The battle against Tuberculosis

The battle against Tuberculosis

MASERU – LIMPHO Taka, a 47-year-old patient with HIV and multidrug-resistant TB, (MDR-TB) lives in Mpokochela, a village in the Drakensberg Mountains of Lesotho. It takes him three hours on his horse to reach the Bobete clinic where he receives treatment for MDR-TB. His family has a little farm with three horses, 73 sheep, eight cows and seven chickens. He grows sorghum, wheat and vegetables for a living.

He fell ill with TB several times, was cured, and then went to work in a gold mine in South Africa to earn more money as he did not want to sell his animals. On his return to Lesotho he got sick and was diagnosed with MDR-TB. According to last year’s World Bank report on TB in the mines, in South Africa alone, TB rates within the mining workforce are estimated at 2 500 to 3 000 cases per 100 000 individuals. This incidence is 10 times the World Health Organisation (WHO) threshold for a health emergency, and is also nearly three times the incidence rate in the general population.

“Mine workers are at a higher risk of contracting TB due to prolonged exposure to silica dust, poor living conditions, and high HIV prevalence in mining communities,” the World Bank report reads. “Furthermore, circular movement of mineworkers across provincial and national borders and a poor cross border health referral system fuel infection rates, adversely affect adherence to TB treatment, and contribute to the incidence of drug resistant strains such as multidrug resistant (MDR) and extensively drug-resistant (XDR) TB in the sub-region.”

Taka started treatment, but failed the standard treatment regimen for the disease because of its harrowing side effects. He was bed-ridden for one year, which caused severe bed sores and oedema. Thanks to the new MDR-TB drugs he is taking as part of the “End TB project” funded by Unitaid, Taka is recovering. His story is the latest which was published by a US-based Medium Corporation, which focuses on health success stories. Taka is still undergoing treatment at the church-owned Bobete Clinic.

Lesotho has among the highest TB incidence and HIV prevalence rates in the world with 17 000 new TB cases annually, of which slightly less than half are notified. Nearly three quarters of TB patients are co-infected with HIV. Lesotho’s mountainous terrain makes it difficult to treat patients in rural villages. In 2007 the Elizabeth Glaser Pediatric AIDS Foundation started a horse courier service for healthcare service after realising that 80 percent of the country is mountainous and has a few paved roads.

Horses, in areas where the foundation has introduced the service, are life-saving couriers, shuttling vital medical supplies, anti-retroviral medicine (ARVs), mother-to-baby pregnancy kits and lab samples to remote clinics that serve villages inaccessible by car. The Global Post reports that the Horse Riding for Health Programme was as a coordinated venture between the Glaser Foundation, the Lesotho Health Ministry and the local communities in the mountainous Mokhotlong district. The programme has not been introduced in Thaba-Tseka yet.

However, Thaba-Tseka is one of the mountainous regions with many areas that are inaccessible by car. Mpokochela village, Taka’s home, is one of such. A three-hour’s ride to the clinic on horseback equals about 25 kilometres. Thanks to the agreement entered between the government and the Christian Health Association of Lesotho (CHAL), patients in Lesotho go to a doctor for free in all public health centres or at a subsidized fee in hospitals. This is important because CHAL has clinics in many hard to reach areas throughout the country.

The government is the largest healthcare provider in the country, operating 110 primary healthcare centres and 11 general hospitals. CHAL operates 61 primary healthcare centres and eight general hospitals, and is completely financed by the Ministry of Health through a subvention payment. In total, there are 372 health facilities in Lesotho. Of these, there is one referral hospital, two specialty hospitals, 18 hospitals, three filter clinics, 188 health centres, 48 private surgeries, 66 nurse clinics and 46 pharmacies. The only tertiary or referral hospital is Queen ’Mamohato Memorial Hospital, which is in Maseru.

Patients requiring services beyond what is offered at the tertiary level are referred to Universitas and Pelonomi hospitals in South Africa at the government’s expense. For CHAL-owned health centres alone, the government’s budget this year is M322 million. CHAL is the biggest employer of primary health professionals followed by the government, according to the Lesotho Annual Joint Review 2016. The government has just 1.12 percent workers fewer than at each CHAL facility, indicating that CHAL employs many health staff at primary health centre level. Also CHAL employs more than double the number of data clerks and around one more HIV counsellor when compared to government-run primary health care.

The Health Ministry’s principal secretary Monaphathi Maraka says paying a lot of money to CHAL is important because CHAL reaches people where even the government does not have facilities. “Hospitals like Paray in Thaba-Tseka and Tebellong in Qacha’s Nek, two areas deep in the mountainous region of Lesotho, are doing a good job for us,” Maraka said. “We have hospitals in the districts and many health centres throughout the country but CHAL is very helpful because it has reached where we are not represented.

