1. Living Conditions
  2. HIV/AIDS
  3. Maternal / Infant Care
  4. Communicable Diseases
  5. Problems Facing the Health Sector
Figures based on LDHS 2014

Living Conditions

Time to nearest health facility

Only 17% of rural households are less than 40 minute away, compared to 71% of urban households

Household drinking water

Only 5% of rural households have piped water, compared to 70% of urban households

Toilet and sanitation

38% of rural households have no facility compared to 5% of urban households

HIV / AIDS

Urban vs. Rural
Urban women are +10% more likely to have HIV
Urban women are +12% more likely to have comprehensive knowledge of HIV
Urban men are +7% more likely to have HIV
Urban men are +16% more likely to have comprehensive knowledge of HIV
Education Level
Women with secondary education are +19% more likely than women with no education to have comprehensive knowledge of HIV
Men with secondary education are +25% more likely than men with no education to have comprehensive knowledge of HIV
Wealth Level
Women in the top wealth quintile are -5% less likely to be tested for HIV than women in the bottom wealth quintile
Men in the top wealth quintile are +23% more likely to be tested for HIV than men in the bottom wealth quintile
Sexual Activity
5% of women and 23% of men have sex by age 15
46% of women and 67% of men have sex by age 18
7% of women and 27% of men reported having 2+ sexual partners in the past year
54% of women and 65% with multiple partners of men used a condom during last sexual encounter
Protection and Precaution
90% of both men and women believe a wife is justified in asking her husband to use a condom if he has an STI
66% of women and 55% of men believe a woman has the right to refuse sexual intercourse with her husband if she knows he has had sex with other women
72% of women and 67% of men agreed children age 12-14 should be taught to use a condom
97% of women and 92% of men know a place where they can get an HIV test

Infant, child and maternal

Infant Mortality per 1000 births

Percentage of Home vs. Facility Births

Children age 12-24 months who recieved all basic vaccinations

Communicable diseases

Diarrhea in children

Percentage of children who had diarrhea within the two weeks of the health survey (age is in months)

Treatment of diarrhea in children

Percentage that used a treatment

Problems in the Health Profession

An apparent problem in the health profession is the supply of health professionals compared to the clients who seek health services. But when looked closely and critically, supply is not the primary problem. With the exception of the medical doctors, there is inability of the health sector to absorb a significant number of health professionals who are roaming outside the health employment sector. Colleges and universities continue to produce hundreds of nurses/midwives, nursing assistants, laboratory scientists and technicians and pharmacists but the real problem is the employment sector’s inability to adequately absorb them despite the acute need for the increased workforce. The bottle neck and the root cause of the low absorption of the graduated health professionals into the employment sector could be traced to the employment policy of the government. There is what is called establishment list which prescribes the number of health workers to be recruited within a certain period of time irrespective of the actual need on the ground. It is apparent that the establishment list policy is not consistent with the magnitude of need on the ground. Notwithstanding, supply of health workers would still remain a concern even if absorption is optimised.
The problem of shortage is exacerbated by disproportionate distribution of health workers, with most health workers based in the lowlands and urban areas of the country at the expense of the rural and mountain areas. The lowlands and urban areas are better endowed in terms of essential services such as electricity, communication mechanisms, reliable transportation, accommodation, entertainment and enjoyment of social life. The inadequate distribution of the health workers against the rural and mountainous areas has a large and negative impact on people’s health, leading to preventable death and suffering.

According to the Lesotho Health System Assessment 2010, although more than 60 percent of health care is supplied at the Primary Health Care (PHC) level, less than 20 percent of the formal sector labour supply is employed at the PHC level, suggesting a poor distribution of the health workforce. The largest share of the formal sector labour force is employed at the secondary level (46 percent), and 24 percent are employed at the tertiary level. As a result, as of 2004, only 31 percent of filter clinics had the full-time equivalent personnel that they required, and only 41 percent of health centres met minimum staffing standards with respect to nursing personnel. Conversely, the national referral hospital had 108 percent of their full-time equivalent nursing requirements met, and district hospitals had 50 percent of their nursing requirement filled.

Staffing at all levels of the health system is inadequate, causing poor service delivery at community health centres, where PHC is essential. Poor service delivery distorts the referral system whereby patients that should obtain care at lower level facilities refer themselves to a higher level within the health system, rendering organization of services chaotic, impairing access to services and negatively affecting the quality of services offered.

The MOH provides a standard incentive package (M275/month) to employees assigned to the mountainous regions of the country. The amount has insignificant impact. In addition, certain cadres of staff (doctors) receive a sitting allowance when required to work over a specified number of hours. Development partners such as the Clinton Foundation are providing a top-up allowance to nurses working in ART clinics.

