ANNUAL REPORT FOR GLOBAL FUND SUPPORT IN LESOTHO

Transcription

1 MINISTRY OF FINANCE AND DEVELOPMENT PLANNING ANNUAL REPORT FOR GLOBAL FUND SUPPORT IN LESOTHO OCTOBER 2010-SEPTEMBER

2 TABLE OF CONTENTS Abbreviations... 4 Executive Summary Introduction hiv grants performance Round 7 HIV GRANT: Overview and background Round 7 Programmatic Performance Round 7 financial Performance Round 8 HIV GRANT: Overview and background Round 8 HIV Programmatic performance Round 8 HSS grant OVERVIEW and background Round 8 HSS Programmatic Performance HSS: Service delivery HSS: Service delivery HSS: Service delivery HSS: Health Workforce HSS: Health Workforce HSS: information system HSS: Procurement and Logistics Round 8 HIV/Hss financial Performance Round 9 HIV GRANT: Overview and background Round 9 HIV Programmatic Performance Round 9 HIV financial Performance TB grants performance

3 3.1Round 6 TB GRANT Overview and background Round 6 TB Programmatic Performance Round 6 Tb financial Performance Round 8 TB GRANT Overview and background Round 8 TB Programmatic Performance Round 8 Tb financial Performance CONCLUSION

4 ABBREVIATIONS ACSM- Advocacy Communication & Social Mobilisation AIDS - Acquired Immune Deficiency Syndrome ANC- Ante-Natal Care ART - Antiretroviral Therapy ARV- Antiretroviral CBO- Community Based Organizations CCM- Country Coordinating Mechanism CFCU- Global Fund Coordinating Unit CGPU- Child And Gender Protection Unit CHAL- Christian Health Association Of Lesotho CHWs - Community Health Worker DSW- Department of Social Welfare DNA-PCR- Deoxyribonucleic Acid-Polymerase Chain Reaction DOTs- Direct Observed Therapy-Short Course GFATM - Global Fund To Fight AIDS, TB and Malaria GOVT- Government H.S.A- Health Service Area HBC- Home Based Care HCWs- Health Care Workers HIV- Human Immunodeficiency Virus HSS- Health Systems Strengthening HTC- HIV Testing and Counselling IEC- Information, Education and Communication LDHS- Lesotho Demographic and Health Survey LENEPWHA- Lesotho Network OF People Living With HIV/AIDS LMPS- Lesotho Mounted Police Service MDR/TB- Multi- Drug Resistance Tuberculosis M&E- Monitoring and Evaluation MOET - Ministry of Education And Training MOFDP- Ministry of Finance and Development Planning MOGYSR- Ministry Of Gender, Youth and Sports Recreation MOHSW- Ministry of Health and Social Welfare MTCT- Mother to Child Transmission NUL- National University of Lesotho OIs- Opportunistic Infections OVC- Orphan and Vulnerable Children PEP- Post Exposure Prophylaxis PLWAs- People Living With HIV & AIDS PIH - Partners In Health PMTCT- Prevention of Mother to Child Transmission PTB- Pulmonary Tuberculosis PR- Principal Recipient PSI- Population Service International SRs- Sub Recipients STIs- Sexually Transmitted Infections TA- Technical Assistance TB- Tuberculosis TVD- Department of Vocational & Technical Training WHO- World Health Organization 4

5 EXECUTIVE SUMMARY Currently the MOFDP PR manages a grant portfolio of five grants which includes three (3) HIV and AIDS grants (Round 7, 8 and 9) and two TB grants (Round 6 and 8) with a total approved budget of $85,448, (HIV /HSS- $72,167, and TB $13,280,674). The disbursement for HIV grants by end of September 2011 from the Global Fund to the PR stand at $48,067, while for TB is to the tune of $5,611, for the current grants. The expenditure for the HIV/HSS as at 30 September 2011 stands at $45,349, while for TB grant is $4,612, The programmatic performance of Round 7 grant indicates that ten indicators out of twelve attained more than 70% while only two achieved less than 30%. The poor performance of the two indicators is attributed to non availability of funds to support interventions because of the new process which was undertaken to consolidate Round 7/9 grants to align with the new Global Fund single stream funding grant architecture. The process which took close 8 months before signing of new Single Stream Funding contributed to the hold up of major activities which are directly linked to the Round 7 phase 2 grant. R7 phase 2 grant was signed in February 2011, and by April 2011, the funds were disbursed to the PR to the tune of $4,053,523 against the approved budget for Y3 of $4,561, while expenditure by end of June 2011 was to the tune of $3,517, which translate to 79% absorptive capacity. At the end Round 8 HIV/HSS phase 1 in October 2011, grant performance was rated as good compared to the slow implementation at the initiation stage. Nine out of the seventeen indicators surpassed their intended targets and five indicators reached more than 70%, while the performance of the three indicators reached less than 50%. The poor performance includes training on Sexual Reproductive Health (SRH) which reached 42% of the target, Male circumcision indicator which attained only 29% and the home-based care indicator which reported 28%. By end of the phase 1 funds disbursed by the Global Fund wereto the sum of $34,115,824 as against the approved budget of $49,999,204. Out of the disbursement received, expenditure incurred was $33,224, reaching 89% absorptive capacity for R8 HIV and 92% HSS by end of October The implementation of Round 9 took only two quarters from January 2011 to June 2011 and thereafter was consolidated with R7 to form a Single Stream Funding. This resulted in majority of the indicators performing below 50%. The funds disbursed beginning of the grant was $1,561,636 and by end of June 2011, the expenditure incurred was $689,986, translating to absorptive capacity of 54%. R6 TB grant had been performing well with more than 50% of the targets exceeding targets and none of the indicators achieving below 50% of the planned intended targets. By end of the reporting period as at September 2011 the funds disbursed by the Global Fund were $3,888, against the budget of $5,543,805 for a period of five years. The expenditure acquired by end of this period was $3,814, reaching absorptive level of 98% for funds disbursed. It is important to note the grant is at its fourth year of implementation and is only left with ten (10) months before its closure. Round 8 TB grant started in October 2010 and the first year of implementation ended by 30 September By end of the year 1 of implementation, the grant performance was very poor due to number of challenges such as agreement indicators to be included in the performance framework; assumptions used which related to epidemiological trends on MDR /TB disease and budget approved for extension of 3 Regional and Referral MDR/TB hospitals. The projected numbers of MDR/TB 5

6 patients were not reached as anticipated as a result of MDR/TB patients supported were low as compared to high planned targets. In addition, budget deficit were encountered with regard to renovations of the MDR health facilities and this resulted in the delays to start renovations while sourcing additional budget, and this impediment resulted in most of the activities not being implemented, and indicators put in the performance framework to measure performance of the grant did not achieve intended targets and reach optimum level. By end of the September 2011, only three indicators out of fourteen attained 100% while the rest were below the 50% mark. The disbursement received from the Global Fund by end of the year was $1,723,734 out of the yearly (October September 2011) approved budget of $4,349,131. By end this first year of implementation only $798, was expended from the funds disbursed, which translate to 18% absorptive capacity. 6

7 1. INTRODUCTION Box 1 PRINCIPAL RECIPIENT: MINISTRY OF FINANCE AND DEVELOPMENT PLANNING (MOFDP)/ GLOBAL FUND COORDINATING UNIT (GFCU) VISION A nation with adequate resources to fight against HIV/AIDS and TB MISSION As Global Fund Coordinating Unit (GFCU) of the Ministry of Finance and Development Planning, the Principal Recipient (PR) for the Global Fund grants in Lesotho, we manage and disburse grants effectively and efficiently to the Public and Private Sectors as well as Civil Society to contribute 1. The Ministry of Finance and Development Planning through its Project implementing unit; Global Fund Coordinating Unit, was nominated by the Country Coordinating Mechanism (CCM) in 2004 as the Principal recipient (PR) to coordinate Global Fund grants for both HIV and TB components. Since that time the MOFDP has been legally responsible for grant proceeds and implementation of five Global Fund grants in Lesotho. 1. The Ministry of Finance and Development Planning through its Project implementing unit; Global Fund Coordinating Unit, was nominated by the Country Coordinating Mechanism (CCM) in 2004 as the Principal Recipient (PR) to coordinate the Global Fund grants for both HIV and TB components. Since that time the MOFDP has been legally responsible for grant proceeds and implementation of five Global Fund grants in Lesotho. 2. The MOFDP PR manages a grant portfolio of five grants, in particular the three HIV and AIDS grants (Round 7, 8 and 9) and two TB grants (Round 6 and 8) with a total approved budget of $85,448, The total funding per disease component are shown in the table below. Total Current Funding by disease component: Component HIV & AIDS TB Current Approved Budgets $72,167, (excluding closed R2 and R5 Grants) $13,280,674 (Excluding R2 closed grant) 7

8 A snapshot for GF grants coordinated by PR, The Ministry of Finance and Development Planning (MOFDP): Grant Time Framework Approved Budget per grant Cumulative amount R7 3 Yrs July 2008 to $12,898, $12,390, June 2011 R8 HIV/HSS Phase 1 2 Yrs- Nov.2009 $49,999,204 $34,115,824 October 2011 R9 Phase 1 2 Years $9,270,544 $1,561,636 Disbursed Jan Dec.2012 R6 5 Yrs- July June 2012 R8 TB phase 1 2Yrs- Oct Sept.2012 $5,543,805 $3,888, $7,736,869 $1,723,734 TOTAL HIV/HSS $72,167, $48,067, TOTAL TB $13,280,674 $5,611, All the Global Fund grants are implemented in two phases. Phase 1 runs for two years and Phase 2 takes three years. In November of 2009, The Global Fund Board approved the new grant architecture (Box 2). This new grant architecture brings important changes to the organization s operating model, including how countries apply for funding, how financing is structured, how performance management is conducted and how decisions about future funding are made. It also involves consolidation of disease specific grants into single stream funding (SSF). 4. HIV grants portfolio: Three HIV and AIDS grants have been approved by the Global Fund for Lesotho. Round 7 grant completed its first phase in September Currently this grant has concluded Year 3 which falls in the phase 2 of the grant. The last two years (4 and 5) of Round 7 have been consolidated with Round 9 grant to form one grant( 18 months of P1 from R9 and 6 months of P2 ) in order to align to the Global Fund single stream funding approach. Round 8 grant which comprises of HIV and HSS components commenced in November 2009 and will complete its phase 1 in October 2011.The CCM has applied for phase 2 of this grant which is anticipated to be consolidated with the R7/R9 consolidated grant so that the country should have only one HIV grant. Finally Round 9 grant started in January 2011 to continue to June 2011, while the rest of the phase 1 period has been consolidated with Round 7 grant. 8

