support to minimize or eliminate duplication of efforts. The forum does not yet involve the MOH to enable ownership of coordinating responsibility. The partners only share information and do not plan together, which does not facilitate elimination of duplication of efforts as anticipated. The need for the MOH to hold the fort in coordinating partners is noted.

The AJR was introduced as a common monitoring mechanism for the Health Sector Review (HSR) and was inaugurated in 2003. It has since continued to be a platform for the joint review of performance of the health sector. One of the main areas of focus for the health development partners is to advocate for joint planning by the MOH and its partners, and for strategies to align donor support with the government financial year. Sector Wide Approach discussions are under way to determine the way forward for its implementation.

3.3 UNReformsStatusandUNDAFProcessThe UN aims to support the Government of Lesotho in its efforts to realize the long-term national Vision 2020, the objective of which is to improve the quality of life of all Basotho. The UN embarked on ‘Delivering as One’ as a strategy that provides an opportunity, not only to improve efficiency of the UN programme, but also to strive for greater impact of its efforts. The approach draws on all UN efforts and expertise to deliver a multi-sector approach to development.

The United Nations Development Assistance Framework (UNDAF) is a strategic framework that defines collective outcomes and activities of the aforementioned support of the UN agencies towards the country’s priorities. This facilitates effective support of the agencies, avoids duplication of efforts and enables the agencies to tap on each other’s comparative advantages.


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The development process of the UNDAF involves participation of resident and non-resident UN agencies, Government and other key development partners. As a member of the UN family, WHO CCS2G is aligned to the UNDAF whose outcomes were presented in Table 5 below.

Table 5: UNDAF and CCS2G outcomes and strategies

UNDAF 2008-2012 Outcomes CCC2G (2008-2013) Strategies• Outcome 1 - strengthened national

capacity to sustain universal access to HIV prevention, treatment, care and support as well as impact mitigation.

• Outcome 2 - improved and expanded equitable access to quality basic health, education and social welfare services for all by 2012.

• Outcome 3 - increased employment, household food security and enhanced natural resource and environmental management.

• Outcome 4 - good governance and gender equality

• Strengthening the control of HIV/AIDS and TB

• Strengthening family and community health, including sexual and reproductive health

• Enhancing capacity for the prevention and control of major communicable and non-communicable diseases

• Strengthening health system capacities and performance

• Fostering health sector partnerships, advocacy and equity.





SECTION 4:

REVIEW OF WHO COOPERATION OVER CCS2G CYCLE

The WHO Country Office regards the CCS as their core guiding tool towards development of operational plans and they ensure that country operations are aligned to national specific priorities.

The Government of Lesotho has provided guidance on the development areas towards improving the quality of life of every Mosotho through Vision 2020. Regarding health, the country’s vision is that by the year 2020, Lesotho will have had “a healthy and well-developed human resource base” (The Lesotho Vision 2020). Vision 2020 is operationalized through short-term strategic plans, such as the Poverty Reduction Strategic Plan (PRSP) and now the National Strategic Development Plan (NSDP 2013 - 2017). The PRSP health sector priorities included promoting access to quality and essential health care by developing clear policies; improving health infrastructure; equipment maintenance and supplies; improving capacity, health management systems; and strengthening disease prevention programmes.

The health priorities are further fine-tuned by the National Health Policy and the Strategic Plan. The country’s health priorities compared to the CCS strategic agenda for the review period were:


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Table 6: Health priorities and CCS2G priorities

Health Priorities CCS Priorities

The POAs which are operational plans of the CCS get finalized with the MOH to present an opportunity for the MOH to ensure that they are aligned to health priorities. This CCS was entirely aligned to the country health priorities as its objectives were broad enough to accommodate current and emerging issues.

4.1 SupportfromHeadquartersandAFRO

The WCO received different kinds of support from both Regional Office and Headquarters (HQ) which included, but not limited to technical assistance, where necessary and financial support, which sometimes is insufficient. Additional support includes annual progress review meetings to assess performance, based on previous year recommendations, with the guidance of the regional office; attendance of meetings which normally includes the MOH staff to reinforce alignment with government strategies, guidelines and protocols.

4.2WHOresponsetochangingcountryneeds Despite documented priorities, the country sometimes experiences emergencies or development actions that warrant modification or refocus of some priorities. These emergencies and development actions include outbreaks, which were experienced during the period under review, floods

• Sexually transmitted infections, TB, HIV/AIDS

• Sexual Reproductive Health, Essential Clinical Services

• Public Health intervention

• Essential Clinical Services and Common illnesses (Diabetes, hypertension, eye infections, skin infections, Oral Health and Mental Health.

• Social Welfare services (Child Welfare, Youth services, Services for Women, Services for adults in difficult circumstances, Services for People Living with disabilities (PWD) and Services for the elderly

• Strengthening the control of HIV/AIDS and TB

• Strengthening family and community health, including sexual and reproductive health

• Enhancing capacity for the prevention and control of major communicable and non-communicable diseases

• Strengthening health system capacities and performance

• Fostering health sector partnerships, advocacy and equity.





and droughts that led to declaration of famine. The WCO has almost always been able to accommodate changes, if the MOH requested variation on the POA.

Food security did not have budget allocation within WHO, but when the Right Honourable Prime Minister declared famine, WHO mobilized funds in response to the declaration. Secondly, WHO has been on the forefront to guide supplementary measles campaigns. On another occasion, WHO assisted the MOH Monitoring and Evaluation Unit with data capturing and analysis to eliminate data backlog. In early 2008, the country experienced anthrax outbreak with 650 human cases in two districts resulting in six deaths. WHO, at the time, provided technical and material support to the MOH. WHO also mobilized procurement of zinc for diarrhoea during an outbreak, although it was not used. During the 2009 Influenza A (H1N1) pandemic, WHO provided vaccines from Headquarters. All government interventions to curb Influenza A (H1N1), with WHO support, were effective because out of 58 cases, there was no mortality, compared to our neighbouring countries which had 15% of mortality. These are a few examples that demonstrate WHO efforts to support the country’s changing needs. Regarding emergencies in general, the UN works as one body, through the coordination of the United Nations Disaster Risk Management Team (UNDRMT) with funding from individual agency funding sources or funding sourced from, among others, the United Nations Central Emergency Response Fund.

