Bongiwe Zihlangu
Shocked by the spike in HIV/AIDS-related deaths, coupled with Lesotho’s regression to number two on the global infection prevalence scale, poor maternal health, high child mortality and the scourge of Tuberculosis (TB), King Letsie III and Prime Minister Pakalitha Mosisili have been spurred into action, personally taking it upon themselves to lead a health sector revitalisation system project aimed at investing in and strengthening “individuals, institutions and actions at the centre of ensuring effective and efficient health service delivery”.
The ‘No More Deaths in Lesotho’ project, whose theme is ‘Revitalising Primary Health Care because the life of every Mosotho matters-for improved maternal health, reduced child mortality and reduction of the scourge of Tuberculosis and HIV’, is scheduled to be launched early next month with His Majesty and Dr Mosisili at the forefront, engaging stakeholders that include church-leaders, civic groups, the media, government ministries, development partners, chiefs, local councils and district administrators, in their quest to rid Lesotho of the pandemic.
According to a World Health Organisation (WHO) 2008 report on which the revitalisation project is based, health systems are defined as “all organisations, institutions and resources that are devoted to producing health actions”.
The report further states that a health system comprises all organisations, people and actions whose primary intent is to promote, restore and maintain well-being adding “this includes efforts to influence the determinants of health as well as more direct health-improving activities.
“A health system is therefore, more than the pyramid of publicly owned facilities that deliver personal health services. It involves the broad range of individuals, institutions, and actions that help ensure the efficient and effective delivery, and use of a spectrum of products and information for prevention treatment, care and support to people in need of these services.”
The WHO report adds: “The provision of health services depends on the proper functioning of a health system which is made of the following building blocks: finances, health workforce, health management information systems, leadership and governance (including community participation), medical product (pharmaceutical and supply chain), infrastructure, and technology and quality assurance.”
Mpopo Tšoele, Director of Pitsong Institute for Implementation Research, a non-governmental organisation engaged to spearhead the project by providing guidance, technical expertise and ensuring implementation, told the Sunday Express that he applauds King Letsie III and Dr Mosisili for the initiative.
Mr Tšoele added unlike other related programmes that government engaged in previously, in the fight against HIV/AIDS, TB and related infections “this one is different because the King and the PM are calling on all Basotho to participate, take ownership and accountability for the outcome”.
“Unlike previous projects which you only heard about but could not participate in because they were centred around the Ministry of Health, the minister and technical staff, this time around all recipients of health services are invited; we are all stakeholders in this project,” Mr Tšoele, a decentralisation expert, said.
“The fact that the King and PM have assumed this leadership responsibility now, pulling their weight behind advocating for greater participation of leaders and accountability in health issues, is a step in the right direction.”
Primary Health Care (PHC) approach, Mr Tšoele said, shifted the emphasis of healthcare to the people themselves and their needs, reinforcing and strengthening their own capacity to shape their health destiny through designing, implementing, monitoring and evaluating health programmes “working through and with the formal health structure”.
“That is why His Majesty the King and PM are opening up primary healthcare, which has always been the responsibility of the Ministry of Health, calling on all stakeholders to come and play a role,” Mr Tšoele said.
According to Mr Tšoele, the media, for one, is part and parcel of the project and could play a role in human resources for health, advocating for the recruitment of village healthcare workers, that they are paid on time and so forth.
“The media can be given a mandate to go and oversee whether health professionals are on the ground, doing their work as expected. Similarly, you can have a role in information, such as establishing how many children are immunised at different health centers a month, or how many people are on TB and ARV treatment,” Mr Tšoele said.
“You can also be a critical arm that ensures that government is devoting funds to purposes for which they were intended; whether resources are following funds or responsibilities.”
Pitsong has been doing its fair share of engaging stakeholders in a bid to solicit their pledges to join the King and Prime Minister in their noble endeavour.