9 5. TB grants portfolio: Two TB grants have been approved by GFTAM for Lesotho. Round 6 grant started its second phase in October 2009 and will run until June Round 8 TB grant commenced in October 2010 and the first phase of this grant will end in September Box 2 Global Fund new Grant architecture 1. The new grant architecture was developed through an intensive consultation and design process, incorporating lessons learned from the first seven years of the Global Fund as well as extensive feedback from country implementers and partners. In November 2009 the Global Fund Board voted to implement the new grant architecture, making it a top corporate priority. 2. At present, a Principal Recipient often manages several grants for the same disease in the same country. One key feature of the new grant architecture is the consolidation of such grants into a single stream of funding per Principal Recipient per disease. This change will reduce the reporting burden for many Principal Recipients and facilitate better alignment of grants and review schedules with national cycles. 3. Moreover, the single stream of funding will allow funding applicants to submit new proposals that incorporate existing Global Fund grants. The ability to consolidate proposals offers the applicant a chance to reflect on experiences and reprogram previously approved funding to better respond to evolving needs. Consolidated proposals also provide the Technical Review Panel with the material to make a more holistic evaluation of the funding request. 4. Periodic reviews are another important feature of the new grant architecture. The mechanics of the new architecture allows grant performance reviews to be scheduled in alignment with national program reporting and review cycles. In contrast to Phase 2 reviews, these periodic reviews permit a broader assessment of the grant portfolio within the context of the entire national disease program. Periodic reviews move away from a focus on the individual grant to the national impact of a series of grants. Source: Making a difference: Global Fund results report 2011 pg 81 The next chapters, that is chapter 2 and chapter 3 will discuss and present programmatic and financial progress and results attained from HIV & AIDS and TB grants through selected key performance indicators as such: Chapter 2: Performance of HIV grants provides an insight on all HIV grants in Lesotho. This chapter presents a summary of the objectives, service delivery areas and major activities in each grant through the overview and background section. Programmatic performance section illustrates the grant s performance through key performance indicators and a summary of progress by service delivery area (SDA). Financial performance specific to each HIV grant will also be detailed in the final section of this chapter. 9

10 Chapter 3: Performance of TB grants provides an insight on all TB grants in Lesotho. This chapter presents a summary of the objectives, service delivery areas and major activities in each grant through the overview and background section. Programmatic performance section illustrates the grant s performance through key performance indicators and a summary of progress by service delivery area (SDA). Financial performance specific to each TB grant will also be detailed in the final section of this chapter. BOX 3: The following is a brief description of the Global Fund's grant-making process: 1. Global Fund Secretariat announces call for proposals. 2. Country Coordinating Mechanism (CCM) prepares proposal based on local needs and financing gaps. As part of the proposal, the CCM nominates one or a few Principal Recipients (PR). In many cases, development partners assist in the preparation of proposal. 3. Secretariat reviews proposals to ensure they meet the eligibility criteria; and forwards all eligible proposals to the Technical Review Panel (TRP) for consideration. 4. TRP reviews all eligible proposals for technical merit and makes one of four recommendations to the Global Fund Board: (1) fund; (2) fund if certain conditions are met; (3) encourage resubmission; and (4) do not fund. 5. Board approves grants based on technical merit and availability of funds. 6. An Internal Appeal Mechanism allows applicants whose proposals were rejected in two consecutive rounds to appeal the second decision. 7. Secretariat contracts with one Local Fund Agent (LFA) per country. LFA certifies the financial management and administrative capacity of the nominated PR(s). Based on LFA assessment, the PR may require technical assistance to strengthen capacities. Development partners may provide or participate in such capacity building activities. The strengthening of identified capacity gaps may be included as conditions precedent to disbursement of funds in the grant agreement between the Global Fund and the PR. 8. Secretariat and PR negotiate grant agreement, which identifies specific, measurable results, to be tracked using a set of key indicators. 9. Grant agreement signed. Based on request from Secretariat, the World Bank makes initial disbursement to PR. PR makes disbursements to sub-recipients for implementation, as called for in the proposal. 10. Program and services begin. As the coordinating body at the country level, the CCM oversees and monitors progress during implementation. 11. PR submits periodic disbursement requests with updates on programmatic and financial progress. LFA verifies information submitted and recommends disbursements based on demonstrated progress. Lack of progress triggers request by Secretariat for corrective action. 12. PR submits fiscal year progress report and annual audit of program financial statements to Secretariat through the LFA. 13. Regular disbursement requests and program updates continue, with future disbursements tied to ongoing progress. 14. The CCM requests funding beyond the initially approved two-year period. The Global Fund approves continued funding based on progress and availability of funds. 10

11 2. HIV GRANTS PERFORMANCE During the period under review from October 2010 to September 2011, three (3) Global Fund grants were implemented namely; Round 7 Phase 2 HIV grant, Round 8 phase 1 HIV/HSS grant and Round 9 phase 1 HIV grant ROUND 7 HIV GRANT: OVERVIEW AND BACKGROUND Round 7 HIV phase 2 grant started in July 2010 and its main goal is to scale up Prevention of Mother To Child Transmission (PMTCT) interventions, Paediatric Anti-Retroviral Treatment (ART) services and mitigating impact of AIDS among Orphans and Vulnerable Children (OVC). The objectives of this grant are: (a)to contribute to the reduction of Mother to Child transmission of HIV; (b)to prevent HIV infection among orphans and vulnerable children in Lesotho; (c)to expand access to quality essential health and social services for OVCs; (d) To promote and provide protective and enabling environments for OVCs; (d)to empower OVCs by providing the education and training needed to ensure a healthy and viable future; and (e)to contribute to strengthening national capacity to monitor and evaluate interventions targeting OVCs. This grant is intended to complement the current level of support by reaching additional vulnerable children as well as addressing other national priorities for OVC. Specific activities to achieve the above include expanding life-skills based education in primary, secondary and for out of school children, establishing a registration system for OVCs and implementing OVC exemption system for health and educational services, developing sustainable food security and livelihoods interventions, scaling up child helpline and strengthening reporting and referral systems of the Child and Gender Protection Units and providing school fees, vocational training and supporting OVC with special needs. In addition, a significant intervention will be directed to the expansion of PMTCT thereby increasing the number of facilities that are able to offer PMTCT services with the aim of reducing mother to child transmission of HIV. The specific activities under this objective consists of scaling up the provision of PMTCT services, promoting appropriate infant and young child feeding practices to reduce post-natal transmission of HIV and strengthen supervisory and monitoring capacity for PMTCT at central and district levels. This grant comprises six service delivery areas (SDA) namely PMTCT, condom distribution, Behaviour change Communication (BCC), support for orphan and vulnerable children, Anti-retroviral treatment and monitoring and strengthening of civil society and institutional capacity building. The programmatic performance in the next section will be presented through the SDA approach ROUND 7 PROGRAMMATIC PERFORMANCE The programmatic performance presented in this report is based on the achievement as at September 2011 which marks period thirteen of this grant. The results are shown for all the six Service Delivery Areas (SDAs) in this grant. 11

12 PMTCT The four key performance indicators used to monitor the performance of the PMTCT SDA are presented in the table below. Indicator Target Results % achievement # of service providers trained to provide PMTCT services including CHWs # of pregnant women who were tested for HIV & know their status # & % of pregnant women who received the antiretroviral drugs to reduce the risk of mother to child transmission out of the total # of women found positive Annual rate of retention of Community health workers 3,800 3, % 22,500 19,737 88% 60% (9,141/15,235) 46% (6,968/15,235) 77% 100%(1,000/1,000) 99%(987/1,001) 99% By end of September 2011, all the four indicators in the PMTCT SDA achieved over 75% as shown by the table above. 3,942 community health care workers were trained on PMTCT issues throughout the country with the aim of strengthening knowledge among the communities in PMTCT. The content of the training covered include the importance of attending Antenatal clinic, promoting adherence to PMTCT drugs by pregnant mothers, encouraging the pregnant mothers to deliver at health facility level rather than at home and to educate the community at large on the importance of breast feeding and good feeding practices in the HIV and AIDS era. Furthermore, 987 community health workers were provided with monthly stipends to strengthen provision of PMTCT support service at community level such as adherence counselling, promotion of appropriate infant and young child feeding practices to reduce post-natal transmission of HIV and tracking antenatal clinic (ANC) defaulters. Through these efforts, about 90%of pregnant women in Lesotho are attending at least one antenatal check-up as shown by LHDS Caption: Above are pregnant women at different health clinics. All are tested to know their HIV status. 12

13 The provision of PMTCT services has been scaled up through the support of this grant and currently there are 195 health facilities providing PMTCT services, which translates into 96% of the eligible sites an increase of 89% from 2004 as shown by PMTCT statistics in the MOHSW, AJR Under the grant, 8 professional counsellors were engaged and 6 are still in place in an effort to strengthen counselling and testing services for pregnant women at health facilities. From January to September 2011, 19,737 pregnant mothers were tested which translates into 88% of the target. The aim of the PMTCT program is to increase the HIV testing and counselling uptake among pregnant mothers so that those that are HIV positive can be provided with anti-retroviral drugs to prevent new infections among infants. 77% of the set target was reached in terms of provision of PMTCT drugs to pregnant women by September 2011 under this grant. At the end of 2010, the MOHSW reviewed and updated the PMTCT guidelines to align with the WHO recommendations towards virtual elimination of HIV infection through maternal transmission. The review process also included updating all PMTCT data collecting tools in order to collect relevant and appropriate data for monitoring of the PMTCT program. Through the support of this grant 330 maternity and ANC registers, 1300 daily ANC tally sheets and 300 monthly summary booklets were printed and distributed to all health facilities providing PMTCT services. This strengthened supervisory and monitoring capacity for PMTCT at central and district level. Furthermore, 1,000 posters and 15,000 pamphlets were printed on PMTCT issues. The IEC materials touches upon issues related to the importance and objectives of the mother-baby pack. The posters will be displayed at health centres and the pamphlets are meant for distribution to the individuals. PMTCT activities are component of the consolidated Round 7/9 grant, which has been approved by the GFATM and is yet to be signed. In this grant funds to the value of $5,164,316 have been approved for PMTCT activities. These activities include community level activities such as trainings of CHW on PMTCT and Printing and distribution of PMTCT IEC materials. Furthermore, in order to promote health seeking behaviour especially among men, an NGO will be engaged to interact with the community and educate them on PMTCT and the benefits of seeking health care during pregnancy, labour and post-partum by both the mother and the father. Additionally, ARV drugs to the value of $247,306 will be procured in the two years for prophylaxis of HIV for both the mother and the baby. Equipment and supplies such as blood pressure machines, foetal heart monitors, haemocue analysers and reagents, point of care CD4 count machines and reagents will also be procured for health facilities to improve maternal, neonatal and child health care in order to improve PMTCT service uptake in all the facilities. The timeframe for the R7/R9 will to follow the National Fiscal year. As such the grant is expected to start from July 2011 to March CONDOM The 2 nd SDA under discussion is Condom which involves procurement and distribution of condoms to the end-users through the health sector structures and youth resource centres. Performance of this SDA is measured through the indicator as depicted in the table below: Indicator Target Results % achievement Number of condoms distributed through health facilities and youth resource centres (i.e. condoms distributed by youth centres, NGO distributors 22,864,393 6,318,000 28% 13