4.3 OtherPatners

Harmonization and coordination among the UN agencies is clearly articulated and is operational. Administrative harmonization within the UN will be enhanced by the new business operation strategy which is being finalized. Other partners do recognize WHO as broker for health at the global, regional and country levels, and therefore do not implement their strategies outside the guidelines, norms, standards and protocols of WHO. At country level, partners support is more guided by the country’s priorities. There is recognition among partners that the ministry regards WHO as a custodian of health guidelines, norms and standards. It is, therefore, essential for WCO to facilitate consistent and effective communication of its priorities to its main partner, the MOH, and to actively undertake its advisory role to the MOH to ensure optimal achievement of the global health agenda.

WHO continues to recognize capacity of other players, such as CHAL, in the health sector to facilitate implementation of some of its activities, albeit on a small scale.


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4.4 AchievementsofCCS2G

Completion of the national health policy is the number one achievement which benefited from WHO technical support, and financial support from other partners. Drafting of the strategic plan has also commenced. A narrative of the key achievements through the support of WHO during the review period is summarized below:

4.4.1 Strengthening control of HIV/AIDS and Tuberculosis

WHO provided support for adoption and implementation of option B+. It was adopted and scaled up in a short space of time. Initial training and rollout of HIV management at the districts was done. WHO initiated the task shifting, even though it has been taken over by other partners, and provided training on adaptation of new guidelines on PMTCT. Conduct of the PMTCT gap analysis and HIV Sentinel Surveillance, as well as HIV drug resistance also benefited from WHO support. New guidelines were developed on ART and prevention, focused on male circumcision and male circumcision strategy was also developed in collaboration with other partners.

WHO also supported review of the TB programme; development of the TB strategic plan; development of the HIV strategic plan; and conduct of the TB drug resistance surveillance. WHO also participated in mobilization of resources through the Global Fund.

4.4.2 Strengthening Family and Community Health

Lesotho MMR continues to be exceptionally high and it is unlikely that the country will reach MDG 5 in 2015. In partnership with sister UN agencies, mentors on maternal, neonates, and child health, including family planning, are available in all districts. Mentorship and supervision of emergency obstetric care at hospitals has been regularized; MDR has been institutionalized and guidelines on pregnancy, childbirth, postpartum and newborn care (PCPNC) are available.

In an effort to increase facility deliveries, Thaba-Tseka was used as a pilot by WHO, together with WFP and FAO, to strengthen waiting mothers’ homes by providing food so that mothers can stay in them. They cook for themselves at the clinics. The waiting mothers’ equipment, such as beds and delivery mattresses for some hospitals, was procured without duplicating areas where MCC is covering. Water tanks were provided to some clinics to facilitate delivery at clinics, as water is one of the barriers to undertaking safe delivery.





Community dialogues were conducted in 6 districts to promote the use of health facilities for ANC and postpartum, including services for children. For the first time in the country, a report on maternal death review was produced in 2010 and disseminated in 2013. Maternal death review tools were developed including a midterm review of the roadmap for accelerating reduction of maternal and newborn morbidity and mortality and a costed MDG Acceleration Framework plan and M&E and FP guidelines and tools.

Implementation of the Integrated Management of Childhood Illnesses (IMCI) has been scaled up in all 10 districts, and follow-ups after training have been strengthened. The Child Survival Strategy is in place. HPV vaccine has been introduced in 2 pilot districts and is expected to be rolled out to all 10 districts by 2015. Adolescent Health Standards are in place for all levels of care.

Infant and Young Child Feeding (IYCF) guidelines and training manual, and the Health Sector Nutrition strategy are available. Capacity of health workers was built on IYCF; management of severe acute malnutrition; and follow-ups on implementation of the Baby Friendly Hospital Initiative.

4.4.3 Enhancing Capacity for Prevention and Control of major Communicable and Noncommunicable Diseases

Six areas of focus were identified within this strategic priority and a summary of achievements are given below.

4.4.3.1 Noncommunicable Diseases

The WHO STEPS survey was undertaken, although only preliminary results are available. The alcohol policy has been completed but not yet disseminated, and the tobacco control bill has been drafted. Within pharmacy list to determine the type of medicine that circulates in the country has been established, and this has been compiled into a book, since it guides the law; this will lead to registration of drugs. The Mental Health Act has been updated; the community mental health programme is functional in five districts and the Mental Health Law has been drafted. The Mental Health Policy and Strategic Plan have been developed and advocacy for Mental Health Services, through Inauguration of Mental Health Day has been strengthened. One Epileptic Group was established in Leribe, the objective being to boost self-awareness of epileptic patients through self-help projects. A mental health gap study on autism is currently under way.


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4.4.3.2 Integrated Disease Surveillance System

The country has been supported to adapt the second edition of the integrated disease surveillance and response guidelines, together with training manuals (participants and facilitators). National and district trainers were trained while the training of health-facility workers is in progress. The guidelines cover priority diseases (communicable and non-communicable), priority conditions and events, including those covered by the International Health Regulations of 2005 (IHR 2005).

The country assessment of core capacities to implement the IHR 2005 was conducted; an implementation plan for improving capacities has been developed and is being implemented. WHO assisted with the establishment of IHR office through procurement of office equipment for five points of entry and establishment of a toll-free phone number at the National IHR Focal Point.

Implementation of the Rio Political Declaration took off with the support of WHO and the Healthy settings initiative was successful in Mohale’s Hoek and Quthing. Following the signing of the Libreville Declaration on Health and Environment in Africa, Lesotho was one of the five top countries to implement its first phase (situation analysis and needs assessment) through WHO support. Port health guidelines were developed and training was provided; occupational health guidelines were developed too. Environmental health indicators and working tools were also developed. A Food Safety initiative on Five Keys to Safer Food, which involved competitions in schools, was successfully undertaken, focusing on schools in Quthing district, and on food-handling establishments in Butha Buthe district. Food safety training manuals “Bringing Food Safety Home”, using the WHO Five Keys to Safer Food were developed, printed and distributed for use by districts.