The NGO says it has established that despite Lesotho allocating 14 percent of its budget to the health sector, the money remains centralised at the expense of Primary Health Care (PHC), the level where the bulk of healthcare service is, thus hampering accountability at all levels of the health system.
“We are told that the health sector workload is predominantly at clinic level and below, or what you otherwise call primary healthcare. But the level of spending at that level is only nine-percent of the total annual budget of the health sector,” Mr Tšoele said.
“This means where the bulk of the work is and critical services are required, less is spent. This is evident when you go to your clinics. There are no ambulances, staff accommodation in some health centres is not conducive and there are no luxuries like you have at headquarters.”
He added: “You have nurses and doctors at headquarters pushing paper and doing administrative work in the face of a blatant shortage of health personnel nationwide. These are people who have been trained. Why should we have doctors here when we know the country needs them at clinic level and below? These are people whose skills we cannot match, but anybody can do administrative work.”
Mr Tšoele further said more people are attracted to working at the headquarters instead of remote areas because “that’s the function of where you put your money”.
“If you take these hard-to-reach health centers like Tlhanyaku, Nkau, Bobete and so on, it’s very difficult to retain health professionals there because there’s no life,” Mr Tšoele said.
“For instance, a nurse will leave Maseru to work at a remote health center, leaving behind her husband and children, only to be expected to fend for herself when she gets there. But at the headquarters people are living the life. This means we are spending our finances at the level where there’s workload.”
He further brought attention to the plight of village health workers, describing them as a very critical arm of the health sector and the first point of care, saying despite their selfless efforts “half the time they are not paid on time and never receive their service kits on time”.
“They are the ones who ensure HIV and TB patients take their medication; that pregnant women attend their antenatal clinics, yet they are neglected.
“But now the PM is saying, to all leaders including the media, the health system has always been managed in a manner we could not comprehend. He is saying, we are critical in understanding how things are done, so that we can all be accountable.”
The emphasis of PHC, Mr Tšoele added, simply means shifting the emphasis of healthcare to the people and their needs, as well as reinforcing and strengthening “their own capacity to shape their health system”.
“We have always been in the dark, assuming that health is about the Minister of Health and technical people. They have a role yes, but so do chiefs, church leaders, district administrators, civic groups, the media and all these other stakeholders,” Mr Tšoele said.
“What is critical now is for those roles to be defined within context. For instance, we can talk about HIV/AIDS at district level and identify what needs to be done at that level. We need to remember that health programmes are not delivered in offices, but at councils where we have chiefs; where we have the church, the media and civic groups.”
He added: “So, it doesn’t make sense to think you can revitalise primary healthcare on your own. That’s why Dr Mosisili is saying, the ministry has tried over the years to revitalise the health sector without much success. But with stakeholders on tow, who have platforms that touch and influence behaviours and opinions, then we are on the right track.”
The WHO report also touches on community system strengthening (CSS), describing it as an approach that promotes the development of informed, capable and coordinated communities and community-based organisations, groups and structures.
“CSS involves a broad range of community actors, enabling them to contribute as equal partners alongside other actors, to the long-term sustainability of health and other interventions at community level, including an enabling and responsive environment in which these contributions can be effective,” the report states.
“The goal of CSS is to achieve improved health outcomes by developing the role of key affected populations and communities, and community-based organisations in the design, delivery, monitoring and evaluation of services and activities related to prevention, treatment, care and support of people affected by HIV, TB, and other major health challenges.”
On the roles expected to be played by different stakeholders, Mr Tšoele said in a bid to influence lifestyle and behavioural changes, church leaders could start by imposing restrictions on members of their congregations.
“For instance, church leaders could start by firmly refusing to marry couples whose HIV statuses are not clear, as a way of encouraging people to change their lifestyles. If I’m an NGO and fail to claim my place in PHC revitalisation, it literally says I am leaving the Minister of Health to do it alone,” Mr Tšoele said.