14 & health centres) By end of June 2010, there were 12 million condoms at the central medical stores (NDSO) which were moving in a stagnant manner. As a result, additional condoms were not procured in 2011 due to sufficient stock available. Performance on the distribution of condoms has not been satisfactory due to various reasons. The most important reason evolve around proper record keeping of condoms that are distributed from the health facilities to the end users, those that are distributed from the district level administration during outreaches to community level and those that are distributed by the Village health workers or non-governmental organisations at community level. As indicated in the table above, only 28% distribution to end user was achieved by end of September However, contrary to the little achievement attained, condom use in Lesotho has improved. This is indicated by the percentage of young people aged reporting the use of condoms the last time they had sex with a non-regular sexual partner which has improved from 44% in 2004 to 52% in 2009 (LDHS 2004 & 2009). The PR undertook a verification exercise in August 2011 to establish the modes and the rate at which condoms are being distributed by health facilities. The verification exercise focused on condoms that were distributed to health facilities by NDSO and PSI to the end-users. The findings indicated that condoms through these channels are moving very slowly as they are only accessed by people who come to health facilities. Efforts will be made in the Round 8 phase 2 to involve community structures to distribute condoms to the community level. The MOHSW in an effort to improve condom distribution and establish proper logistics management information system for condom distribution to facilitate condom use at community level initiated the process of recruiting an NGO under this grant. However, the MOHSW was faced with challenges in relation to procurement processes thus delaying the activity BEHAVIOUR CHANGE COMMUNICATION (BCC) This SDA is mainly concerned with expansion of life-skills based education in primary and secondary schools and for out of youth school youth. The performance in this area is indicated in the table below: Indicator Target Results % achievement Number of young people reached by life based HIV/AIDS education out of School 36,546 41, % Number of children with special needs reached with Life-skills education 1,000 1, % 14

15 Life-skills education activities targeting OVC in out of school settings such as Life-skills road shows and string games have been included in the consolidated Round 7/Round 9 grant in order to reach more youth at community level. However, as an extension of Round 2 grant, the Ministry of gender, youth, sports and recreation (MOGYSR) through youth resource centres (YRC) and youth leaders are continuing to educate youth on HIV and AIDS and life-skill education. The YRC expanded dramatically from 13 in 2010 to 28 in 2011 and it is through these efforts that more youth are being reached and the performance in the indicator has surpassed the set target by 15%. In addition, life-skills learners books were procured and were distributed to all primary and secondary schools. The intention was to strengthen the life skills education in schools. In January 2012, MOET will conduct a survey to establish the number of children reached with life-skills education and the impact it has in the lives of such children in increase life skills and knowledge about HIV and AIDS. MOET through the special education also held workshops for special education schools with the aim of strengthening life-skills education for learners including OVC with visual and hearing disabilities. 1,466 the children in specialised and other public schools were reached with life-skill education in an effort to decrease new HIV infections among this target group. Children with disabilities in normal public schools were also reached as the MOET is also advocating for integration of such children in normal schools SUPPORT FOR ORPHAN AND VULNERABLE CHILDREN This SDA is measured utilising four indicators as shown below. Support for orphans and vulnerable children include provision of essential services such as paying for OVC at hospital level for services rendered, educational requisites such as hygiene kits and school uniform, establishment of gardens and encouragement of OVC to produce food security, provision of food packages and renovation or construction of OVC homes. Other activities include operational support for Lesotho Save the Children to ensure that the child helpline is functional at all times. Under this grant OVC attending secondary school were also assisted in form of tuition, book fee, stationery, exam fee and boarding fees. The table below present the performance on the SDAs. Indicator Target Results % achievement Number of OVCs whose households is provided with the following Essential services: Education, Health, Food and toiletries and shelter Number of OVC reached through the helpline who are provided with at least one of the following services : 56,019 49,900 89% 4,185 4,056 97% face to face counselling, play therapy or referrals to service providers Number of OVC provided with financial support to attend school 1, % 15

16 Number of OVCs in vocational training provided with Business and entrepreneurship training. 1,400 1,204 86% The three indicators pertaining to support for orphans and vulnerable children performed extremely well in the first year of the Round 7 phase 2. Peka Development Group (PDG) reached 792 with food packages and blankets. The areas covered included Quthing district where 248 OVC in Likhohlong, Mokotjomela and Liphakoe community council were reached. In the Butha-Buthe district, 299 OVC were reached in Likila, Linakeng and Kao community council and lastly Thaba-Tseka district 245 OVC were supported in Mphelebeko, Bokong and Makheka councils. The distribution of these packages was done in conjunction with the department of Social Welfare (DSW). In addition,the DSW reached 17, 194 OVC with essential services and this is inclusive of 15,000 OVC who are getting cash grants supported by European Union as well as receiving monthly stipends from Government of Lesotho. Caption: Left the OVC accompanied by his grand mother received uniform in Berea district. On the right is the group photo of OVC received uniform from Social welfare in Mokhotlong district. In addition Peka Development Group initiated preparations for renovation or construction of 110 OVC houses. To date verification of OVC lists, inspection of houses and determination of quantities of material needed has been completed and the actual construction will be commence as soon as the consolidated R7R9 grant has been signed and funds disbursed. By end of October 2011, the Lesotho Save the Children (LSC) reached 4,056 OVC through the child helpline which translates into 97% of the target. These children have been provided with at least one of the following services: face to face counselling, play therapy or referrals to service providers such as CGPU and master of the high court. Through the assistance of UNICEF and Vodacom, the child help-line is providing access to children or any person who come across a vulnerable child by calling the toll-free line and asking assistance. Child helpline is manned by counsellors who are supported under this grant in terms of salaries. These counsellors provide counselling services on line, set up appointment special cases that require further face to face counselling sessions and alert various departments such as police and master of the high court. Cases of abuse, OVC s property grabbing and child trafficking have been identified and referred accordingly. Continuous work is on-going in terms of popularising the child helpline to all the communities including hard to reach areas. 16

17 1,071 OVC were supported with school fees for 2010 utilising funds for the first quarter of R7 phase 2 grant (October 2010). Even-though the money came in late all outstanding fees for 2010 were fully paid and about 191 OVC were supported with school fees for 2011 academic year. However, the funds for school fees were withheld by Global Fund due to the condition precedent (CP) which had to be fulfilled before more funds for school fees can be disbursed. This CP involved the development of the Bursary programme monitoring and evaluation (M&E) Plan and other issue such as monitoring duplicates with other donors and selection criteria in respect to the OVC to be paid under Global Fund s money. The M&E plan was developed and the CP was partially met in April 2011, however, the funds for this activity were included in the R7R9 consolidated grant which is yet to be signed. During the reporting period, 103 OVC were supported with school fees for vocational studies. The support includes tuition fees, tools, book fees and exam fees. This was done in conjunction with establishment of entrepreneurial subject in the vocational and technical schools so that the OVC can be able to set up their own businesses upon completion of their studies. To date 1,204 students were taught entrepreneurial or business at vocational school thus translating into 76% of the set target ANTI-RETROVIRAL TREATMENT AND MONITORING Under this grant support is availed for MOHSW to engage paediatric doctors and procure paediatric ARVs subsequent to the phasing out of UNITAID s funds in-order to strengthen provision of ARV drugs to children in Lesotho. One indicator is used to measure performance in this SDA as shown below: Indicator Target Results % achievement Number of children (0-14) with advanced HIV Infection receiving ART. 7,026 4,886 70% The funds to the value of $2,448, which were budgeted from July 2011 under this grant were included in the consolidated R7R9 grant and will be available once the grant has been signed and funds disbursed. However, through assistance of other partners such as CHAI and Baylor huge strides have been made in terms of paediatric ART programme. By September 2011, 70% of the set target for provision of children on ART had been reached. At national level 61% of the health facilities offer HIV treatment for children as stated in the HIV/AIDS service provision in Lesotho 2010 report. The report further states that the district with the lowest percentage of sites offering ART is Maseru (35%), Followed by Mafeteng (56%) and Leribe with 66%. The districts with the highest paediatric Art coverage by sites is in Quthing (91%) and Thaba-Tseka with 86%. Furthermore, 9 paediatric doctors have been engaged and to support the health facilities. The MOHSW is stepping trainings for paediatric ART for all the nurses and physicians in order to scale up paediatric ART treatment. As at December 2010, a total of 329 (235 nurses and 94 physicians) health service providers were trained in paediatric care and treatment therefore resulting in 17% of 17

18 the health facilities having at least one physician and 35% having at least one nurse trained to provide these services for children (HIV/AIDS service provision in Lesotho 2010 report) STRENGTHENING OF CIVIL SOCIETY AND INSTITUTIONAL CAPACITY BUILDING Two M&E officers within the DSW department are in place and a vehicle was procured for the department in order to strengthen M&E supervision and data verification. During the reporting period four supervisory visits were carried out in Leribe, Berea, Butha-Buthe and Mokhotlong districts. During the visits the district officers were also provided with on-site training on basic principles of M&E and shown the correct way of collecting and recording OVC data, data collation and analysis and report writing. They were also taught how to verify and crosscheck data in order to assure enhanced quality ROUND 7 FINANCIAL PERFORMANCE July 2010 to June 2011 is the annual period for R7 grant, and this is Year 3 of implementation, the first year of R7 phase 2 grant covering Quarters from 9 to 13. From July 2011, the beginning of year 4 to the end of Year 5, the R7 grant was consolidated with the Round 9 HIV grant to form the HIV SSF Grant. During the period under Review, funds were disbursed to cover the period from July 2010 to June 2011 to the tune of $4,053,523. Below in the table, is the analysis of approved budget versus expenditure from July 2010 to June 2011 by category. This table categories how the funds received were spend versus the budget approved for the entire year. Category Budget Expenditure Variance % usage of funds Human Resources 1,803, ,772, , % Technical Assistance 80,000 63,583 16,417 79% Training 378, , , % Health Products and Health Equipment 0 1, Infrastructure and other equipment 350, , , % Communication materials 78, , % Monitoring and evaluation 210,661 12, , % Living support to clients/target population 1,615,751 1,042, , % Planning and administration 39, , % Overheads 3,439 3, % Total 4,561,544 3,517, ,044, % As depicted above, overheads, infrastructure and other equipment spent more than what has been allocated, followed by the Overhead. The reason for over expenditure in these two categories was the result of activities whose expenditures were occurred by end of phase 1; but the invoices were paid beginning of year 3 as delivery of equipment was received in July Categories such as HR and TA absorbed major part of the allocated budget, while Communication, Planning and Admin and 18