4.4.3.3 Expanded Programme on Immunization

WHO supported the introduction of new vaccines; HPV and Human Influenza B (Hib); and establishment of sentinel surveillance to identify disease burden for Hib diseases and pneumonia. New tools to collect monitoring data at district level and data quality self-assessment tools were developed, and now the country is able to meet surveillance indicators. Cold chain equipment has been procured. WHO also facilitated introduction of strategies to improve immunization coverage; and vaccine management and IDSR training were carried out.





4.4.4 Health System Strengthening The first achievement under this strategic priority is the main one mentioned at the beginning of this section, namely development of health policy, drafting of a costed strategic plan, although it has remained in a draft form since 2012; the PHC policy has been drafted. Further achievements include development of research policy; establishment of health research agenda; facilitation of functionality of the ethics committee, with regular meetings that attract some sitting allowance; development of research strategy and office support through procurement of office equipment.

4.4.4.1 Monitoring and Evaluation Quarterly supervision at district level was facilitated; COHOT analysis exercise was undertaken; HIV and AIDS data system was upgraded and data collection tools reviewed; and all ten districts were trained on the tools.

Within Pharmacy in Disease Control and Main Pharmacy, training on new WHO guidelines was done; country profile for pharmaceuticals was undertaken and pre-qualification of ARVs was also undertaken.

Together with other partners, WHO continued to support the Ministry of Health in undertaking quarterly review sessions with districts, as well as the annual joint review for the health sector. The annual joint review looks into the sector’s performance from the management, programme and district levels.

4.4.5 Fostering Health Sector Partnerships, Advocacy and Equity WHO managed to resuscitate the health development partners’ forum as a communication platform for development partners. Meetings were held as scheduled, though involvement of the MOH still falls short. Other areas of focus are also not performing to expectation, as provision of technical support to partners did not occur and capacity of the WCO remains a challenge.


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4.5 ChallengesinImplementationofCCS2G

The following challenges were noted as obstacles (at different degrees) to implementation of the CCS. Challenges included generic ones experienced within the health sector, but ultimately had an impact on implementation of the CCS.

There was generally lack of knowledge about the CCS, and limited clarity on the content of the POA to some MOH programmes; this led to poor performance and participation of relevant people in some activities. Inadequate communication about the WHA and RC resolutions and agreements, as well as insufficient funds from WHO in some programmes were other noted challenges. Implementation progress is dependent on MOH counterparts, who sometimes seem overwhelmed by demands on them by all partners, due to limited coordination. The WCO has limited capacity in terms of number of staff with the required technical skills and expertise.

External challenges include: Limited human resource capacity within the MOH; programme management at the MOH which is sometimes handled by staff with limited technical expertise; also personnel are not provided with the necessary capacity to facilitate their work; and District Health Management Teams (DHMTs) still do not have standing management. They are led by volunteer focal persons whose turnover is too frequent. Most of the doctors are not from the local area and so turnover at the district hospitals is equally high. They get trained, but during follow-up, one finds a new doctor. This renders training effort ineffective and leads to concentration of resource utilization on one agenda. The Health Management Information System (HMIS) is weak; hence there is lack of credible data. There is limited accountability within the MOH. Submission of reports to WHO after expenditure is always delayed; lack of standard procedures to guide what should be done within the MOH, coupled with limited communication to all parties concerned are the recognized contributing factors. Furthermore, there were too many administrative changes, without the latter being communicated to the officers concerned with such changes. A SWOT analysis in Annex C summarizes the strengths, weakness, opportunities and threats facing WCO for implementing the CCS, while the table below summaries the financial and human resource allocation to each strategic agenda. Overall, the prevention and control of communicable and non-communicable diseases was better resourced while the area of health systems strengthening was the least resourced during the period 2008-2013.





Table 7: Financial and human resource allocation per strategic agendaStrategic Agenda Budget

Allocation (USD)

% to total budget

allocation

Human Resource AllocatedNational International Total

Strengthening the control of HIV/AIDS and Tuberculosis

2,368,268 19.4 0 1 1

Strengthening family and community health,

2,091,390 17.2 1 0 1

Enhancing capacity for the prevention and control of major communicable and non-communicable diseases.

3,632,415 29.8 3 0 3

Strengthening health systems 1,254,870 10.3 0 0 0

Fostering health sector partnerships, advocacy and equity.

2,834,460 23.3 9 1 10

TOTAL 12,181,403 100 13 2 15


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SECTION 5:

STRATEGIC AGENDA FOR WHO COOPERATION

Determination of the strategic direction for WHO is based on the country’s key health challenges and priorities; WHO priorities at global and regional level; and LUNDAP outcomes and feedback from consultations providing overview of the perceived comparative advantages of WHO. Major health challenges as identified by the health policy include:

• High maternal mortality due to limited accessibility of essential maternal care services;

• Faltering trend of under-five and infant mortality;

• Decline in immunization coverage;

• Increased morbidity and mortality from HIV and AIDS, and concurrent resurgence of tuberculosis overburdening the weak health system;

• Inequity in allocation of resources and in access to health services;

• Behaviour change in light of drivers of the HIV and AIDS pandemic is an evasive and pervasive element;

• Poverty;

• High inequality of income and consumption;

• Vulnerability is very high in Lesotho; 553,000 Basotho were unable to meet their annual food requirements after the drought of 2007, while in 2012, households that were food insecure were 725,000 (Lesotho Vulnerability Assessment 2007 and 2012).

Emerging health problems are identified to include: HIV-related conditions and stigma; obesity and concurrent NCD, MDR/XDR-TB; trauma due to road traffic accidents and assault. The outcome of prioritization during the review


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process was the identification of 5 priority areas which are meant to support national efforts towards meeting the MDGs and Universal Health Coverage: HIV and AIDS, TB and other communicable diseases; maternal and child health; non-communicable diseases; health systems strengthening and social determinants of health, as elaborated below and in Table 7.

