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RATIONAL
The reform process was initiated in 2002 following wide
consultations with all stakeholders of the sector. It is a
ten year programme, currently in its fourth year and start
of the second phase focusing on policy and institutional
reform. Phase one focused on institutional capacity building
(See annual joint review reports for more detail) Phase
three will involve sector wide implementation of guidelines
and protocols developed in the first two phases. Health
sector reform was a response the rapid increase in demand
for health and social welfare services coupled with
dwindling resources for the sector. The intended outcome of
the process was to improve management systems in the sector
so that the scarce resources are used more efficiently. The
reform programme entails a rearrangement of structures and
definition of policies so that the service delivery system
is responsive to the needs as identified at the community
level. This programme is one of the biggest initiatives
being undertaken by the MOHSW. In 2004/05 the budget for the
health sector reform programme alone was approximately 46%
of the total development budget of the sector. The key
partners supporting this programme are Lesotho Government
Development Corporation of Ireland, European Union, World
Health Organisation, African Development Bank and the World
Bank
AREAS & OBJECTIVES for REFORM
The key areas of reform were defined as:-
Policy & institutional development
The objective here is to define a set of cost effective
protocols and procedures to improve standards of care and to
improve efficiency and enhance local accountability. The
implication of this was to rationalise and decentralise
health a management systems and define a basic package of
health services that will be cost effective, affordable and
improve the referral system.
Thus far the Ministry has succeeded in defining the district
health package with defined standards for health personnel
and equipment needs at the district hospital and health
centre levels. The process of defining standards for quality
assurance has also been initiated. District Health
management teams a being piloted in three districts: Thaba
Tseka, Mohale’s Hoek and Berea. The ministry also in the
process of strengthening management competencies at the
district level as well as developing procedures and
guidelines in the areas of financial management, planning &
budgeting and monitoring and evaluation.
The key challenges facing this area of reform is to continue
to build capacity in line with the sector needs as well as
other initiative being undertaken by government,
specifically the establishment of local councils under the
broad national decentralisation strategy. Over and above
this resources, need to be mobilised for expansion of the
pilot to other districts. The district health package
remains to be costed to facilitate more transparent
processes of allocating resources in a decentralised
management context. See Strategy & action plan document for
further details
Social Welfare
Social welfare reforms were a response to a general lack of
cohesion and focus in the delivery in the delivery of
services as well as a lack of capacity to carry out this
function. The objective therefore is to improve the systems
for the provision of protective, preventive an
rehabilitative social welfare services to those in need.
Target groups here include geriatrics, vulnerable children
and disabled persons. The reform process sought to respond
to the lack of capacity of this department, particularly in
the areas of increasing the number and quality of social
workers and to increase access and awareness of social
welfare services to those in need. In addition systems in
the way services are delivered was to be improved through
the development of relevant policies legislation and
guidelines.
Thus far a social welfare policy and strategic plan have
been developed. Child protection legislation has been tabled
for consideration by cabinet. Training has been undertaken
to address needs related to disability and specialised
social welfare needs and a programme to strengthen
vocational training for disabled persons has been initiated,
coupled with strategies to promote rehabilitation and
prevention of disability at the community level. Guidelines
for monitoring of income generating projects have been
developed. The key challenge facing this area of reform is
insufficient resources to meet the needs at the community
level.
Strengthen HIV/AIDS response
Public sector capacity to implement a multi-sectoral
approach to control of the HIV/AIDS pandemic was one of the
key facets of the reform programme. Hence establishment of
the national AIDS coordinating body LAPCA. The objective of
this reform area is to build the capacity of the MOHSW to
play a leading role in building national responsiveness to
this pandemic. The MOHSW is expected to provide technical
support to both private and public institutions involved in
the fight against HIV/AIDS and to provide medical and
clinical care to AIDS patients.
The Ministry has successfully refined the mandate of the
AIDS Programme and emulated it to directorship. The
structure ahs been revised to accommodate the new challenges
faced by this programme. The areas of focus include
prevention & health promotion; care & treatment; Health
standards & systems informed policy and strategy
development. Furthermore, clinical guidelines for the
prevention of mother to child transmission (PMTCT) are being
implemented and the voluntary counselling programme has been
initiated in various institutions around the country.
Efforts are underway to strengthen the capacity of
stakeholders, particularly in the private sector, to carry
out mitigation activities at the community level and to
strengthen coordination at the central level of the MOHSW
and the National AIDS Secretariat. The procurement and
distribution of anti-retrovirals is another area identified
for strengthening under the Health sector reform programme
The key challenges facing this area of reform are to
continue to streamline activities so that they are
responsive to control and management of HIV/AIDS across the
country; to ensure sustained access to appropriate treatment
and care for people living with AIDS, to institutionalise
systems and provide the right infrastructure for effecting
HIV/AIDS strategies,
Pharmaceuticals Supply &
Management
Reforms in the pharmaceuticals sector were a response to the
absence of clear drug regulation, irrational prescription
practices and inefficiencies in drug procurement, management
and distribution. The objective of reform was therefore to
improve efficiency in the procurement, distribution, quality
control and used of drugs as well as to strengthen the
capacity of pharmaceutical sector personnel to carry out
their mandate more efficiently.