19 Monitoring and Evaluation absorptive capacity of finances was unsatisfactory. The variance was because of delays to initiate procurement of PMTCT brochures and PMTCT registers because the procurement was initiated only when funds were made available by end of April, In addition, radio talk s schedules only started after June 2011, and as results payments were only incurred after the period ended. Moreover, accreditation survey was postponed, consequently funds were never expended. With regard to Monitoring and Evaluation, supervision conducted only occurred towards end of June 2011, and invoices were only paid after the end of the June In addition, a review meeting for the districts was held in Maseru in June 2011 but payment was not effected until July The financial analysis was further done for SDA to demonstrate how funds allocated performed per intervention. Expenditure Analysis by Service Delivery Area (SDA) Service Delivery Area Budget Expenditure Variance % usage of funds as per SDA PMTCT 1,005, , , % Condom distribution 80,000 1,029 78,971 1% Community outreach 64,008 61,870 2,138 96% Support for Orphans and Vulnerable 2,255, ,556, ,852 69% Children Antiretroviral therapy 322, , ,001 91% Strengthening of civil society and 151,354 98,490 52,863 65% institutional capacity building Program management and 683, , , % administration Total 4,561, ,517,008 1,044,536 77% None of SDA as depicted above spent 100% of the budget allocated. Training for Community health workers for PMTCT strengthening at community level were conducted, however payments were only expended in July Funds that were earmarked for payment of incentives were not entirely spent due to wrong Bank accounts numbers. No condoms were procured due to overstock and slow movement of stock at NDSO. Funds earmarked to support distribution of condoms were never utilized because of expensive quotations received from Service Providers. Funds under living support for the clients earmarked to support essential package such as production of passports, birth and death certificates was carried forward to year 3 due to the delayed procurement processes Lastly expenditure analysis was further performed to compare absorptive capacity by each sub recipient and the PR. 19

20 Expenditure and budget analysis by implementing entity Implementing Entity Budget Expenditure Variance % Expenditure/Budget MOFDP/GFCU 711, , % Ministry of Health and 2,087, ,620, , % Social Welfare Ministry of Education and 1,079, ,027, , % Training Ministry of Gender, Sport, 64, , , % Youth and Recreation World Vision,LRC,CHL 570, , , % CGPU,M0HA 49,191 19, , % Total 4.561, ,517,008 1,044,536 77% The table above depicts the expenditure analysis by implementing entities. It indicates that there is low absorptive capacity by the NGOs (World Vision, Lesotho Red Cross, and CHL), in particular World Vision as it s the SR with the highest budget. The reason for such financial performance is because the World Vision did not implement activities but returned funds to the PR on the basis of insufficient administration csots. The GCPU and MOHA spending did not reach optimal level by end of the reporting period. This was due to delays in the printing of passport, birth and death certificates for OVC were delayed. Good absorptive capacity was achieved by the MOH, Finance as well as MOET. For Education, funds were used to pay schools fees, while MOH managed to pay remuneration of its staff, series of trainings were conducted for community health care workers. In conclusion the R7 grant performance has been good and rating stand at B1. However, the delays in terms of signing agreement for Phase 2 hindered excellent performance as has been the case since Phase 1. Funds to support Implementation for entire year were only received in April, 2011, and expectation was that the funds that were earmarked to be utilized for 12 months were to be squeezed and expended within three months. This situation resulted in most invoices paid after the quarter ended ROUND 8 HIV GRANT: OVERVIEW AND BACKGROUND The overall goal of the Round 8 HIV and HSS grant is to reduce HIV and AIDS related morbidity and mortality. There are 5 objectives under this grant and thirteen Service Delivery Areas (SDA). In this section, the SDA for each objective will be discussed in details. The activities executed by various sub-recipients in each SDA will be presented along with the programmatic performance attained for this grant from November 2010 to October The first objective, to reduce incidence of new infections in both the general and specific populations is comprised of five SDAs namely Behaviour change communication (BCC) Mass Media, BCC 20

21 Community Outreach and Schools, Condom Programming, Male Circumcision, and STI Diagnosis and Treatment, Activities under BCC media SDA include developing and distributing materials to address HIV risk reduction within multiple and concurrent partnerships. This activity supports the implementation of the new BCC Strategy, focusing primarily on men and women between the ages of 15 and 49, with special emphasis on young women aged 15 to 24 due to high HIV prevalence in this age group. Another activity is to Develop and distribute HIV-prevention messages in collaboration with NGOs and private sector partners. Through mass media interventions, dissemination of messages to target groups such as men, youth and people living with HIV and AIDS (PLHWA) are used to encourage them to seek health care services. Furthermore, journalists will be equipped with skills to provide the quality and accuracy of the HIV prevention information through developing media guidelines and a Code of Conduct on HIV and AIDS reporting. BCC outreach SDA focuses on providing HIV prevention interventions for vulnerable groups. Various target groups, individuals and groups with special needs within the general population have been identified for BCC outreach programme. These include MSM, men and women of reproductive age, CSW, Youth, PLHWA, mobile populations, people with disabilities and prisoners. Targeted activities for this programme include focus group discussions to learn more about HIV-related needs within their environment, community outreach efforts such as BCC during sporting activities, and peer education training and support. Other activities include providing ongoing support for youth resource centre and upgrading adolescent health corners. At least one youth centre was established in each district under previous grants such as the Round 2 grant. The centres have quickly become successful platforms for youth involvement in health challenges, including HIV/AIDS and currently there are 28 youth Resource centres and about 110 youth leaders are in place in these centres. Under this SDA incentives and training for youth leaders attached to the resource centres is continued. Refresher training of trainers for staff responsible for skills building for youth on HIV, SRH, STI, gender issues especially in the adolescent health is maintained. Moreover, the adolescent health corners will be upgraded through provision of furniture and equipment in order to provide youth friendly health services within health facilities. The main aim of this SDA is to reach as many people as possible with prevention messages in order to reduce the incidence of new HIV infections in both the general population and specific population. Condom is amongst the SDA and is a continuation from Round 2 Phase 2, as well as scale up of the reach of condom promotion and distribution for young people funded through Round 7. The condoms are distributed based on condom promotion guidelines and distribution strategy under the leadership of the MOHSW. The proposed activities under the SDA that support Male circumcision, the implementation of the new national strategic and operational plan for MC in Lesotho, and the development of a package of 21

22 interventions on the benefits of MC in the light of STIs and HIV. Activities included sensitization of public and private health care providers, community leaders and the public on male circumcision as a component of HIV prevention; training providers from both public and private sectors to deliver MC services, proving them with MC kits and conducting formative operational research on uptake and impact. The messages included will also target female and male partners, and mothers of male infants for early intervention. Another intervention was to integrate into key services such as SRH and STI services, and CBC training. The fifth SDA comprises interventions such as sexual transmitted infections diagnosis and treatment. Activities under this SDA include finalizing and printing the draft guidelines for STI management; Developing, printing and disseminating STI operational plan for a five-year period together with the training manuals that will have been revised for the various service levels and expansion of a package of services including prevention, diagnosis and treatment of STI to district and community level. Other activities proposed include strengthening the two existing OPD STI clinics at hospital level through the procurement of equipment; strengthening STI sentinel surveillance in 10 sentinel sites; procurement of STI drugs and commodities and provision of refresher training on these new standards to public and private sector PHC providers. The second objective, to increase universal access to HIV testing and Counselling (HTC) services covers only one SDA HIV testing and counselling. Through MOHSW restructuring, supervision and support for HTC services will be decentralized to the district level and strengthened through the creation of Senior Counsellor Positions. Thus activities under this SDA are build on this new MOHSW decentralized implementation structure And activities such as mapping of HTC sites will be conducted on annual basis in order to update the directory of services and their quality. Moreover, other activities include the revision and updating of national guidelines and standards and provision of training based on the revisions; provision of equipment and supplies to new HTC within the government sector; and finally, professional support and quality assurance through monthly debriefing workshops and improving national and district level supervision. The third objective, to strengthen and scale up comprehensive HIV chronic care services and Antiretroviral therapy for people living with HIV encompasses five SDAs namely ART Provision and Monitoring, Prophylaxis and Treatment of Opportunistic Infections (OI), Integration of SRH and HIV, Care and Support for the Chronically Ill, and TB and HIV interventions. The purpose of the ART Provision and Monitoring SDA is to scale up ART from the 25% coverage to the envisaged 80% coverage of treatment for those in need through the expansion of public-private partnerships (PPP). All sectors will be supported to provide nationally accredited services in new sites, particularly in rural, remote and hardest-to-reach areas. Other activities include scaling up access nutritionals support with the goal of ensuring equitable access for adults, children and infants by the end of the grant implementation period. Procurement of additional ARVs for both adults and children will compliment the drugs procured under other GF grants and government of Lesotho. CD4 machines will be procured in order to enhance HIV diagnosis and monitoring of HIV positive patients. 22

23 Prophylaxis and Treatment of Opportunistic Infections (OI) SDA aims to scale up treatment and care to adequately address OI prevention and management, common co-infections and other comorbidities, and ensure equitable access for OI services for adults, children and infants at the facility level. Refresher training for HCWs on the diagnosis and management of HIV infections is again continued to ensure acquisition of proper skills to manage HIV. Furthermore, procurement of OI drugs is also included in this SDA. The sexual and reproductive health (SRH) of women living with HIV/AIDS is fundamental to their well-being and that of their partners and children. Strengthening SRH and HIV integration at district and community level will expand access to both types of services and thus bring about greater coverage. This is achieved under the SRH SDA through the development of guidelines, training of HCWs on the integrated management of SRH and HIV, and the engagement of community partners at the local level for social mobilization activities aimed at increasing demand for combined services. Activities under the Care and Support for the Chronically ill SDA include providing training, and incentives to community-based caregivers (CBCGs) and strengthening their supervision and support; procurement of commodities e.g. CHBC kits; and engaging more community partners in the provision of CBC programmes. New CHWs will be recruited and incentives provided for existing staff to complete an initiative started under other Global Fund grants. Round 8 also seeks to ensure continuous provision of therapeutic feeds, the procurement and distribution equipment and tools for nutritional assessment, and strengthening nutritional services at district facilities levels by recruiting 10 district nutritionists and training them in the specifics of nutrition and HIV and AIDS under this SDA. Activities under the TB/HIV SDA include prevention, diagnosis and treatment of TB associated with HIV to manage the extremely high rate of TB/HIV co-infection; scaling up the delivery of an integrated approach at community and household level in relation to TB/HIV; distribution of guidelines to the providers, managers and supervisors across all sectors to be used as a basis to orient providers in provision of integrated HIV and TB services and improving coordination and provision of services at the district and community level by conducting integrated training in HIV and TB for all cadres of HCWs. Other activities supported through this grant include establishment of a joint working group to update the monitoring tools at the central level and District-level joint supervisory and monitoring teams for conducting integrated supervision at that level. The national HIV care guidelines require that all HIV infected clients should be screened for TB during every encounter with the health provider. The fourth objective- To reduce the negative social and economic impacts of HIV and AIDS on individuals, families and communities is represented by one service delivery area namely strengthening the national policy framework. The National AIDS Commission (NAC) is mandated to guide the strengthening of the HIV and AIDS national policy frameworks and therefore this grant aims to support NAC to achieve this commitment by supporting the development of the HIV prevention plan for Lesotho. A critical component in strengthening prevention capacity in Lesotho is the development of an operational plan that directs all stakeholders in the implementation of a 23