Strategic priority 1: Strengthening Prevention and Control of HIV & AIDS and TB and other Communicable Diseases

HIV and AIDs and TB remain the biggest health challenges which need primary focus towards achieving the MDG targets. WHO is expected to continue with support towards achievement of the health-related MDGs.

WHO will continue to support the country in implementing the IDSR strategy, based on the recently updated IDSR technical guidelines that incorporate selected non-communicable diseases, priority events and conditions. The strategy will be used as the vehicle for implementing the International Health Regulations (2005) including the building of core capacities.

Support will be provided for developing and implementing the health sector disaster risk management strategy. The capacity of community-level structures on preparedness and response to emergencies will continue to be built and strengthened.

The following programmatic approaches will be pursued and/or strengthened: Securing sustained funding for core TB prevention and control activities; enhancing HIV and TB programme performance; strengthening TB Laboratory services; decentralizing and integrating delivery of HIV and TB prevention and control services; developing and implementing programmatic management of drug-resistant HIV and TB; community involvement in TB prevention; advocacy, communication, and social mobilization in action; strengthening programme monitoring; disease surveillance and operational research; addressing TB and HIV in high-risk groups and populations; contributing to health system strengthening, based on the primary health care concept; monitoring and evaluation and impact measurement; participating and adopting the post-2015 HIV and TB strategy, including mainstreaming and linking universal access and social determinants of health into HIV and TB programming.





Strategic Priority 2: Strengthening Maternal and Child Health Services

There is evidence that Lesotho is struggling to improve on goals 46 and 57 of the MDGs. All efforts are required to turn around the situation to facilitate meeting the targets as intended in 2015. The MOH has introduced performance-based financing as one of the strategies to improve demand for services by pregnant mothers through the involvement of community health workers. This is, however, a largely donor-funded initiative which will, initially, cover only two districts and later on rolled out to 9 out of the 10 districts. In acknowledgement of the magnitude of the problem, a roadmap was developed and the UN introduced the MDG Acceleration Framework (MAF) to identify bottlenecks and develop solutions to improve maternal and neonate health. Implementation of evidence-based cost-effective interventions on maternal and neonate care services at all levels of care within the health sector will be essential, in addition to strengthening of the health system.

WHO will be expected to revisit immunization strategies with a view to improving immunization services and coverage. Noting that the country recognizes PHC as a fundamental strategy towards improving health outcomes, policy and guidelines will be required to provide a guided approach to community participation in mother and child health. Guidelines on management of severe acute malnutrition will also be updated to guide agencies whose core business is nutrition.

Strategic priority 3: Prevention and Control of Non-communicable Diseases

Noncommunicable diseases are silent killers and tend to have quick adverse effects. They develop over a long time, as well as their risk factors. The number of deaths attributed to NCDs is high; they are projected to be the most common cause of death in Africa by 2030.

WHO will take advantage of existing competencies within the UN to tackle some of the areas within this priority. WHO support for NCDs should be to monitor progress, based on the indicators contained in WHA resolution on NCDs, and facilitate implementation of priorities of the strategic plan for mental health. Mental health treatment in the country is heavy on the

6 Reduce child mortality

7 Improve maternal health


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use of drugs, and patients get dependent of them. There is, therefore, a need for support on procurement of tools which will enhance therapy and harmonization of patients’ assessment.

Major areas of focus to effectively deal with NCDs include development of a national multisectoral, integrated NCDs strategic plan, and the development of cancer control plan and registry to facilitate availability of data. Health promotion has been limited on cancer, hence a strategy will be developed towards promoting healthy diets, tobacco and alcohol use.

Strategic priority 4: Health Systems Strengthening

The Ouagadougou declaration on PHC and HSS, and pronounced interest in the country to resuscitate the PHC approach forms a basis for implementation of this priority area.

The emergence of importance to focus on the Ouagadougou Declaration on Primary Health Care and Health System in Africa, as passed by WHO-AFRO Member States in April 2008, directs the country’s strategic approach. The MOH used the Ouagadougou Declaration as basis for the latest 2012/13 Annual Joint Review as an indication for the MOH’s interest to revive the approach. Following on the lead, it is advisable for WHO to focus on PHC in its implementation strategy for all the priority areas.

PHC has been re-launched in the country and the MOH intends to introduce operational plans from health centre level and monitor their implementation. The plans would be expected to involve the community. The health sector should take advantage of the draft health strategic plan to be finalized, which is aligned to the Ouagadougou Declaration and the PHC revitalisation plan.

The overall strategy for all would include enforcing education of communities because they are the most affected, but also least informed and therefore make uninformed decisions about their lives which exposes them to risks. For instance, for an uninformed mother, delivering at home is not a problem. It would therefore be beneficial to encourage demand-driven service delivery.

Information and Communication Technology (ICT) is considered by WHO as the most cost-effective mechanism for health and health-related purposes. The importance of e-health has therefore been considered and agreed to by Member States in a number of fora including Resolution WHA58.28 and the Ouagadougou Declaration on PHC. Being aware of the information management systems implementation strategies of different countries, WHO has identified what works and what does not work. It is in a position to advice





the MOH on the best approaches to follow regarding software, and solutions to daily challenges. Lesotho has established an EMR through the support of MCC. Implementation is piloted in one district prior to rollout, which is dependent on addressing the challenges noted so far.

Reliable data management systems are the key to accurate data used to ensure accurate comparison of the country with the rest of the world. Currently, Lesotho has a challenge of data accuracy; for instance, PMTCT data change a number of times before any can be adopted.

Research provides a country with an opportunity to use evidence-based information to make decisions and in development of policies and strategies. Lesotho has developed a national health research policy to guide policy agenda. Through WHO support, the MOH has also developed a national health research strategic plan and agenda. Support is further provided for the operations of research governance structures (meetings of national health research ethics committee and institutional review board).

