The unsung heroes of Lesotho’s healthcare
They are the first point of care at community level, ensuring HIV/AIDS and Tuberculosis (TB) patients as well as pregnant mothers, take their medication and attend antenatal clinics regularly.
Without them and their dedication to saving lives, there would be little TB and HIV/AIDS response at community level.
Yet, Lesotho’s Community Health Workers (CHWs) are a marginalised lot and hardly get the support they deserve to make their job easier. Their measly M400 monthly allowances hardly come on time, and neither do the service kits without which they cannot provide the much-needed community-based healthcare.
Making their job even more difficult is the country’s rugged terrain, particularly in the highlands where villages are hard to reach due to the poor condition of roads.
The plight of CHWs has been brought under the spotlight yet again—this time as a result of the pending launch of a project to be jointly run by the offices of His Majesty the King and the Prime Minister.
The ‘No More Deaths in Lesotho’ project, whose theme is ‘Revitalising Primary Health Care because the life of every Mosotho matters-for improved maternal health, reduced child mortality and reduction of the scourge of Tuberculosis and HIV”, is scheduled to be launched later this month, with King Letsie III and Prime Minister Pakalitha Mosisili leading from the front.
His Majesty and Dr Mosisili would be engaging stakeholders such as church-leaders, civic groups, the media, government ministries, development partners, chiefs, local councils and district administrators in their efforts to ensure a healthy nation.
Village health workers have also been identified by the project’s directors as critical stakeholders who need empowerment to improve health services at grassroots level.
Mamohau Makhata (55) of Pitseng-London in Leribe district, has been a CHW since 1992 and currently cares for 36 patients, most of them HIV-positive. Village health workers are selected by fellow residents in the presence of community leaders such as chiefs and supervised by trained nurses.
The CHWs are given medical kits to help patients at home. The kits, procured with the support of Global Fund grants, are distributed by the National Drugs Services Organisation.
Makhata says providing care for the patients has not been an easy journey, particularly due to lack of tools and the ever-present danger of infection.
“We don’t have gloves to handle patients with, which puts most of us at risk of contracting diseases, particularly HIV. Even at clinics where we normally ask for utilities, they also don’t have gloves,” Makhata told the Lesotho Times.
Medication, which Makhata says forms part of the service kits, is also one of the major challenges, she added.
“It becomes even worse when you have to treat patients just before accompanying them to a clinic or hospital, but you don’t even have paracetamol to give them,” Makhata said.
“We also are in dire need of toiletries to clean our patients with. Most of our patients have absolutely nothing to their name.”
Makhata further says due to lack of access roads to villages and the challenging mountainous terrain, it is difficult to get patients to health centres on time, adding the situation is made worse by the meagre allowances they are paid “which also don’t come regularly”.
She continued: “The majority of our patients are poor and don’t have much. We have to dig dip into our pockets to pay for transport to get them to hospital. There are cases where pregnant women even give birth on the way to hospital.”
Makhata further maintains that of the 36 HIV-positive patients in her care, the majority is bedridden or not strong enough to travel long distances, hence her constant travel to the hospital to collect their antiretroviral medication.
On allowances, Makhata says she is paid M900 every three months, but is quick to add not every CHW gets the money.
“Some of the new workers are worse off because unlike us who get M900 every three months, they go for months without being paid anything. It is difficult, very difficult,” Makhata said.
Lesotho has the second highest rate of HIV-infection in the world behind Swaziland, with almost one-quarter of the adult population estimated to be HIV-positive. Some studies put the country’s average life expectancy at less than 40 years as a result, while the steep mountains and harsh weather exacerbate the situation by making it hard to access health services for many people. Many patients walk for an average of four hours over the bleak terrain to access healthcare, and by the time they reach clinics or hospitals, they condition would have become worse.
‘Matiisetso Ntobaki (47) is also a village heath worker but based in Mphosong in Khoaba-la-e-ja-Bohobe. She has been a CHW for almost two years and mostly cares for pregnant women and new mothers.
“I have been a village health worker since last year, and it has not been easy at all,” Ntobaki said.
“We don’t get our allowances on time and service kits are very scarce. This makes it difficult for us to treat patients.
“Even when the money finally arrives, it is very little if one considers the job we do. For instance, sometimes we have to accompany pregnant women to the hospital at night and need to pay for transport. But because the money won’t be there, we have no choice but to walk to the hospital, thereby endangering our lives.”