24 comprehensive prevention programme. Under this SDA, the Round 8 grant ensures that NAC is supported to develop a fully elaborated plan that can be simply implemented by all stakeholders. Finally, the sixth objective to scale-up HIV related policies and programs in both public and private sector workplace is implemented through the supportive environment: workplace program in public sector. The activities under this SDA include an institutional assessment on current status of workplace policies and programmes and review, update and institutionalising the terms of reference of the ministerial workplace focal persons. In addition, provision of training and capacity enhancement opportunities public sector workplace programs are presented under this grant coupled with the actual robust implementation and a variety of support mechanisms such as development of operational plans and Monitoring and Evaluation frameworks ROUND 8 HIV PROGRAMMATIC PERFORMANCE The programmatic performance under this grant is presented through the SDAs mentioned in the above section BEHAVIOUR CHANGE COMMUNICATION - MASS MEDIA This SDA is measured by one indicator as indicated below. Service Delivery Area Indicator description Intended target by October 2011 Achieved results October 2011 by Percentage achievement BCC Mass media Number and type of IEC materials broadcasted and distributed 15,000 (Print materials) & 20 (radio spots) 23,865 (Print Materials) & 67 (radio spots) 159% (print materials) & 335% (radio spots) By end of reporting period, 15,000 print IEC materials and 20 radio spots were intended to be distributed and conducted, and by October 2011, print IEC Materials composed of posters, pamphlets and brochures were distributed, 179 copies of a DVD film called Lekau La Poho II were also distributed while 67 radio spots were aired through radio spots with four local radio stations in the Country. The IEC material is intended to promote behaviour change among youth, people living with HIV, men having sex with other men, males and females at reproductive age, commercial sex workers, prisoners and herd boys. The local consultancy firm, Mantsopa communications was engaged by NAC in collaboration with MOHSW to undertake the collaborative development of messages, materials and tools for behaviour change communication and to distribute the messages. A Formative research was conducted in the early stages of designing BCC messages to understand the current practices, motivators, and barriers related to ideal behaviours. This formative research provided an opportunity for stakeholders to 24

25 participate in and contribute to the development of BCC messages, tools and IEC materials by keeping the focus on issues important to the community. 165 Stakeholders were consulted in three regions of the country. The Formative research identified the following strategies on which to base the development of messages: Increase appropriate self-perception of risk and use of primary behaviour change Empower PLWHAs to accept and seek care for their HIV status Increase risk perception of HIV among partners (Partner reduction) Increase usage of condoms in higher risk sexual intercourse among young men and women Increase the proportion of Basotho aged 12 and above who know their HIV status Following development of messages various IEC materials were produced and an example is shown below. FIGURE 2: SHOWS SOME OF THE IEC MATERIALS PRODUCED BY MANTSOPA CONSULTANCY In addition, 30 episodes by 15 minutes radio/tv drama named khetho ea ka and a sequel to the feature film Kau La Poho have been produced and have been aired in various areas of the country. 25

26 BEHAVIOUR CHANGE COMMUNICATION - COMMUNITY OUTREACH The achievement on this indicator is measured by the indicator below: Service Area Delivery Indicator description Intended target by October 2011 Achieved results October 2011 by Percentage achievement BCC Mass media Number of people reached by HIV and AIDS prevention messages through outreach 28,190 47, % By October 2011, 47,654 people were reached with prevention messages which translate into 169% of the target set for the end of phase 1 of this grant. These prevention messages were targeted at youth out of school, prisoners, MSM, men and women of reproductive age, CSW, PLHWA, mobile populations and people with disabilities and prisoners. The interventions contributing towards the achievement of the set targets are discussed below. During this reporting period, 265 inmates peer educators from all prisons around the country were trained on HIV and AIDS by the Lesotho Correctional Services (LCS).The trainings were conducted using the newly developed inmates peer education manual which was put in order with the support of Care Lesotho. Inmates Peer educators managed to reach approximately 2,089 prisoners with HIV prevention message. This activity has resulted in improved HIV knowledge as demonstrated in the Lesotho Correctional services prevalence study (2011) that more than 70% of the inmates have general knowledge about HIV modes of transmission. Furthermore, the inmates are presently acting on the information they possess as more want to know their status and the HIV positive ones are living openly with the virus. The January to March LCS report designate that 115 were tested for that period, 442 are living openly with the virus and 220 are on ART programme. By April 2011, Mantsopa Communications- an NGO with speciality on BCC issues, carried outreach activities in all the ten districts of the country showing a HIV/AID film called khetho ea ka. The key messages of the film include HIV prevention, adherence to treatment, concurrent partnerships. The outreach activities were implemented in schools, community halls, sports fields, military sites, correctional institutions, bus and taxi ranks and other public places. Through these outreach activities people were reached with the prevention messages. These people included youth in and out of school, adults, prisoners, military personnel, hawkers at the districts, buses and taxi operators and commuters. 26

27 Furthermore, LCS procured 200 chairs and 30 tables to use during peer education within prisons. The furniture has been distributed to juvenile training centre (JTC) and female prison in Maseru. FIGURE 3: EQUIPMENT BOUGHT FOR JTC AND FEMALE PRISON FOR PEER EDUCATION PROGRAM In addition, the MGYRS contributed extensively to this indicator through peer education by the youth leaders where approximately 12, 865 youth were reached with prevention messages. By end of October, 2011, 104 youth leaders from the ten districts of Lesotho were trained on management skills for the youth Resource centres and skills to implement HIV prevention interventions utilising the minimum package guide on HIV prevention programming developed by Ministry of Gender & youth, sports and recreation. In addition, the youth leaders with the stewardship of the district Youth Development Officers trained youth on life-skills, entrepreneurship, HIV and AIDS and string games story. The trainings were conducted concurrently in February 2011 in 10 districts of Lesotho whereby 750 youth were trained. In Conclusion, continuous distribution of prevention messages following training of the youth, prisoners, LMPS and LCS staff and communities through community dialogues and focus group discussions have been found to be successful CONDOMS Since these condoms are supplementing those procured under Round 7, the indicator which measures distribution of condoms is aligned for both grants as shown below: 27

28 Service Delivery Area Indicator description Intended target by October 2011 Achieved results October 2011 by Percentage achievement Condom Total number of male and female condoms distributed country wide 7,615,144 6,809,400 89% 6,809,400 free condoms were distributed through the health facilities by NDSO and PSI by end of October 2011 and this translates into 89% achieved target. PSI was able to distribute 1,058,000 to facilities by April The PR undertook a verification of all these condoms to establish if they have been distributed to end users. The activity conducted between the months of July, August and September It was found out that all the condoms that were distributed in April have reached end users. During August and September 2011 PSI again distributed 1 620,000 male condoms and female condoms to facilities. The condoms distributed are targeted for sexually active people including most at risk populations to promote safe sexual behaviour. Through the Disease Control Directorate, the MOHSW procured 247 condom dispensers which were distributed to the DHMTs during June and July Furthermore, the MOHSW has engaged a condom strategy officer to facilitate the development of the national condom strategy, a support from PSI Lesotho MALE CIRCUMCISION Male circumcision is still done as an elective surgery at hospital level. This has in turn impacted poorly on the achievement of the indicator utilised to measure MC in Lesotho as shown below. Service Area Delivery Indicator description Intended target by October 2011 Achieved results October 2011 by Percentage achievement Male Circumcision Number of males circumcised 11,232 3,225 29% By April 2011 people reached with male circumcision procedures has reached By October 2011an increased improvement was seen whereby the reported data from public hospitals shows that 1002 MC procedures were further performed, adding to a total of 3,225. Facilities that recorded the high number of MC procedures include Maluti(184), Scott(167), Seboche(136) and Paray (89). The rest of the facilities performed between 2 and 79 procedures by end of October Performance on the indicator is expected to improve in Phase 2. The MOHSW with the technical assistance of JHPIEGO will be scaling up MC services.the results achieved translate to 29% achievement of the set target. Spectrum/EPP modelling has shown that if 40,000 youth are circumcised, six thousand new infections will be averted annually. Hence the prevention strategy and national HIV and 28

29 AIDS strategy 2011/12-15/16 identifies adult male circumcision as one of the key sexual transmission prevention strategy in Lesotho. Furthermore, LDHS 2009 indicates a prevalence of male circumcision among stand at 52 % compared to 47 % in 2004 among the same age group. There is a high demand for voluntary adult male circumcision in the health facilities leading to the need to expand the capacity to provide the services. The MOHSW through the support of JPIEGHO will recruit doctors specifically for MC to meet the high demand. It is also envisaged that health Care workers will be trained to provide MC and is also being planned to be rolled out in 2012 to at least 8 hospitals SEXUALLY TRANSMITTED INFECTIONS DIAGNOSIS AND TREATMENT. STI diagnosis and treatment have improved in Lesotho over the last decade. In 2010 alone according to the MOHSW AJR 2011, cases were seen at health facilities. Support to the health facilities under this grant include procurement of Medical equipment and furniture which were delivered to Mokhotlong, Mohale s Hoek, Quthing, Qacha s Nek hospitals, as well as Samaria Health Centre to assist with service delivery for STIs. Four (4) OPDs in Louis Gerard, Semonkong, Koro-Koro and Bethel health centres have been renovated through the support the R8 HIV phase 1. Furthermore, the procurement of STI drugs to the value of $58, were procured and the delivery to the central medical stores. 3,000 STI flowcharts were printed and delivered to each district to guide treatment of STIs at public and private health facility level. An example of the flow chart is shown below. FIGURE 4: STI FLOW CHARTS STI Management protocols were developed to standardize STI management in the country to all health facilities using the respective flow chart according to disease. On the right is the flow chart. Furthermore, 321 Health care workers were provided with refresher training on STI management and guidelines by end of October The trainings were aimed at updating the nurses on new information on management of STI and on how record and report the STI data. The topics covered in this training included rationale for standardised treatment recommendations, selection of STI drugs, STI syndromic case management and proper record keeping. 29

30 HIV TESTING AND COUNSELLING (HTC) The second objective under the grant R8 grant is to increase universal access to HIV counselling and testing services. The only SDA persuade strengthening HIV Testing and Counselling. The achievements are measured through the following indicator as depicted below: Service Area Delivery Indicator description Intended target by October 2011 Achieved results October 2011 by Percentage achievement Prevention: Testing & Counselling # of people who received HIV counselling and testing and know their results 190, , % Commendable progress has been made in the provision of HIV counselling and testing services countrywide. By October 2011, 247 sites were established and strengthened to provide HTC services. Cumulatively 428,868 people were tested and counselled by end of October As shown in Figure 5, the number of people tested increases gradually each year. In 2010, 13% was reached. This is mainly due to growing emphasis on provider initiated testing in the health facilities as recommended by World Health Organisation. FIGURE 5: SHOWS THE COUNSELLING AND TESTING FIGURE FROM 2006 TO 2010 Through the HSS support, engagement of 33 new HTC counsellors was accomplished. The engagement was followed by an intensive training of the newly recruited counsellors and this was conducted in September 2010 in Maseru district. Moreover, 500 health care workers were sensitised 30