“Area chiefs can hold public gatherings with health-workers, sensitise people about the importance of testing for HIV, sticking to their TB treatment, pregnant women attending antennal classes and so on.
“District Administrators (DAs)as representatives of the central government, could pull their weight behind the immunisation of children under the age of five years and ensure the collection of correct statistics per district to ascertain that people at the grassroots receive relevant health services.”
Elaborating more on the role of district administrators, Mr Tšoele said more often than not, DAs leave the responsibilities pertaining to health to workers instead of striving to be part of them.
“For instance, when health workers at district level request transport from the DA’s office to travel to villages for the immunisation of children under the age of five years, the DA needs to establish where exactly they are going, how many children they plan to immunise in each village and why there is need to immunize them.
“That way, the DA is taking charge to ensure immunisation goes right and putting himself in a position to provide the correct statistics of immunization in his district because he is being hands-on.”
But, Mr Tšoele added, that link has always not been there because DAs become irritated when health workers request transport because they do not understand that to a large extent “they have an obligation and are therefore accountable for poor health outcomes in their respective districts”.
The project will also see government ministries delivering their respective services in different areas around the country “to make this project a success”.
“The other sectors will be capacitated to understand that if they support this initiative, it will be for the greater good. For instance, the Ministry of Local Government building access roads to villages where health centers are situated, is one way of contributing to the success of the PHC revitilisation project,” Mr Tšoele said.
In a nutshell, Mr Tšoele maintained, for HIV programmes to be more effective in Lesotho, they must reach more people on a sustainable basis by addressing social and structural issues that deter people from accessing services.
Community mobilisation, improved access to HIV testing, prevention and treatment services, and the promotion of adherence to treatment as well as taking ownership of the revitalisation project by all stakeholders, are all Lesotho needs to achieve its noble cause.
At a seemingly stagnant population of just 1.8 million, Lesotho ranks number two in the world on the HIV/AIDS infection prevalence scale, with just under a quarter of its people infected by the virus, and with women and children bearing the brunt of infections.
A 2014 United Nations Development Programme (UNDP) report indicates that although the population of Lesotho has historically had better health than many other sub-Saharan African countries, increasing poverty and a high prevalence of HIV and AIDS, has rendered families more vulnerable to health challenges.
Meanwhile, King Letsie III and the PM seem to be following in the footsteps of UNAIDS, the Joint United Nations Programme on HIV/AIDS, advocating for the reduction of Aids-related infections by half by 2020, and no new recorded infections by 2030.
Through UNAIDS, the world is embarking on a Fast-Track: Ambitious Targets are= Entirely Achievable strategy, to end the AIDS epidemic by 2030.
According to UNAIDS, to reach this visionary goal after three decades of the most serious epidemic in living memory, countries need to use the powerful tools available, hold one another accountable for results and make sure no one is left behind.
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THE UNAIDS REPORT IN BRIEF
- To accelerate progress towards ending the epidemic, new Fast-Track Targets have been established for the post-2015 era.
- These targets aim to transform the vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths into concrete milestones and end-points.
- For the first time, there is a global consensus to aim for 90% of people living with HIV knowing their HIV status, 90% of people who know their status receiving treatment and 90% of people on HIV treatment having a suppressed viral load so their immune system remains strong and they are no longer infectious.
- These 90–90–90 targets apply to children and to adults, men and women, poor and rich, in all populations—and even higher levels need to be achieved among pregnant women.
- Achieving the 90–90–90 by 2020 targets would still leave 27% of people living with HIV with unsuppressed viral loads in 2020, so expanded investments in proven HIV prevention strategies will be critical to hopes for ending the AIDS epidemic.
- The Fast-Track Targets for recommended prevention programmes (e.g. under the investment approach) are even higher than previously recommended.
- In high-prevalence settings, more people will need to be reached by mass media and face-to-face meetings that encourage sexual risk reduction.
- Antiretroviral therapy is projected to account for 60% of infections prevented through scale-up of these priority strategies.