Thus far pharmaceutical reform has involved a baseline study
which informed the policy and legislation for regulation of
this sector. These documents have been submitted to cabinet
for approval. The strategic plan which includes training of
personnel in the pharmaceuticals sector, establishment of a
drug regulatory body, implementation of the national
standard operating procedures, capacity building and
definition of the national drug procurement body NDSO. The
expectation is that implementation of the standard treatment
guidelines and essential drug list will address problems
such as drug pilfering, mismanagement. All these initiatives
are geared towards facilitating efficient management and
rational use of drugs. Initiatives are also underway to
revise the organogram of the Pharmacy department and improve
numbers and quality of pharmacy personnel.
The key challenges facing the pharmaceuticals sector to
attract and maintain the right calibre of personnel to
regulate the drug sector in the country as well as to change
from inefficient prescription practices to those defined
under the standard treatment guidelines. Moreover, the
sector is also challenged to create appropriate incentive
systems for the retention of trained staff, especially in
areas outside the capital
Human Resources Planning, Management
& Development
Reform in the area of human resources was a response to
a chronic shortage of health personnel partly due poor
working conditions and ineffective management systems, which
have led to high attrition rates of health personnel,
particularly trained nurses and doctors. The health sector
reform process was intended to develop systems for tracking
staff deployment and skills, addressing training outputs;
recruitment, retention and incentives. Thus far a
comprehensive study has been undertaken to assess the
situation in terms of personnel and skills gap at the
different levels of the health system. The outcome of this
study was a human resources development plan. Progress in
other areas such as the development of the district health
package have added value to processes of training and
deploying the right personnel and skills in the right
places. Public service sector reform has also had a positive
impact on the Human resources department of the sector,
which was strengthened as a result.
One of the factors contributing significantly to slow
progress in implementing effective incentive systems such as
appropriate career ladders and staff housing in the mountain
areas is the dependence on other the Ministry of Public
Service, Ministry of Public Works and Ministry of Finance &
Development Planning to effect decisions taken at the level
of the MOHSW. Nevertheless, challenges facing the health
sector are rationalisation and deployment of staff so that
the district health package is implemented as envisaged,
this will include attracting and keeping trained personnel
in places that have historically been underserved.
Furthermore, attraction and retention of trained staff
through implementation of effective and sustainable
incentive systems will remain a challenge for some time to
come, especially as Lesotho is competing with not only other
SADC countries but also countries as far off as the Middle
East and Europe for nurses in particular.
Health Financing & Financial
Management
Financial reforms were meant to respond to problems of
inefficient management procedures which resulted in under-utilisation
of budgets and therefore lack of responsive ness to health
needs at the community level. Also in the interests of
equity there was a need to develop resource allocation
mechanisms that would facilitate equity distribution.
Financing of health services because of the dwindling
resource base which gave rise to a need not only to use
resources more efficiently but to broaden the base for
resource mobilisation. The objective for this area of reform
was therefore to improve allocative efficiency, equity,
ensure sustainable financing for the sector as well as to
generate appropriate financial information for decision
makers at all the levels of the health system
Thus far the Ministry has succeeded in improving the
structure of cost centres and developing a budgeting system
which attempts to link programme objectives to the budget. A
costed three year programme based on the strategic plan has
been developed to guide realisation of the sector priorities
in the long run. A financial management system which
attempts to generate financial reports linked to activities
was also developed, though this works only for the
development budget. The practice of generating monthly
expenditure reports has been improved. Financial reporting
remains inadequate because of a severe shortage of competent
accounts personnel in the Finance department of the MOHSW.
Hence, since expansion of cost centres was not complemented
with additional accounts personnel reporting by established
cost centre still remains problematic. Reforms being
undertaken in the Ministry of Finance & Development Planning
should have a positive impact on the financial management
practices in the health sector. Through the reform process
the MOHSW was able to establish a project accounting and
procurement unit, both of which fall under Health Planning.
In addition to overseeing implementation of donor
requirements, these two units are also charged with
providing technical support to established departments of
the Ministry and were responsible for developing procurement
and disbursement guidelines which will be used for
facilitating decentralised financial management.
Consultations within the region have been initiated on the
issue of social health insurance which is a possible option
for increasing the base for resource mobilisation for the
sector. Options for standardising user fees structures
between CHAL and government providers are also being
explored. This initiative is important not on for promoting
equitable access but also for forging a transparent and
rational partnership between the government and CHAL.
Infrastructure Development &
Maintenance
The objective of infrastructure reforms is to strengthen
maintenance systems within the sector as well as to
rationalise development initiative so that they promote both
efficiency and equitable access. The need for these reforms
arose as a result of extremely run down facilities and
equipment due to poor maintenance systems, infrastructure
gaps which resulting from initiatives such as
decentralisation and the district health package and other
sector development initiatives.