WHO will also be expected to provide guidance and ensure advocacy with other partners for implementing the human resource retention strategy and improving the supply chain management so as to avoid repeated stock depletion and overstocking of medicines and medical supplies.

Strategic priority 5: Addressing the Social-cultural and Environmental Determinants of Health

Following the successful implementation of Phases I and II of the Libreville Declaration on Health and Environment during CCS2G, WHO will support the country in the implementation of Phase III, where the focus will be putting the national plan of joint actions into operation. The support will also address monitoring and evaluation of the implementation process, using the regionally agreed M & E Framework. The priority areas to be targeted for support will include: Strengthening drinking water quality surveillance and implementation of water safety plans; strengthening food safety; supporting implementation and monitoring of the health-care waste management system and health in the workplace.

Support will be provided for the delivery and coordination of health promotion across sectors, programmes and at community level; review and/or development of the national health promotion policy and strategic plan, including its implementation. The capacity of districts in providing health promotion will be strengthened through skills development and technical backstopping. Support will be provided in provision of health promotion


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services across all programmes, including development and/or updating and implementation of programme-specific behaviour change and communication strategies.

Table 8.1: Proposed priority areas for CCS 3GStrategic Priority 1: Strengthening prevention and control of TB, HIV and AIDS and other Communicable Diseases Main Focus Areas Main Focus Areas1.1 Improving the country capacity to prevent, detect and respond to communicable diseases and events of national and international concern

1.2 Strengthening country capacity in disaster risk management

Strategic Approaches Strategic Approaches1.1.1 Support scaling up of community and health facility based HIV Testing and counselling

1.1.2 Support scaling up of PMTCT and VMMC

1.1.3 Develop guidelines and strategies for reducing treatment defaulters

1.1.4 Support continuous implementation of BCC strategy

1.1.5 Develop protocols on the management of adverse drug reactions for people on ART treatment and anti-TB medicine

1.1.6 Develop MOH capacity for monitoring of drug resistance

1.1.7 Stimulate generation of strategic information and evidence

1.1.8 Provide support for implementation of the 2nd edition of the IDSR guidelines

1.1.8 Support implementation of country IHR plan 1.2.1 Support improvement of national policies for the identification and reduction of risks to human health, prevention, preparedness, response and early recovery capacities

Indicators: HIV and AIDS Indicators: TB and STINumber of testing conducted in the past 12 months

Number of pregnant women receiving and maintained on ART

Number of Men receiving VMMC ART CoverageTB Treatment Success RateHIV and TB related Mortalities

Evidence based ACSM plans National reports on ART and ant-TB medicine adverse events

Number of country reports on HIV and TB Drug Resistance

HIV and TB programme monitoring and surveillance reports

Availability of a national strategy addressing resilience and preparedness for emergencies including epidemics





Table 8.2: Proposed priority areas for CCS 3GStrategic Priority 2: Strengthening Maternal and Child Health Services Main Focus Areas Main Focus Areas2.1 Strengthening the country’s capacity to improve access and provide quality services for sexual and reproductive, maternal and neonate health care including healthy aging services

2.2 Strengthening the country’s capacity to improve access and provide good quality child survival services.

Strategic Approaches Strategic Approaches2.1.1 Advocate for increased skilled birth attendance with necessary infrastructure, drugs and equipment

2.2.1. Scale up immunization services

2.1.2 Support implementation of integrated management of pregnancy, childbirth, postpartum and newborn care

2.2.2 Implement minimum package for child health care services and IMCI guidelines

2.1.3 Support implementation of integrated outreach services

2.2.3 Use health promotion strategies to empower communities

2.1.4 Collaborate with other partners for implementation of adolescent health standards, guidelines and tools

2.2.4 Strengthen vaccine management systems and technologies

2.1.5 Collaborate with other partners for implementation of FP guidelines and tools at all levels

2.2.5 Scale up polio eradication activities at all levels

2.1.6 Strengthen referral systems and development of protocols and guidelines for referral

2.1.7 Use health promotion strategies to empower communities

2.1.8 Advocate for removal of financial and social barriers to access

Indicators IndicatorsProportion of deliveries by skilled birth attendants

National immunization coverage of 90% and 80% in every district and health facility with three doses of DTP containing vaccine and OPV

Proportion of health facilities providing CEmONC and BEmONC

Proportion of first level facilities with at least 60% of health workers who care for children trained on IMCI

Contraceptive prevalence rate Proportion of first level facilities with at least one of the health workers who care for children trained on IMCI

Proportion of postnatal attendance Reduced under-five mortality from 117/1,000 live births to 79/1000

Proportion of ANC attendance national immunization coverage of 90% and 80% in every district and health facility with three doses of DTP containing vaccine and OPV

Reduced maternal mortality from 1 155/100 000 to 778/100,000

Proportion of adolescent pregnancies


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Table 8.3: Proposed priority areas for CCS 3GStrategic Priority 3: Prevention and Control of Noncommunicable Diseases

Main Focus Areas Main Focus Areas3.1 Strengthening prevention and control of non-communicable diseases

3.2 Promotion of healthy lifestyles

3.3 Strengthening country capacity to develop, maintain information systems and research for mental health

3.4 Funds mobilization for functional psychometric test tools to improve mental therapy care

Strategic Approaches Strategic Approaches3.2.1 Development and implementation of comprehensive NCD strategic plan

3.3.1 Improving mental health information and surveillance for evidence-based mental interventions

3.3.2 Development of guidelines and training of health workers on mental health

Indicators Indicators25% reduction in harmful use of alcohol. 25% relative reduction in the prevalence of raised

blood pressure.

10% relative reduction in prevalence of insufficient physical activity

Halt the increase in diabetes and obesity

30% relative reduction in mean population intake of salt/sodium

At least 50% of eligible people receive drug therapy and counselling to prevent heart attacks and strokes.