31 on Testing and counselling guidelines including Provider Initiated Counselling and Testing (PICT). Presently there are 96 public health facilities providing PICT and it is envisaged that following orientation on the guidelines and standard operating procedures more facilities will provide PICT. HTC counsellors engaged through the Round 8 HSS support HTC counsellor cadre Number recruited and trained Health Facility Senior counsellors 1 St. Joseph s Hospital (1) HTC Counselor 7 Thaba Tseka Health Division (1) St. Joseph s Hospital (1) Paray Hospital (1) Scott Hospital (1) Mokhotlong Hospital (2) Machabeng Hospital (1) Asst. HTC Counselor 10 Machabeng Hospital (1) Mokhotlong Hospital (2) Matsieng Health Centre (1) Berea Hospital (1) Thame Health Centre (1) Butha Buthe Hospital (1) Queen II Hospital (1) St. Ann Ha Mokhoro (1) Ntsekhe Hospital (1) Asst. Counselor Community 15 St. Leo HC (1) St. Rose HC (1) Queen II Hospital (2) Berea Hospital (3) Motebang Hospital (2) Mokhotlong Hospital (2) St. Rodrique (1) Thaba Bosiu (1) Quthing Hospital (1) Khubetsoana (1) St. Barnabas HC (1) Total # engaged 33 Furthermore, strengthening of the HTC health facilities was attained through provision of furniture that include 35 chairs and 18 tables which were distributed to 19 health facilities. Below is HTC furniture per one clinic in Mafeteng. 31

32 In conclusion, the collaborative support that has been extended to the MOHSW through various partners has born positive results. According to the DHS 2009, 92.6% of the women between 15 and 49 know where to get an HIV test, and more than 65% were ever tested and know their results PROVISION AND MONITORING OF ART The achievements on this SDA are measured utilizing the indicator below Service Area Delivery Indicator description Intended target by October 2011 Achieved results by October 2011 Percentage achievement Antiretroviral treatment (ARV) and monitoring # and % Adults and children with advanced HIV infection receiving antiretroviral therapy 77,697/98,521(79%) 81,031/98,521 (82%) 104% *Completeness of ART reports = 91% By September 2011, 81,031 people were currently put on ARV treatment, and the figure is composed of 76, 591 adults and 4,440 children. This result is attributable to the implementation of activities detailed under this SDA. The MOHSW annual joint review report 2010/2011 indicated that 74% of people initiated on ART in 2009 were still alive after 12 month initiation of ARV treatment. Figure 6 shows the survival rate trends of different cohorts that completed 12 months on ART. This shows that an average of 76% of people initiated on ART will survive the first year following initiation of ART. The success of ART program within MOHSW is attained through the GOL initiatives and support of the Global Fund. Annual cohort survey of survival rates for PLHIVs on treatment regimes is conducted, and this type of cohort survey was first done in December 2007 for the UNGASS report and it is currently conducted each year thereafter. 32

33 FIGURE 6: 12 MONTH S SURVIVAL RATE OF PEOPLE ON ART FOR 3 YEARS. In December 2010, the MOHSW revised and updated the ART guidelines. Various modifications embraced in the new guidelines include emphasis on the cut off point of 350 CD4 count for eligibility of ART, initiation of all TB patients on ART and some variations in terms of ART drugs allocated for first and second line for both adults and children. The guidelines were printed and distributed simultaneously with the revised PMTCT guidelines to all health facilities in January Orientation for health care providers on the new guidelines commenced in December 2010 and it is ongoing and so far about 480 health care workers have been orientated. FIGURE 7: REVISED PMTCT AND ART GUIDELINES Furthermore, MOHSW procured ARVs to the value of $4,487, through the support of this grant in Additionally the MOHSW placed an order for ARVs amounting to $5,063, by end of Global Fund is contributing approximately 30% of the support towards procurement of ARVs while the rest is contributed by the government of Lesotho. To date 112, 467 people were ever enrolled on ART since the inception of the ART programme within the MOHSW. Figure 8 illustrates the new patients enrolled on ART per annum from 2008 and that approximately 21, 600 new patients are enrolled on ART yearly. The number of ART sites increased from 68 sites by December 2006 to 33

34 197 health facilities (92%) by December 2010 and according to figure 2 on average 1,800 patients are enrolled on monthly basis. FIGURE 8: ILLUSTRATES THE NEW PATIENTS ENROLLED ON ART PER ANNUM FIGURE 9: ILLUSTRATES THE NEW PATIENTS ENROLLED ON ART PER MONTH IN 3 YEARS Various trainings were conducted by MOHSW to strengthen ART program during the reporting period. These include training of trainers for district master trainers on adherence counselling, management of adolescents and HIV where 40 trainers from all districts were offered training skills on these topics. In addition, 69 health providers were endowed with skills to manage HIV and AIDS through the Integrated Management of Adolescent and Adult illnesses (IMAI)training held in Qacha s Nek district and 55 health care providers including nurses, doctors, pharmacists, etc were educated on advanced paediatric HIV/AIDS management and management of childhood illnesses

35 laboratory personnel from public and private health facilities were trained laboratory quality assurance. Various diagnostic consumables were also procured by end of October These include 2,450 rapid test kits for HIV, 57 DBS kits with 50 tests each and 71 DNA PCR kits. Furthermore, 4 point of care CD4 machines have been distributed to Semonkong clinics St.Leonard and Semonkong government clinics. Quality assurance for these machines was conducted in April 2011 and the two CD4 machines were sent to other hard to reach areas such as Semenenyane and Palama health centres in Leribe. Other laboratory reagents to the value of $1,325, were procured. These include Full blood count, chemistry, phlebotomy and viral load reagents. All these reagents are used for continuous monitoring of PLWHA at facility level. In conclusion, provision and monitoring of ART within the MOHSW have been greatly supported through this grant to enable more patients to be put on ART and to monitor them consistently to ensure longer and better quality of life for People living with HIV and AIDS. Significant amount of resources were availed to support a variety of interventions. It is also worth noting that good performance on this service delivery area is linked to high HIV test uptake within the health facilities PROPHYLAXIS AND TREATMENT OF OPPORTUNISTIC INFECTIONS By end of October 2011, an opportunistic infections (OI) rapid assessment was conducted and results used o informed the PSM Plan which drugs for OIs need to be procured.. The main purpose of this study was to identify common OIs presented to health facilities. The findings from the assessment revealed that TB is the biggest prevailing opportunistic infection in Lesotho at 30%. Other conditions that show high prevalence include oral thrush, URTI, chronic vaginal discharge, diarrhea, etc. The results also indicated that the threatening opportunistic infections such Cryptococcal Meningitis and Pneumocystis Pneumonia (PCP) are still been seen by health care workers though to a lesser extent. These are treated with amphotericin B of which 2 injections is given per patient. Cotrimoxazole (CTX) is given as a prophylaxis for Pneumocystic Carinii pneumonia which is one of the deadly and common OI for HIV positive patients and is required by HIV positive patients with low CD4 count. 35

36 SEXUAL REPRODUCTIVE HEALTH The indicator utilized to measure this indicator is shown below: Service Area Delivery Indicator description Intended target by October 2011 Achieved results October 2011 by Percentage achievement Sexual Reproductive Health and Number of service providers staff trained to provide information on SRH STI and HIV and referral as appropriate 1, % By October 2011, 494 nurses were trained on sexual reproductive health (SRH) which translates into 42% an increase of 46% from the achievement that was realised in April SRH trainings were not implemented as planned under the current grant and this negatively affected performance under this SDA. Two main reasons affected the performance namely; low turnout of participants during trainings and rescheduling of trainings of which some ended not taking place at all. It has been noted through the LDHS 2009 there is a high (92%) ANC attendance, much still needs to be done as only 33% of women received ANC in the first trimester. Furthermore about 59% of the women deliver at facility level but this scenario narrated has not yet had an impact on maternal mortality because a high figure of 1,155 deaths per 100,000 was reported by LDHS CARE AND SUPPORT FOR THE CHRONICALLY ILL Service Area Delivery Indicator description Intended target by October 2011 Achieved results by October 2011 Percentage achievement Care and support for the chronically ill Number of PLHIV receiving community home based care and support 18,000 4,208 23% By October 2011, only 23% out of the intended target to support PLHIV to receive community home based care was reached. The main challenge which significantly contributed to underperformance was the absence of the data collection tool to be used by Support groups to record home base care services provided to the chronically patients. Collaborative efforts through the PR and MOHSW were whereby an interim data collection tool was prepared and distributed to Village Health Worker to improve recording of data. 36

37 4,500 Home Based Care (HBC) Kits were procured, assembled through the support of NDSO and distributed to the health facilities from July 2011 to community health workers (CHW) in all districts to support families of the chronically patients. Data reported by end of October 2011 indicated that 1396 people were reached with home base care services. From May to October 2011 only three districts reported and these include Thaba-Tseka supported 13 people, Leribe with 457 and Maluti with 424. TEBA the agency assisting miners and ex-miners with chronic illnesses, reported 502 people who are under their home base program. Caption: Community health workers trained before they received home base care kits TB/HIV Therefore, the performance for this indicator is shown by the indicator below. Service Area Delivery Indicator description Intended target by October 2011 Achieved results October 2011 by Percentage achievement TB/HIV # And % of HIV infected clients attending HIV care / treatment services who are screened for TB. 60% 91% 152% ICAP, an implementing partner of the MOHSW conducted a survey and the findings demonstrates that out of the 74,366 screened for TB, are HIV infected. This was a sample drawn from the HIV patients that attended their last clinic visit from October 2010 to March The service provision survey (2010) further indicates that more than 80% of health facilities perform TB screening for HIV-positive patients. 37

38 National guidelines for TB/HIV have been developed and the final draft is available. These guidelines emphasizes 3 Is Intensified Case Finding (ICF), Isoniazid Preventative therapy (IPT) and TB Infection Control for provision of comprehensive care for PLWHA. The recommendation therefore is to ensure that, ICF and IPT must be made available in all public health facilities. By end of July, 2011, 500 guidelines were printed and were distributed to health facilities. In November 2010, two infection control trainings were conducted in Qacha s Nek. During the first training, 43 health care workers were guided on how to improve infection control and how to reduce TB infections within the hospital and clinic settings. In addition, 54 uniformed staff such as police, soldiers and prison warders was also trained on infection control applicable to their line of work STRENGTHENING THE NATIONAL POLICY FRAMEWORK The fourth objective is to reduce the negative social and economic impacts of HIV and AIDS on individuals, families and communities and Service Delivery Area include Prevention, Testing and Counselling. During Phase 1 for R8 HIV grant the National Prevention strategic plan was prepared and finalized. This was followed by the development of the National Revitalization Preventions Action Plan that has been implemented through facilitation by the Health Education Department who initiated community dialogues in the Roma Catchment area in 23 villages by the end of October The dialogues targeted men and boys in order to enhance their health seeking behaviour and render them as ambassadors in prevention of HIV and AIDS. 117 working men such as teachers, police and road contractors and 136 boys in school and out of school were reached in these villages. Figure 10 and 11 below show some of the interventions held in two areas Ha Khanyetsi and Ha Ramabanta. Key messages such as: Always use a condom consistently and correctly (demonstration of condom use was done), Know yourself, your partner, and your HIV status, Communicate-talk about sex with your partner and children, Love your partner and help love each other, Avoid risk drink moderately, Avoid taking risk, avoid unprotected sex, Communicate about sex with your partner, and Be faithful to your partner-stick to one partner and Seek treatment for STISs and HIV were discussed with the targeted groups. More community dialogues will be followed through the country during the Phase 2 period. 38

