The imminent cut in funding for HIV adherence counsellors in Lesotho is likely to create tension and cracks in an already severely under-resourced health service as healthcare workers, especially nurses, face additional responsibilities, and as people living with HIV become more vulnerable to the consequences of managing their treatment incorrectly.
Lesotho has the third highest HIV infection rate, after Botswana and Swaziland, in Southern Africa – the epicentre of the pandemic. The Lesotho ministry of health and social welfare estimates that 23% of people between the ages of 15 and 49 are infected with the virus. HIV infection rates peak at 40% in both men and women in the 30 to 34 age group.
Lesotho's HIV epidemic affects every sector of Basotho society. Between 1996 and 2006, the country had a population growth rate that declined from 1.5% to 0.08%. On average, the life expectancy of the Basotho is only 41. In addition, 68% of the population lives on less than $2 a day.
The country has a severe shortage of health workers. Médecins Sans Frontières (MSF) data show that 89 doctors and 1123 nurses serve a population of 1.8-million, and only six out of 171 health centres adhere to minimum staffing requirements.
A special group of HIV/TB adherence counsellors are trained and certified to work at health facilities in Lesotho. They play a crucial role in getting patients to adhere to their treatment. Known as lay counsellors, this cadre provides HIV testing and counselling as well as education on HIV, TB and prevention of mother-to-child transmission. They also assist with basic clerical tasks and are expected to provide ongoing therapeutic counselling, facilitate support group discussions and help nurses. For this important yet underestimated role, lay counsellors earn 700 maloti a month (R700).
Unfortunately, lay counsellors are not paid by the Lesotho government because of a wage bill ceiling imposed by the International Monetary Fund. Counsellors have to rely on external funding for support until a long-term strategy is found. Currently, there are more than 600 lay counsellors in the country. About 300 are funded by the Global Fund to Fight Aids, Tuberculosis and Malaria, and the rest from non-governmental organisations, some of which receive their funding from the United States government's President's Emergency Plan for Aids Relief.
Owing to contribution shortfalls from donor countries, the Global Fund said in November 2011 that applications for grants from recipient countries would not be considered until 2014. In December 2011, only $40-million of Lesotho's $70-million application had been approved.
Funding for the support of lay counsellors will decrease incrementally: full funding this year, 70% next year and 30% in 2015. Lesotho will then be expected to provide the finance or find another plan for these workers, as some of the other organisations that are present in the country have also withdrawn their funding, arguing that lay counsellors are unsustainable.
Donars want to see quantifiable results
Evidence-based policy is what interests donors, but it's difficult to quantify the effect that lay counsellors have had. It's also unethical to wait for a quantifiable public health catastrophe before making a judgment on their added value.
During the first six months after grant approval in December 2011, the ministry of health bridge-funded more than 300 counsellors while the country finalised the implementation plan. But from July 2012, counsellors stopped receiving salaries.
The Global Fund mission visited Lesotho in August 2012 and informed the ministry of health that the grant agreement had been signed and that the government could request disbursements. After agreement on the standard conditions for disbursements, the government submitted a document in September outlining how all the requirements had been met.
In late September, MSF met the Global Fund to communicate its concerns and was assured that the grant money would be disbursed by the end of October, but this did not happen.
Some of the lay counsellors continued to work as unpaid volunteers. Many, however, had to stop working. Some went as far as organising themselves into a registered community-based group called Tlamanang Lay Counsellors and personally pleaded with MSF for help. Funds finally arrived at the ministry of finance in December, but only the amount that was owed up to then.
If lay counsellors are to be paid in the next few months, the government needs to submit a progress report detailing how this latest disbursement was spent. This creates a vicious cycle as a large portion of the money is being used to cover the counsellors' back pay.
The Global Fund pays for the antiretroviral medication of 60000 HIV patients in Lesotho – three-quarters of everyone on HIV treatment. Lay counsellors play an important part in getting patients to take their pills correctly. If the correct procedure is not followed, the drugs become ineffective, leading to the waste of donor-funded medicine.
Dr Indira Govender is the deputy medical co-ordinator for Médecins Sans Frontières in South Africa and Lesotho