30% relative reduction in prevalence of current tobacco use in persons aged 15+ years





Table 8.4: Proposed priority areas for CCS 3GStrategic Priority 4: Health Systems Strengthening Main Focus Areas Main Focus Areas4.1 Strengthening health systems leadership and governance at all levels

4.2 Strengthening human resources for health

4.3 Improving access to and rational use of safe medicines and health technologies including strengthening the country regulatory capacity

4.4 Strengthening health system information and evidence

Strategic Approaches Strategic ApproachesSupport implementation of community health programme

Development and support for drug regulatory authorities

Support the development of eHealth policy and strategic plan

Enhance country health research capacity and governance

Capacitate the MOH, to ensure Quality Assurance of medical products to prevent further development of antimicrobial resistance.

Strengthen country capacity for the implementation of the revised essential service package

Support the implementation of the 2012-17 NHSP

Support development of guidelines for implementing the human resources for health retention strategy

Strengthen DHMTs to facilitate their functionality for the implementation of the PHC revitalisation plan

Support for the comprehensive assessment of civil registration and vital statistics and development of strategic plan

Facilitate dialogue and collaboration on integrated service delivery and multisectoral action for attaining universal health coverage

Indicators Indicators DHMTs with stable leadership Availability of functional national drug regulatory

system

% of facilities reporting stock outs of medicines on the Essential Medicines List (EML)

Number of facilities providing complete EHP/ESP

Number of Health Centres producing annual plans and reports

Number of annual joint reviews conducted with reports produced

Number of hospitals reporting cause of death information using the International Classification of Diseases (ICD-10)


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Table 8.5: Proposed priority areas for CCS 3GStrategic Priority 5: Address the Socio-cultural and Environmental Determinants of Health

Main Focus Areas Main Focus Areas5.1 Strengthening country capacity to assess health risks, develop and implement strategies for prevention, mitigation and management of health impacts of environment

5.2 Strengthening infrastructure, delivery and coordination of health promotion

Strategic Approaches Strategic Approaches5.1.1 Support implementation of the national plan of joint actions under the Libreville Declaration

5.2.1 Facilitate the orientation of District Health Promotion Focal Points on health promotion

5.1.2 Support monitoring of the implementation of health-care waste management system

5.2.2 Support capacity building for community participation in health promotion

5.1.3 Facilitate establishment and functioning of the Health and Environment Strategic Alliance

5.2.3 Provide technical support for development of the health promotion policy and strategic plan

5.1.4. Facilitate adaptation of the regional food safety strategy and support implementation of the national strategy

5.2.4 Support the review and update of programme-specific behaviour change and communication strategies and plans

5.1.5. Strengthen water quality surveillance 5.2.5 Advocate for adaptation and implementation of the Health in All Policies (HiAP) Framework

5.1.6 Facilitate implementation of the national health adaptation plan to climate change

5.2.6 Support promotion of healthy habits such as hand hygiene, reduction of tobacco and alcohol use.

5.2.7 Implementation of framework convention on tobacco control

Indicators IndicatorsProportion of the population without access to improved drinking-water sources

Percentage of HCFs where the 3Bin system is operational

Proportion of drinking-water sources with high risk score and positive faecal coliform results

Percentage of HCFs that have access to an incinerator

Proportion of the population without access to improved

Proportion of first level facilities with at least one of the health workers who care for children trained on IMCI

HESA in place and functional





5.1 ValidationofCCSstrategicagendawithNationalPolicy

Health priority setting was guided by consideration of the contributors to the heaviest burden of disease and periodically updated essential health package. As reflected in Annex C, the CCS3G priorities are fully aligned to the health sector priorities.

5.2 ValidationofCCSstrategicagendawithUNDAF/LUNDAPoutcomes

The UN Country Team decided to combine the UNDAF with its action plan and therefore renamed it LUNDAP. The principle of the document remains the same, which is to enable the UN agencies deliver as one body towards supporting the Government of Lesotho’s priorities, as outlined in the NSDP. The LUNDAP has identified 10 outcomes which are closely aligned to the MDGs. The alignment of the WHO CCS is mandatory as guided by the ‘delivering as one’ strategy, which recognizes the LUNDAP as an overall strategic document owned by all UN agencies. The challenges facing the health and nutrition cluster, which is spearheaded by WHO, already identify with the CCS3G priorities and areas of focus as they both draw from challenges identified by the MOH.

In developing the LUNDAP, WHO is committed to contributing to the outcomes noted in Annex D.

5.3 ValidationofCCSstrategicagendawithWHOGlobalandRegionalPriorities

Both Regional and Global priorities guide the high-level agenda. It is essential for the CCS to be aligned to these, and comparison in Annex E shows same.


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SECTION 6:

IMPLEMENTING STRATEGIC AGENDA: IMPLICATIONS FOR WHO

6.1 NatureandLevelofSupportNeededfromWHORegionalOfficeandHeadquarters WCO already receives support in terms of global health guidance from Headquarters resulting from decisions made by Member States in different forums. Opportunities are availed to WCO and its implementing counterparts of the MOH to attend workshops and training on any new developments in the form of guidelines and protocols. This kind of support is expected to continue to ensure that Lesotho is also up to date with technical assistance to adopt new developments.

To ensure effectiveness of this support, WCO needs to take a bold step in guiding the MOH in its choices for participants in various training sessions, especially because after training, WHO expects implementation from relevant departments. WHO is therefore expected to provide guidance to the MOH in the interest of country performance in line with global and regional requirements.

It is evident that WCO has some capacity deficiencies which cannot be addressed in the short to medium time frame, due to the global economic situation. However, as WHO is expected to take a lead in driving the health agenda in the country, WCO will need a lot of technical support from both Regional Office and Headquarters, depending on availability. WCO is not expected to deny technical support to the country for lack of local technical expertise.

It sometimes appears that Regional Office and Headquarters are not clear about the communication channels expected to be followed by the WCO. Clear guidance is required by the WCO to avoid delays in addressing issues. Specific support required includes: technical assistance to match all the gaps


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identified in WCO; per requests to be forwarded by the MOH, training for both the Ministry and WCO staff, in line with the training plans to be incorporated in the POAs.

