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                                                  C O O P E R AT I O N S T R AT E G Y 2 0 1 4 - 2 0 1 9    i

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            AFRO Library Cataloguing-in-Publication Data

            WHO Country Cooperation Strategy 2014-2019 Lesotho

            1.   Health planning
            2.   Health plan Implementation
            3.   Health Priorities
            4.   International cooperation
            I. World Health Organization. Regional Office for Africa

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

                                           © WHO Regional Office for Africa, 2014

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


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

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

                     CHALLENGES .........................................................................3

          2.1     Geography ………….......................................................…………….............3
          2.2     Demographic Profile and Characteristics of Population ……………................3
          2.3     Politics and Governance Structure ……...…………………………….........…....4
          2.4     Socioeconomic Status ………..........................................................................5
          2.5     Social Determinants of Health ..……………………….........................…..........6
          2.6     Health Status of the Population .………………………..………..............…......8
          2.7     National Response to Overcoming Health Challenges …………….....….…...11
          2.8     Health Systems and Services ………...................................................…......15


          3.1    Aid Environment in the Country ………........………………………................. 17
          3.2     Coordination and Aid Effectiveness int he Country ……………….…............ 18
          3.3     UN Reforms Status and UNDAF Process ……..............………….........…… 19

                                                     C O O P E R AT I O N S T R AT E G Y 2 0 1 4 - 2 0 1 9              iii

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

            4.1 Support from Headquarters and AFRO .......……..……………....................... 22
            4.2 WHO responses to changing country needs ........……………....................... 22
            4.3 Other Partners .......……..……………............................................................. 23
            4.4 Achievements of CCS2G .......……..……......................………....................... 24
            4.5 Challenges in Implementation of CCS2G …..…..............………….........…… 27


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

                       IMPLICATIONS FOR WHO..................................................... 43
            6.1 Nature and Level of Support Needed from WHO Regional
                Office and Headquarters .......……..……………............................................. 43
            6.2 Appropriate competences and skills required to implement CCS3G ........…. 44

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

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

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


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           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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          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.

                                                  C O O P E R AT I O N S T R AT E G Y 2 0 1 4 - 2 0 1 9   ix

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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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          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.

                                                   C O O P E R AT I O N S T R AT E G Y 2 0 1 4 - 2 0 1 9   xi

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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.

                                                   C O O P E R A T I O N S T R A T E G Y 2 0 1 4 - 2 0 1 9 xv

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          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

              Annex A provides details.

                                                  C O O P E R AT I O N S T R AT E G Y 2 0 1 4 - 2 0 1 9   1

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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

           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

           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.


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          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 Geographic profile and characteristics
                      of population
          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

              30,355km2 of area
              Leribe, Berea and Maseru
              76% of the population

                                                  C O O P E R AT I O N S T R AT E G Y 2 0 1 4 - 2 0 1 9   3

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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 Politics and governance structure
           The 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.

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


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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

          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-economic status
          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 Social determinants of health

           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


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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 Health status of the population

           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


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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


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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 National response to overcoming
                     health challenges
          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.


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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

          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


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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 UN Reforms Status and UNDAF Process
          Historically, 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
                                         # of               # of                         # of
                                                                    # of Health                   Total # of
           Proprietor                General            Primary                        Filter
                                                                         Centre                   Facilities
                                    Hospitals          Hospitals                      Clinics
           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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