39 FIGURE 10: FACILITATORS DEMONSTRATING CONDOM USE TO HERD BOYS DURING COMMUNITY DIALOGUE SESSION AT HA KHANYETSI FIGURE 11: COMMUNITY DIALOGUE SESSION WITH WORKING MEN (HA RAMABANTA) SUPPORTIVE ENVIRONMENT WORKPLACE PROGRAMME: PUBLIC SECTOR This is the only SDA under the objective - To scale-up HIV-related policies and programmes in both public and private sector workplaces. Performance under this SDA was assessed based on the indicator shown below. 39

40 Service Delivery Area Indicator description Intended target by October 2011 Achieved results October 2011 by Percentage achievement Supportive Environment- Workplace Program: Public Sector Number of employees reached through workplace programs 1,800 2, % By October 2011, the performance on this indicator demonstrated that 128% of the intended target has been achieved. This good performance is related to contribution from various public sector ministries and departments. Activities under this SDA were coordinated by Ministry of Public Service in collaboration with NAC. A consultant -Nonyana Hoohlo and associates was commissioned in September 2010 by NAC in conjunction with the Ministry of Public Service to undertake a capacity assessment of the public sector to implement HIV and AIDs and TB workplace programmes. The assessment report is available. The report indicated current strengths which include availability of workplace policies and HIV and AIDS committees in most ministries and the existing dedicated personnel to direct HIV and AIDS activities within the public sector. However, certain challenges were found to be associated to these strengths. These include lack of dissemination of policy contents to all the workers, misrepresentation in the AIDS committees only professional staff is part of the committees thus sidelining support staff and unclear responsibilities for ministerial focal persons. The training programme based on the capacity needs assessment report was prepared in November 2010 by the MOHSW wellness centre. In December 2010, NAC in collaboration with Ministry of Public Service held a workshop where the workplace programme was amended and various departments were guided to develop their own workplace operational plans. In February 2011 an intensive two weeks training was conducted for 45 focal persons from 23 ministries, agencies and departments. The training was basically on HIV and TB competency within the workplace including HIV and AIDS mainstreaming and implementation of workplace programmes. A two day annual workplace fora were held in 2010 and The main aim of the first annual forum was to sensitise senior management on the HIV and TB workplace programme. The reason for this target group was to gain buy-in and it s very significant as the openness about HIV and AIDS on the part of the organisation s leadership can lead to an effective workplace program. In addition, under this SDA, LCS contracted Armstrong Associates Consulting (Pty) Ltd. to carry out a national study to collect sero-prevalence and behavioural data from inmates and staff in all of its facilities. The guiding purpose for this study was to obtain for LCS comprehensive system wide 40

41 data on HIV sero-prevalence together with data on knowledge, attitudes, beliefs and practices amongst prison inmates and staff. In February 2011, the study was completed and a final report is available. One of the main findings of the study is that more than 76% of both the inmates and LCS staff perceive that there is a high risk of contracting HIV in the prison setting. The high risk activities include sexual activity, use of drugs and physical violence. Another significant observation is that there is a high prevalence rate of HIV among inmates (31.4%) awhile that among staff is similar to the general population. On average condom use was found to be 50% among inmates and among staff due mainly to personal unavailability at the time of use. Another important behavioural aspect to note is that most people who are already HIV positive among the inmates and staff do not use condoms due to their status thus posing a huge risk for HIV infection. It was also recommended that LCS should scale up the HIV infection control strategies. These include among others strengthening availability of commodities such as condoms, lubricating gel for male to male sexual encounters that is also found to be existing in the prison setting, peer education to transform high risk behaviours such as non condom use and provision of sterile blades and needles. By October 2011, 173 Correctional services officers and 229 police officers were trained in HIV and AIDS and TB competency. The trainings were done to strengthen the HIV workplace programme within the police and prisons settings. Through the HIV and TB competency trainings, LCS staff gained immense knowledge thus making them competent in dealing with HIV and TB challenges in their line of work. This is attested by the HIV sero-prevalence and LCS behavioural results which confirmed there are high levels of knowledge regarding HIV transmission (81%) among staff. In addition 360,000 condoms were distributed within the prisons settings. Caption: on the left are different levels of LCS staff attending HIV and TB competence training. On the right are HIV focal persons from line ministries meet to share progress and experiences. By end of October 2011, 112 LCS officers were trained to be peer educators to support HTC, interventions, including adherence for usage of ARV and TB drugs. This training is one of the strategies under the scaling up of HIV and AIDs programmes in correctional institution aimed at 41

42 preventing HIV infections and strengthen the LCS HIV workplace programme, and by end of September 760 people were reached with peer education in the two settings. HIV prevention programme among the inmates also gained momentum. About 820 inmates were tested in 2010 as compared to 447 in Support groups for inmates living with HIV were formed and are fully functional in 7 prisons. Nurses were engaged on fulltime basis in all district prisons clinics and 220 inmates are currently on ART. Moreover female prison is now providing ante-natal and postnatal care including PMTCT. There are also plans to place a full time nurse at juvenile training centre. 2.3 ROUND 8 HSS GRANT OVERVIEW AND BACKGROUND Health System Strengthening (HSS) is one component that has been included within the R8 HIV/HSS grant in order to provide an enabling environment for both the HIV and TB grants success. Strengthening health systems means addressing key constraints related to health worker staffing, infrastructure, health commodities (such as equipment and medicines), logistics, tracking progress and effective financing. Within the HSS section, each HSS building block will be discussed in details. The activities executed by various sub-recipients in each building block will be introduced and the programmatic performance attained for this grant by end of the phase 1 implementation will be highlighted. Strengthening Health Service delivery action is framed within the context of the health sector reform (HSR) and decentralisation process that is already ongoing in the country. It includes revision and strengthening of the overarching health sector policy to incorporate specific components addressing accreditation and regulation of health services, whether they are provided through the public, nongovernmental or private sectors. The Round 8 proposal along with other current health reforms and donor funding, complement these activities through an extensive programme of activities to improve private sector provision of services. The HSS component focuses on Human resources for health (HRH) which constitute a critical component of health service delivery. The objective of this HSS action is to support the Human Resources Development and Strategic Plan by assisting in the provision of the manpower and skills needed for effective service delivery. This component will focus on the health workforce through strengthening the following areas: (i) the recruitment of health personnel; (ii) the distribution of health personnel; (iii) the retention of health staff; (iv) development of health personnel capacity; and (v) health personnel productivity. The range of activities will include strengthening workforce management, improving incentives to address the distribution and retention of staff, and Task Shifting to less specialised workers. The successful decentralisation of the health delivery system and its management are dependent on a well-functioning Health Management Information System (HMIS) at all levels of the system. Recognising the importance of data flow in maintaining and scaling up service provision, this HSS 42

43 section aims to monitor and evaluate the national HIV and TB response through ongoing feedback of data, information and research findings into the system, thus enhance the delivery of PHC provision. The goal of the National HIV and AIDS Strategic Plan (NSP) is to establish a functioning decentralized financial and procurement system by This HSS section thus aims to support the implementation of the NSP through strengthening the existing procurement and supply management system with the decentralised health delivery system. A well-functioning health system ensures equitable access to essential medical products and equipment; and, for this to be in place, the system has to be supported by sound national policies, guidelines and regulations; procurement, supply, storage and distribution systems that minimise leakage and other waste; robust supply chain management; and well-trained and supervised procurement, warehouse and logistics staff. Lesotho is well on its way to achieving this situation; but the additional stress on the system arising from the increased uptake of HIV, AIDS and TB services and subsequent rise in drug use has led to shortfalls and deficiencies ROUND 8 HSS PROGRAMMATIC PERFORMANCE The programmatic performance under the HSS component is based on the Health Strengthening system components interventions INTERVENTION 1: STRENGTHENING HEALTH SERVICE DELIVERY TO IMPROVE PHC OUTCOMES Health Service delivery interventions are measured using the two indicators shown below: Service Area Delivery Indicator description Intended target by October 2011 Achieved results October 2011 by Percentage achievement HSS: delivery Service Indices on Care of patients (COP) and Access to and continuity of care (ACC) for all health facilities COP 65% ACC 25% COP 51% ACC 14% COP 78% ACC 56% HSS: delivery Service Percent of service delivery points surveyed with no drug stock outs of more than 1 week in the last 12 months (average for the drugs for the 3 diseases HIV, TB and STI drugs) 80% 76% 95% 43

44 The first two indices are measured through the accreditation survey. The last accreditation survey indicated a ten percent increase on the care of patient and access to and continuity of care indices as shown in the 2010 MOHSW AJR report. The former basically measures the service delivery aspect in all health facilities and the latter shows access to, follow up and continuity of care to the community level. The indices achieved 78 and 56%of the set target respectively. The most recent accreditation survey was done in 2010 and a moratorium has been put on this activity until the recommendations of the last survey have been fully implemented. Furthermore, the medicine access survey conducted by the MOHSW indicated that on average 24% of facilities experience a 1 week stock-out of HIV, TB and STI drugs. The main reason cited for stockout relates to administrative issues such as not ordering on time and poor stock management. This therefore justifies for all health care providers especially clinicians at health centre level to be trained on supply chain management issues. The Ministry has engaged six (6) clinical mentors through the support of Global Fund, while 4 mentors have been engaged through Clinton Foundation funding. The mentors are deployed at the DHMT level in the 10 districts, ensuring that the mentoring programme is fully functional in all the districts. The mentor s role is to provide clinical mentoring at facility level in order to improve delivery of primary health care, and ART services. They support the districts by jointly assessing the facilities and delivering support through a six-week mentoring session at the designated facility. By September 2011, 30 clinics received the 6 weeks mentoring sessions. Based on the recent assessments of facilities conducted by the mentors, eight sites were selected to receive mentorship starting April These sites include Katse, Mohlanapeng and Linakeng in the Thaba Tseka district, Ngoajane in Butha-Buthe, Peka health centres in Leribe, St. Francis health centre in Qacha s nek, and Tsenoli health centre in Berea and Malefiloane in Mokhotlong district. Clinical mentoring has helped support the rapid scale-up of HIV treatment programs across the country and also has increased the confidence of nurses to initiate ART. Under this grant supervision is one of the key strategies to improve service delivery at facility level and it is measured through the indicator shown below: Service Area Delivery Indicator description Intended target by October 2011 Achieved results October 2011 by Percentage achievement HSS: delivery Service Number and percentage of health care facilities that received supervision in the past six months % 44

45 During the reporting period, of the facilities that were envisaged to be provided with supervisory visit 87 out of selected 120 were reached, constituting a 73% achievement. These include the 18 public hospitals and 69 health centres. As part of its objective to strengthen central level supervision of DHMTs, the Primary Health Care Department hosted district forums in each district to review performance and outcomes with health workers. The main purpose of the districts visits was to revive Districts Primary health Care meetings in Lesotho. The MOHSW held the 11 th annual Joint Review (AJR) meeting in June 2011 in an effort to provide feedback to the health facilities and its partners. The meeting focuses on the review of delivery of health services in the last financial year with district implementers, central level program managers, stakeholders and implementing partners taking part. The AJR provides a platform for the health sector to reflect on the performance of the previous financial year. A report stipulating achievements and challenges in relation to the MOHSW objectives taking into consideration the Millennium Development Goals including the goal to combat HIV and Aids, Health reform strategy and medium Term expenditure frameworks is in its final stages. One of the important interventions under this SDA was to improve health services at prisons. Through this support, LCS was able to render comprehensive health care services available to prisons populations. Figure 12 below shows that in 2010 a number of people provided with health services increased by 3 folds as compared to the services provided in Caption: Prefab offices were procured for prisons in the 10 districts of the country to be used as PHC clinics for inmates. On the right the office furniture and equipment were also procured for health workers. 45