6.2 AppropriatecompetencesandskillsrequiredtoimplementCCS3G It cannot be overemphasized that the WCO is overwhelmed with workload. Since work at the WCO is dependent on availability of funds, it has downsized international positions in the areas of disease prevention and control, and health systems strengthening and administration. A disease control officer would be beneficial to oversee all disease-based programmes, including HIV and AIDS and TB. Additional staff member focusing on health systems is also essential to assist all programmes, with emphasis on community involvement.

Another need of the WCO is an epidemiologist to assist with guidance on management of epidemics and data. The need is more critical based on the fact that the MOH does not have this expertise from within.

Nutrition is another area where the technical expertise gap was identified. However, medium-term technical assistance on nutrition could be used to facilitate development of guidelines, and allow long-term expertise to be drawn from other UN agencies whose core mandate is nutrition. WCO could consider sourcing UN volunteers to temporarily fill in the gaps in the office, and approaching other local partners for positions such as epidemiologist.

Generally, the key success factors for implementing the CCS include:

• Availability of adequate number of human resources;

• Skilled HR available in both WCO and MOH;

• Managers with the necessary skills leading MOH departments;

• Joint planning by the MOH and its partners;

• Joint monitoring and evaluation based on agreed indicators;

• Structured and continuous supervision at implementation level;





• Keeping good working relationships with counterparts;

• Finding various ways of communication, based on the preferred mode by counterparts;

• Acknowledging opportunity to learn from others where one does not know;

• Effective use of resources.

The new political leadership could be deemed an opportunity to pursue Social Health Insurance as an alternative health financing to ensure sustainability of affordable health care to all, and to ensure continued equity. Mobilizing other health partners’ support will facilitate sustainability of all initiatives.

Harmonization for Health in Africa (HHA) is a mechanism through which partners provide support for reaching the health MDGs. This requires discouraging individualized approaches and embarking on joint planning, implementation and monitoring. Evidence of uncoordinated partners’ efforts is that, VHWs earn different amounts from different partners in the same community. This can be easily eliminated through joint planning. One of the challenges for HHA take-off has been its timing for implementation which coincided with the elections and therefore could not be given attention. Efforts have been made to revive it through a facilitating meeting with the Ministry of Finance, but there is no response yet.

With respect to the health development partners’ forum, the entire membership of HHA is already in place, with the exception of MOH and the ministry of finance. It is, however, worthy of note that involvement of both ministries is key to the success of partnership coordination.

Table 9: Proposed budget allocation within strategic priorities

Strategic Priority Proposed Percentage Budget Allocation

Strengthening the Control of TB, HIV and AIDS and Other Communicable Diseases

30

Strengthening Mother and Child Health 30

Non-communicable Diseases 11

Health Systems Strengthening 25

Social Determinants of Health 4


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SECTION 7:

MONITORING AND EVALUATON OF CCS

Monitoring of the CCS 3G will be through the following mechanisms:

• Validation of the WCO biennium plans against the strategic priorities contained in the CCS to ensure that they are in harmony;

• Ascertaining periodically whether competencies and skills required to execute the CCS are being addressed, be it in the long or short term.

• A mid-term review of the CCS will be conducted in 2016 to assess the overall strategy implementation, and how it has contributed to implementing the national health strategic plan and the Lesotho United Nations Development Assistant Framework/Plan;

• The strategy will be evaluated during the course of 2019 to see how it has performed against each of the strategic priorities and main areas of focus. Findings will inform the next CCS.


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Annex A:

CCS DEVELOPMENTAL PROCESS

The methodology engaged in the review process was multifaceted. The main focus was consultations and extensive review of documents to gather relevant information relating to global, regional and country-specific health issues. The consultations were in the form of structured qualitative interviews to enable open and detailed feedback. The interviews were mostly administered in one on one or group sessions. This implies that the information in this section is entirely a record of the findings not an opinion of the author.

Internal Stakeholders Consultations

The consultations began with internal stakeholders who are mainly WCO staff. This included the WHO Representative (WR), all technical staff and representation of administration. The purpose of the interviews was to establish the office’s view on the implementation of the CCS2G and for the team to share their thoughts towards the CCS3G. The responses from WCO also facilitated the development of a tool for engaging with other stakeholders, specifically their counterparts in the MOH.

External Stakeholders Consultations

External stakeholders include the MOH staff, mainly the counterparts of WHO technical team, the DHPS and PAU who are directly involved in the planning and reporting processes. Some UN agencies, health development partners and representation of church based organization were also consulted. The purpose of the consultations was to establish their opinion about WHO and its contribution to achieving the country health objectives and to get guidance on the areas of focus for the next CCS based on their thoughts around the competitive advantages of WHO.

Documentation Review

A search and review of relevant documentation relating to WHO at all levels and the health sector in general was undertaken. This also provided guidance with regards to the current status and the way forward.


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Limitations

An attempt to constitute a review team was made but responsiveness was not quick enough prior to commencement of the process hence extensive focus on individual organizations consultations. An effort was made to meet the majority of the members of the planned team, however, circumstances did not permit meeting all of them. The limitation with internal consultations has been that some technical staff members were fairly new in the organization and therefore were not able to provide much opinion about the CCS under review as they had little or no interaction with it.

Some stakeholders had limited integration with WHO and therefore could not provide constructive opinion. A validation session where all stakeholders will provide comments in a guided session is planned to facilitate finalization of the document.

Annex B: Health Development Partners Support 2010/11 to 2012/13Development Partner 2010/11 2011/12 2012/13ADB credits and grants Health VI 4,977,865 11,371,569 -

Irish AID 19,575,145 22,626,475 31,191,462

UNICEF Grant 8,334,582 1,907,743 2,596,881

Clinton Foundation 3,175,190 1,920,800 -

Global Fund TB and HIV/AIDS All Rounds & Phases 30,463,035 31,823,773 70,564,665

Kellogg Foundation (Family Medicine) 6,072,726 - -

WHO Grant 448,436 672654 4,229,848*

UNFPA 3,237,948 - 321,647

EU OVC Support 9,273,214 19,311,747 45,588,239

MCC HSR 120,942,671 300,041,779 172,297,421

Foundation for Innovative New Diagnostics (FIND) 367,368 - -

World Bank HTAP + PBF Preparatory 10,194,529 7,158,542 6,564,195

CDC/PEPFAR LAB SERV + LBTS + Ref Lab 5,695,310 13,848,834 32,122,983

KNCV 235,300 - -

NORAD Grant - 313,344 -

GAVI - 697,911 -

SolidarMed - 90,356 2,606

Sources: Audit Reports 2010/11 – 2012/13; WHO Lesotho financial reports *Covers support for 2012-2013 calendar years.