In an attempt to rationalise infrastructure development and
maintenance systems the MOHSW established the Estate
management department whose responsibility is to oversee all
the infrastructure needs of the Ministry including sector
maintenance and development policies and strategies. To
address dire infrastructure situation of CHAL facilities, a
Health Centre rationalisation study and the Health Study
were undertaken to assess the baseline that would inform the
best way to address problems. These studies generated useful
data for decisions on distribution and calibre of hospitals
that would facilitate efficient functioning of the referral
system. Information generated would also inform allocation
of government subsidies to CHAL facilities, one of the
requirements for establishing a memorandum of understanding
between government and CHAL.
Based partly on these two studies an infrastructure
development plan for the sector was developed. This plan,
which costs approximately 1.3 billion incorporates all
government and CHAL sector facility and equipment
development & maintenance needs, including health posts,
health centres, filter clinics, district hospital, referral
hospital, specialised hospitals, health training
institutions, MOHSW headquarters building, staff housing and
decentralisation. Needless to say mobilisation of resources
for and prioritisation of this plan will be huge challenges,
given urgency of the need. Other challenges include building
capacity of the maintenance unit through the right numbers,
skills and distribution of staff as well as
institutionalising planned preventive maintenance practices
throughout the health system.
Partnership & Donor
Coordination
The rationale for undertaking reforms in this area is to
improve collaboration and coordination between the MOHSW and
its partners. The objectives are to strengthen service
delivery systems through rationalising partnerships with
other service providers, particularly CHAL and to facilitate
sustainable support from development partners of the
Ministry.
Efforts to improve collaboration with other service
providers have concentrated mainly on CHAL, mainly because
CHAL provides 40% of health services in the country. In the
areas the MOHSW has succeeded to establish a GOL/ CHAL
coordinating body which was consequently emulated to the
Public private partnership unit. This unit coordinates all
partnerships between the Ministry and other providers. Key
successes have been in the areas of establishing a
supplementary emergency financing facility (SEFF) to assist
CHAL institutions to improve their quality of service to a
standard that would be appropriate for a partnership with
the government. This facility provides for 20% of the total
operating costs of each facility and is meant to run up to
March 2005. Efforts are underway to develop a comprehensive
financing framework, quality assurance framework, supportive
legislation and to undertake accreditation of CHAL
facilities. All these initiatives are geared towards
finalising a memorandum of understanding between CHAL and
the government of Lesotho. The PPP unit has also facilitated
a formal partnership between Blue Cross and government
following the end of support from the Norwegian government
in December 2004.
Coordination with development partners has been facilitated
through joint quarterly monitoring and evaluation meetings
between programme managers and donors as well as and annual
joint reviews where all parties including the districts
review progress in implementation of the Health reforms
programme and general performance of the sector. Monitoring
is also enhanced through monthly meetings between the top
management of the Ministry and the donors active within the
MOHSW.
The challenges faced by the MOHSW in this area include
finalisation of the memorandum of understanding with CHAL
and rationalising partnerships with other service providers,
this will require strengthening the capacity of the PPP unit
especially as the MOHSW is currently negotiating a PPP deal
with the World Bank for construction and management of a new
national referral hospital in the Lepereng area. In the
areas of donor coordination the challenge is to facilitate
pooling of funds and adoption of standard procurement,
disbursement and reporting systems for all parties involved.
MONITORING & EVALUATION
The need for a strengthened monitoring and evaluation
function can be linked to the need to make the most of
scarce resources in the sense that the Ministry recognises
the need to link objectives, performance and expenditure,
thus ensuring that expenditure is linked to impact on health
and social welfare needs. The monitoring and evaluation
function is intended to facilitate evidence based planning
and allocation of resources according to established needs.
In addition recognition of the comprehensiveness of the
reform, gave rise to a need to define baseline indicators
that would be tracked periodically to ensure that intended
outcomes are realised. The key objective of establishing a
monitoring and evaluation unit under Health Planning &
Statistics, was to ensure generation of accurate information
that would assist decision makers in gauging the vital
indicators of the health sector such as, financial
performance, burden of disease, epidemiology, drug
availability, staffing profile etc.
Thus far the Ministry has successfully conducted quarterly
M&E meetings and annual joint reviews that are also linked
to coordination with development partners. These meetings
have been useful for decision making on issues that may be
limiting performance of the sector and for generating
insight on what the priorities are at a given point in time.
Attempts have also been made to improve data collection and
analysis through development of standard data collection
tools. As part of the decentralisation initiative
statisticians have been placed in the three pilot districts
to improve data management at this level. The M&E policy and
strategic plan have been developed.
The key challenges facing the Ministry include building
capacity for data management and appreciation at all the
levels of the health system. Use of this data for planning
and budgeting is also a practice that needs to be integrated
into decision making processes for improving the performance
of the sector.
Contacts for more information: Health Planning &
Statistics or relevant departments
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