Brain drain plays a significant role in creating shortages in the health workforce. The fact of the matter is health professionals are a scarce resource throughout the world. Therefore competition over the workforce has become a prominent feature in the health sector. Lesotho is particularly confronted with fierce competition from the neighbouring South Africa, which like other developed countries such as the United Kingdom has more competitive remuneration packages that attract health professionals from poorer and less competitive states. The country has made an effort to train more professionals but attrition is very high and the country has not made an equal effort to promote retention of the trained workforce.
Limited medical equipment, insufficient and inconsistent drug supply and other health commodities is one of the most glaring challenges in the health profession in Lesotho. Most health facilities lack the basic equipment and drugs necessary for delivering basic health services. In few facilities where the equipment and drugs are available, it is of a very inferior quality. Even the more advanced Queen ‘Mamohato Memorial Hospital has proved to be limited in a number of cases hence heavy referrals onto the South African medical system. Purchase of drugs takes one of the biggest proportion of the budget of the Ministry of Health. There is frequent stock run-outs and the fact that these drugs are not produced internally becomes very expensive for the country.
A related problem is the limited number of medical doctors and other health professionals with specialisation. There is scarcity of surgeons, psychiatrists, gynaecologists, cardiologists, dermatologists etc. Most doctors, nurses, pharmacists and medical laboratory scientists are general practitioners who are unable to get to the bottom of a lot of chronical and non-communicable disease. In the like manner there is heavy reliance on the South Africa system. The country does not only lose millions of maloti for referrals into the South African facilities, but a lot of lives that could otherwise be saved through specialised practice are being lost every day. The problem owes to lack of decisive policy decisions to produce specialised health professionals and implement retention programmes.
While there may be clear targets for service delivery on the part of the health workers, accountability mechanisms are very weak. Adherence to standards and number of clients to be served in a day is very minimal. The problem is related to weak or total lack of supportive supervision, a sign for weak management and leadership in the health institutions. Professional errors are always reported in health facilities but perpetrators are seldom held to account. The weak accountability and supervision are to a large extent responsible for poor service delivery in the health facilities and hence failure to meet national and international targets and standards. A related phenomenon, arguably caused by scarcity of medical doctors in the system coupled with weak accountability and supervision is that medical doctors spread themselves too wide, working in public health facilities, as consultants and in private practice. Efficient and effective service delivery gets compromised as they shuttle between the different duty stations, resulting also in late arrivals and limited focus.
The health workers in Lesotho have for long time been criticised for relating quite poorly with patients and clients. While there have also been reported errors in the technical aspect of their work, the outcry, particularly in public facilities, is that health workers display bad attitudes, impatience, intolerance and highly compromised work ethic. The cause of these unprofessional behaviours is related to a multiplicity of realities; health facilities are understaffed and therefore staff are overwhelmed by unbearable work overload. Health workers are also strained by bad management and leadership of the health institutions that is so “top-heavy” onto them with little people management skills. They are also demoralised and demotivated by lack of upward movement in their career paths. Quite admittedly the health professionals also come out of universities and colleges ill-prepared to deal with public relations pressures that are a characteristic of the sector.
According to WHO Atlas of African Health Statistics 2012, compared to its peers, Lesotho spends $54 per capita on health, which is higher than the $34 per capita required to provide a minimum package of health interventions. The World Bank (2009) reveals that Lesotho does not suffer from an inadequacy of funds, but rather from chronic underspending of health resources, as well as from a less than optimal allocation of health resources. The most serious implication of consistent underspending of the MOH recurrent budget is that it portrays a picture that there is no need for additional funding for health care services in Lesotho in the short and medium term. There is a shared view that Lesotho is over-resourced in the health sector, with the major problem being that funds do not reach intended beneficiaries in adequate amounts and on time. The key question is to deal with the bottlenecks in health funding in Lesotho; otherwise, any attempt to raise additional revenues for health care services will be met with serious scepticism. The MOH needs to seriously address the root causes of underspending its recurrent budget before attempting to raise additional revenue.
Interview with the key informants revealed that issues of good governance within the health sector are not held high. In particular, participation of the health professionals who do not only have expertise and first-hand experience but are also the primary implementers of the health policies, strategies and programmes, do not get to inform policy direction. Limited participation of the implementer results into weak ownership of the health frameworks, hence cripples implementation. Limited participation has to do with the generic problem of lack of consultation culture in the policy environment in Lesotho.