Annex C: SWOT AnalysisStrengths Weakenesses• Team spirit within WHO country office. • Consultative and information sharing

leadership style of the current WR office.• Technical expertise in given areas. • Retention of staff. Staff turnover is low.

Since 2007, there has been one resignation from support department and none from technical staff.

• Leadership retained much longer than other partners hence institutional memory on health partners issues.

• Strong support to staff from WR• Strong and reliable online monitoring

system.

• Inadequate dissemination of the CCS & POA to stakeholders.

• CCS not sufficiently being used as a planning tool.

• Overloaded staff members due to thin staffing of the office.

• Inadequate funding.• Inadequate communication between MOH

programmes and the WCO.• Discontinuation of regular reviews/

monitoring meeting of POA with implementing programs.

• Limited capacity of WCO in terms of numbers of technical staff at the country level.

Opportunities Threats• Access to TA from regional office and

Headquarters. • Access to guidelines for in the country

adoption. • Access to training for WCO staff. • Opportunity for motivating change with the

new government wanting to be seen to perform.

• Strong harmonization with the UN agencies. Delivering as one, standard salary scale for short term staff.

• Clear monitoring mechanisms from AFRO and HQ.

• Availability of clear guidelines and tools for development and implementation of CSS and for ensuring compliance with WHO regional and global priorities.

• Availability of multi-professional human resource base within the UN system.

• Inadequate commitment within the MOHSW. • Lack of knowledge about WHO support in

general. • Human resource crisis in health sector.


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Annex D: Comparison of CCS3G and Health Sector PrioritiesHealth Sector Priorities (Health policy 2011) CCS 3G Priorities

• HIV and AIDS care, treatment and prevention tops the list of needs Priority 1

• Tuberculosis detection and treatment Priority 1

• Raising and sustaining immunization coverage Priority 2

• Managing childhood illnesses (Neonatal conditions, ARI, Diarrhoea) Priority 2

• Ensuring safe motherhood, newborn, child and adolescent health Priority 2

• Addressing non-communicable diseases (Hypertension, Diabetes, Trauma, heart disease and cancer, health of the elderly, etc.)

Priority 3

• Sanitation and hygiene Priority 2 and 5

• Disease prevention through education and health promotion Strategy to all priorities.

• Addressing existing severe health systems weaknesses, particularly the shortage of and Inequity in distribution of key qualified health professionals, leadership, fragmented health Information, supply chain management for essential medicines and vital supplies, and poor budget execution.

Priority 4

• Strategic information (Surveillance, Research and M & E) Priority 1, 2, 3, 4 and 5

Annex E: LUNDAP Outcomes Compared to CCS3G PrioritiesLUNDAP Outcomes CCS 3G Outcomes

Outcome 4: By 2017, national and lower level institutions make evidence based policy decisions

Priority 4

Outcome 6: By 2017, Lesotho adopts environmental management practices that promote a low-carbon climate-resilient economy, sustainability, manages natural resources and reduces vulnerability to disasters.

Priority 5

Outcome 7: By 2017, equitable access to and utilization of high-impact, cost effective health and nutrition interventions achieved for vulnerable populations

Priority 1

Outcome 9: By 2017, multi-stakeholders in the country contribute to the reduction of new annual infections especially among youth, children and adults.

Priority 1

Outcome 10: By 2017, people living with HIV and AIDS have access to and benefit from integrated service delivery that includes nutrition support, ART and care, and HIV/TB co-infection management.

Priority 1





Annex F: Validating the CCS Strategic Agenda with WHO Global Priorities 12th GPW and CCS3G PrioritiesDevelopment Partner

CCS3G PRIORITIES

Strengthen the control of TB, HIV and

AIDS and Other Communicable

Diseases

Strengthen Maternal and Child

health

Non Communicable

Diseases

Health Systems

Strengthening

Social Determinants

of Health

• Advancing universal health coverage

XX XX XX XXX (HR, data)

• Health-related MDGs

XXX XXX XXX XX X

• Addressing the challenge of NCDs

XXX XX XX

• Implementing provisions of International Health Regulations 2005

XX (risk preparedness)

XXX(real time data and risk

preparedness)

XXX

• Increasing access to essential, high quality and affordable medical products

XXX (medicines) XXX (Vaccines)

XX (medicines) XXX (Health technologies,

EMR)

• Social, economic and environmental determinants of health as a means of reducing health inequalities within and between countries

XXX

• Strengthening WHO’s governance role

X X X X X

• Reforming management policies, systems and practices

XX


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Annex G: Validating the CCS Strategic Agenda with WHO Regional Priorities The six strategic directions set out by the Regional Director for 2010-2015

CCS3G PRIORITIES

Strengthen the control of TB, HIV and AIDS and Other

Communicable Diseases

Strengthen Maternal and Child

health

Non Communica-ble Diseases

Health Systems

Strengthening

Social Determinants

of Health

• Continued focus on WHO’s leadership role in the provision of normative and policy guidance as well as strengthening partnerships and harmonization

X X X XX

• Supporting and strengthening health systems based on the Primary Health Care (PHC) approach

XXX

• Putting the health of mothers and children first

XXX

• Accelerated actions on HIV/AIDS, Malaria and Tuberculosis

XXX

• Intensifying the prevention and control of communicable and non-communicable diseases,

XXX XXX

• Accelerating response to the determinants of health

X X X X XXX