Government subvention to CHAL has increased by 121 percent from 2011/12 to 1016/17, according to the World Bank’s Public Health Sector Expenditure Review of 2017. Above 90 per cent of the health sector budget is financed from government sources. In the 2016/17 fiscal year, the total budget for health was M1.9 billion. Of the budget, M1.7 billion (90.8 per cent) came from the government.

M155.8 million (7.9 per cent) came from counterpart budget and M23.8 million came from grants. Donor financing, as a percentage of the total health sector budget, declined in real terms from 8.6 per cent in 2013/14 to 1.2 percent in 2016/17. Funds from other partners, as a share of total health expenditures, also declined from 17.8 per cent in 2013/15 to 8.7 percent in the 2016/17 fiscal year. Maraka applauds CHAL hospitals “for playing an important role in the provision of health services, especially in the hard to reach areas in the mountainous regions of the country”.

An example of such hospitals is St. James, situated in Mantšonyane in Thaba-Tseka district. St. James has been an integral part of the Mantšonyane community since the early 1960’s. Founded by the Anglican Church in Lesotho with help from USPG, the Society of the Sacred Mission, and many others in the community, St. James has grown from a small traditional Basotho hut-hospital to a 55 bed facility in the heart of the Maluti Mountains. The hospital has a staff of nearly 120 workers who support the 70 000-person Mantšonyane health services area, which spans an area nearly 2 000 square kilometres in size.

The staff is caring for the mental, physical, and spiritual wellbeing of the people in the Mantšonyane. According to its website, the hospital’s annual budget is around M10 million, 80 percent of which is provided by the government. The remaining 20 percent comes from the Anglican Diocese of Lesotho, other sponsoring organizations like the Anglican Church of Southern Africa and patient fees. Management of hospital funds is overseen by the St. James Board, which is chaired by the Bishop of Lesotho, Bishop Adam Taaso. On the website, the hospital says even with the support from the government, diocese, and other donors, St. James operates at a M2 million deficit each year.

“Government funds provide for operational costs directly linking to medical care and for the salaries of professional employees (doctors, nurses, medical technicians, etc),” the website reads. “Government funds do not cover the salaries of other vital St. James employees, like the maintenance staff, domestic staff, and administration staff,” it says. “These funds do not cover the upkeep of hospital buildings and vehicles, including staff housing and off-site clinics. These costs that are not covered by government funds make up a large portion of the St. James’ budget.” Patient fee prices at the hospital, like in any other CHAL hospital, are set at a low price by the government.

As such, these fees do not contribute a significant amount to the overall budget. Gaps in the budget that are not supported by government funds are supposed to be covered by the Anglican Diocese of Lesotho. Due to ongoing financial constraints at the diocese, these funds often vary from year-to-year. “The lack of consistent funding has caused serious financial concerns. Without adequate funding, St. James’ community development and engagement programmes suffer severely in both quality and quantity, as funds must be diverted to essential hospital functions,” the website reads.

The main hospital facility has an inpatient ward, outpatient clinic, operating theater, maternity ward, laboratory, pharmacy, and a radiology department. In addition to regular hospital services, St. James runs a Primary Health Care department (PHC). St. James’ PHC department is responsible for overseeing four rural health centres along with several community development programmes. The World Bank has recommended that there should be a change in the payment system for hospitals to provide greater autonomy in the day-to-day management of individual hospital facilities.

“Allocations to individual hospitals should be based on some measure of the services (in terms of volume and quality) delivered by the same health facilities, and not input-based norms,” the World Bank says. “It is worrisome that bed occupancy rates of most district hospitals (both government and CHAL owned) are abysmal (32 percent), signalling service quality and reliability issues that need to be addressed,” it says. The World Bank has also recommended efficiency and equity in primary health funding “as there are large variations in funding per health centre and per medical visit across Lesotho”.

“Allocations to individual primary health centres could be based on capacitation, with adjustments related to gender and age of the patients living in their catchment areas,” the World Bank says. The World Bank also recommends that the CHAL Memorandum of Understanding with the government should be revised to ensure greater accountability and oversight of funds and health outcomes. The concern here is that the current agreement with CHAL involves a lump-sum payment that it applies across the entire organisation and the government has little control over how the funding is allocated.

“Given that CHAL is being paid to operate over 20 percent of the primary health centres and 40 percent of the hospitals in Lesotho, and that its facilities have significant efficiency disparities with its GOL counterparts, we advise changing the structure of the contract to increase GOL leverage, and link at least some of the payment to service delivery results,” the Bank says.

Staff Reporter

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