Both Makhata and Ntobaki are appealing to government to ease the burden of CHWs by providing them with the necessary equipment and their stipends on time.
“I appeal to government to improve our working environment because we are committed to caring for our people and saving lives,” Ntobaki says.
“We were promised allowances on a regular basis, monthly to be specific. But they always come late and when they do, they are never backdated. We never get paid the whole amount.”
Makhata also urges government to build roads in every part of the country to ease movement and enable them to reach health centres timeously.
“We take patients to clinics and hospital on a daily basis. We also go there to collect medication for those who are not strong enough to travel, but without roads, this is extremely difficult,” Makhata said, adding government should also ensure clinics and hospitals are supplied with enough medication.
Meanwhile, Teboho Phakoa, Director of Live and Safe Life Association Maluting—a non-governmental organisation based in Semonkong—says the plight of CHWs is moving.
According to Mr Phakoa, the bad terrain and inaccessible roads make it difficult for patients to receive medical attention on time, adding half the time, they are nursed by untrained village health workers.
Mr Phakoa has also lamented lack of medical equipment among the workers, as well as the meager allowances.
He suggests for the CHWs to get the recognition they deserve, implementing bodies such as the Lesotho Council for Non-Governmental Organisations (LCN) and Lesotho Network of People Living with AIDS should ensure funds from donors “reach their rightful beneficiaries”.
“If people are going to do their jobs effectively, beneficiaries need to get their monies directly because implementing bodies always fail to ensure this happens,” Mr Phakoa said.
“Only a small amount of donor funds reaches beneficiaries, which creates a host of challenges at grassroots level.”
Mr Phakoa has urged donors to engage consultants to ensure the funds are disbursed on time.
“Donors must engage consultants to work directly with grassroots organizations because mother-bodies delay in ensuring the monies reach the grassroots,” Mr Phakoa says.
Thakane Kotelo, the Executive Director of Phelisanang Bophelong—an NGO based in Leribe—also said CHWs do not get the respect they deserve.
“They don’t get paid, yet these are the same people who fill the gaps left by the Ministry of Health. Without them, there would be no HIV and TB response,” Ms Kotelo says.
“These are people who are on the ground, providing services at community level.”
Failure by the health ministry to recognise CHWs, Ms. Kotelo adds, is due because it “relies on its own structure”.
“The ministry does not recognise civic groups, yet we are their watchdogs, always making noise and ensuring government policies are implemented. We don’t even ask for credit because we have a role to play,” she said.
“When we arrive at villages, we approach the ministry and ask what gaps we can fill to assist and how best we can incorporate our challenges. But there is no coordination or relationship between the ministry and civic groups.”
The ministry, she added, should start to seriously engage community health workers because “we’re working within the National Development Plan”.
Ms Kotelo further says she applauds the Primary Health Care Revitalisation Project and its focus on investing in “individuals, institutions and actions that create an environment for the speedy delivery of health services”.
“If the project takes off, village health workers are going to benefit immensely. Here we are talking about investing in people and institutions that speed the delivery of health services. I encourage this community-led approach; services need to be decentalised and local government is that gateway to services coming to the community.”
Partners-in-Health Lesotho Director, Dr Garry Gottlieb, has also highlighted the importance of CHW, saying they are vital because they “provide integrated community-based care”.
Partners-in-Health (PIH) is one of the organisations at the forefront of the PHC revitalization project and has already invested heavily in CHW.
PIH/Lesotho was launched in 2006 at the invitation of the Lesotho government and in consultation with the Clinton Health Access Initiative. The organisation is working to improve the health of eight remote communities, providing integrated services for maternal and child health, HIV, and tuberculosis, while managing the national program to treat multidrug-resistant tuberculosis (MDR-TB). The programme brings healthcare to nearly 200000 people.
Contacted for comment, the Ministry of Health Information Officer Mateboho Mosebekoa referred the Lesotho Times to the Director-General Health Services, Dr Nnyane Letsie.
However, both Dr Letsie and Health Minister Dr ‘Molotsi Monyamane were not readily available.
Dr Letsie’s mobile phone rang unanswered yesterday, while several attempts to contact Dr Monyamane also proved futile as he was said to be in a meeting.
Attempts to reach the minister later in the day proved fruitless as his phone was now on voicemail.