46 FIGURE 12: SHOWS NUMBER OF PEOPLE PROVIDED HEALTH SERVICES AT PRISON SETTING Overall, service delivery at health facilities including prison s clinics improved dramatically due to collaborative efforts supported by various Partners in the Country INTERVENTION 2: STRENGTHENING THE HEALTH WORKFORCE FOR SERVICE DELIVERY The interventions supported through SDA under Health workforce is measured by the following indicators: Service Delivery Area Indicator description Intended target by October 2011 Achieved results by October 2011 Percentage achievement HSS: Workforce Health Annual rate of retention of health service providers at public health care facilities 88%(2768/3146) 97%(3351/3446) 110% By end of October 2011, 97% of the health service providers were retained. The MOHSW managed to recruit and deploy 183 community counsellors, 142 professional counsellors and 12 senior counsellors. The Community Counsellors are deployed at health clinic level to strengthen counselling services at peripheral, while the Professional and Senior Counsellors are deployed at DHMT level to oversee all HTC activities at district level. 46

47 17 radiologists and 10 nutritionists were also engaged, however through support of the GOL, thus demonstrating the GOL intention to gradually absorb its personnel. The money which was set aside was regarded as savings. Caption: Additional work force engaged to both CHAL and GOL hospitals to improve service delivery. BELOW IS THE SUMMARY OF HR THAT WAS SUPPORTED UNDER R8 GRANT. TABLE 16: SHOWS THE RECRUITMENT FIGURES FOR POSITIONS UNDER HSS WORK-PLAN Position Target Number Filled Vacant Nurse Mentors Mentor Coordinator Retired HCWs (nurses) Nurse Clinicians Senior Tutors professional counsellors Community Counsellors Senior Counsellor Pharmacist Accountants HR Officer Data Clerks TA for M&E (DSW)

48 TA for TB/HIV (Programme. Officer) M&E Officer (Programme. Officer) Human Resources Officers NDSO staff Storekeeper Procurement Officers Procurement Analyst Drivers Total (90%) 58 By October 2011, 2,163 professional health care providers from MOHSW and CHAL institutions were provided with salary complements as one of the strategies to retain them. Table 17 depicts cadres that have been identified as priority through Retention Strategy to support service delivery in all levels of Primary health care, and numbers as supported through the Global Fund. TABLE 17: SHOWS THE HCWS WHO WERE PAID SALARY COMPLEMENTS BY CADRES Position Number provided with salary complements Doctors 143 Nurses 1659 Radiographers 23 Pharmacists 123 Laboratory Technicians 113 Orthopaedic Technician 13 Physiotherapists 7 Ophthalmic Technician 1 Occupational Therapist 7 Dietician 7 Dental Assistants 28 48

49 Tutors 36 Clinical Psychologist 3 Total 2,163 Human resource turnover is one of the major challenges faced by MOHSW in terms of provision of quality health care services. One of the main reasons stipulated in the AJR report (2010/2011) is the low government wages. Through the HSS component, the Global Fund has supported the country to provide better salaries to staff as a complement to already remuneration provided by the GOL. In addition to the salary complements, 400 Health Care workers were benefited from hardship allowances which have been increased from M275 to complement it to M600 for all those deployed at hard to reach areas as an incentive to reside in the remotest health care facilities. A verification Report that contained finding from Health Facilities whose staff receive Salary complements is attached as Annex 1. Furthermore, 36 tutors were also supported with salary complements while 18 senior tutors were engaged in an effort to reduce a high ration of students to a teacher, and to augment enrolment number of students to within CHAL and MOHSW Nursing health training institutions. The MOHSW is anticipating that a significant increase in the student nurse enrolment will be realised once the effort to expand the infrastructure for classes and dormitories have been completed. Currently, the tutor to student ratio decreased from 1:50 in 2009 to 1:20 in This indicator exceeded the set target by 18%. Millennium Challenge Account (MCA) is assisting the MOHSW in upgrading the National Health Training Centre (NHTC). Service Area Delivery Indicator description Intended target by October 2011 Achieved results by October 2011 Percentage achievement HSS: Workforce Health Ratio of tutors to students (General nursing) % When renovation and construction of teaching halls and dormitories are completed by MCA, it is anticipated that increased nursing students will be attained in order to increase the pool of nurses within the country. 49

50 INTERVENTION 3: STRENGTHEN THE MANAGEMENT INFORMATION SYSTEM (MIS) TO IMPROVE SERVICE DELIVERY Submission of timely and complete report is used as an indicator of performance for this intervention as indicated below. Service Delivery Area Indicator description Intended target by October 2011 Achieved results by October 2011 Percentage achievement HSS: system information Number and Percentage of districts submitting timely, complete and accurate reports to the national level 80% 80% 100% By end of October 2011, 8 out of 10 districts submitted HTC and ART data on time for all the health facilities in the district. The recruitment of 89 of data clerks and 10 Health Information officers has helped improve timely and complete data as indicated in the MOHSW AJR 2011 and through the activities stipulated below. The MOHSW received computers from IRISH AID, in addition to those procured under Global Fund Round 8 HSS, for data management at health facility level. 23 out of 45 computers procured under this grant have been placed in pharmacies (Main and ART) to support the roll out of RX solution which is an electronic system to be utilised for inventory management and for patient data. Moreover, the Ministry intends to conduct an assessment of the capacity for data management, nationwide through implementing the HMIS Situation Analysis: Lesotho Public Health Centre Infrastructure Audit This will include, among others, the audit of the following at health facility level: Availability of electricity/solar power Availability of a telephone line (for internet connection that will facilitate submission of data) Security of procured equipment The Health Planning and Statistics Department conducted data verification visits in 6 of the 10 districts of Lesotho. These sites visited were Hospitals such as Botha Bothe, Mokhotlong, Mafeteng, Mohale s Hoek, Quthing and Qacha s Nek respectively. In addition, health clinics supervised were Motete, and Boiketsiso in Butha Buthe district, Libibing in Mokhotlong, Samaria in Mafeteng, Ha Tsepo in Mohale s Hoek, Mphaki and Villa Maria in Quthing, as well as Mohlapiso and Hermitage in Qacha s Nek. The verification looked at outpatient and inpatient data and PMTCT data to ensure that data collection, data capturing and collation of reports and remedial actions identified are consistent with the reports submitted to the central level, as well as to address challenging issues immediately. 50

51 INTERVENTION 4: STRENGTHENING THE PROCUREMENT AND LOGISTICS MANAGEMENT SYSTEM TO IMPROVE SERVICE DELIVERY The indicator that measures performance for this intervention is shown below. Service Area Delivery Indicator description Intended target by October 2011 Achieved results by October 2011 Percentage achievement HSS: Procurement and Logistics Number of service providers trained on supply chain management % Five pharmacists from the DHMT have enrolled for a year long course on the procurement and supply management course conducted by Institute of Development Management (IDM) Lesotho. Furthermore 11 people from NDSO, MOHSW and Ministry of Finance and Development Planning attended a 2 weeks course on ARV procurement and supply management, emphasis of the training being forecasting and quantification, Monitoring and Evaluation of the PSM plan, knowledge management and contemporary issues on provision of ART. By October 2011, at least 236 out of the intended target were achieved, constituting a 74% achievement of the number of personnel involved in procurement and supply chain management. Efforts are being done by the MOHSW to decentralise trainings to the district level. The trained pharmacists within DHMT will facilitate step down training and mentoring of the health centre nurses on issues related to PSM such as addressing the challenges related to forecasting and quantification of drugs for consumptions by patients, inventory management of drugs, and threshold for ordering as an examples. 2 4x4 delivery vans were also procured in support for NDSO to facilitate distribution of goods from the central medical stores to the district level and 2 4x4 double cabs for the Procurement Unit. In addition logistic support has been extended to NDSO to insure the medicines and health goods warehoused at NDSO. This is to done to counter act some of the risks such as fire and proliferation. Caption: Vehicle was procured to ensure quick delivery, supervision and monitoring of services. 51

52 Even though the implementation of this grant started very slow, by end of October 2011, a remarkable improvement in terms of programmatic and financial performance was attained to rate the performance as B1. The next section will provide the summaries of financial analysis as per the Category, the SDA and the Implementing Agencies under the R8 HIV/HSS grant ROUND 8 HIV/HSS FINANCIAL PERFORMANCE By end of October 2011, the total Phase 1 approved budget as per the workplan/budget was US $ 49,999,204. Out of the approved budget, by end of Phase 1 only US $ 34,115,824 was disbursed by the Global Fund and the expenditure incurred was $33,222, Out of this amount disbursed by the GF, $2,330,400 was carried forward from R5 which was consolidated with R8. The Financial analysis that is presented will only discuss a yearly report that include periods from November 2010 to October 2011 as per R8 HIV/HSS grant. The total budget approved from November 2010 to October 2011 stand at US$ 25,176,726. Below is financial analysis summary as per Global Fund categories Category Category Financial Analysis Budget versus Expenditure Budget US $ Expenditure US $ Variance US $ Human Resources 11,721,686 10,582,956 1,138, % Technical Assistance 437, , ,147 35% Training 2,175, , ,216, % Health Products and Health Equipment 2,717,330 2,973, , % Medicines and Pharmaceutical Products 6,169,368 6,453, , % Procurement and Supply Management 138,584 35, , % Infrastructure and other equipment 430, , , % Communication materials 466, , , % Monitoring and evaluation 547, ,167 86, % Planning and administration 273,249 86, , % Overheads 99,267 36, , % Total 25,176,726 23,050,707 2,126,019 92% % on Usage per category The summary above depicts spending as per categories. Even though the initial start of implementation was slow during year 1 of implementation in all categories, the momentum picked up during the second year of implementation as most of conditions precedent was fulfilled. The attainment of the conditions resulted in the release of funds to support the interventions. 52

53 Almost all HR that was earmarked to be engaged was achieved with exception of TB/HIV coordinators. With regard to the TA, most of the funds that were allocated for the engagement of the TA were not used because most of documents were prepared through the Health Care Programme Officers in consultation of the various committees. As results only 35% funds would be used. As has been highlighted from the above programmatic analysis, most of the trainings were not implemented due to various challenges and competing priorities within the Health Sector. The trainings included those related to Reproductive health, Male Circumcision as well as those related to Procurement supply chain management. As a result, only 44% was expended for the training. The table further indicate that the health products and equipment cost category was overspent by 9% in Year 2. The reason for overspending as depicted was due to year 1 invoices paid during year 2 because of delays in the delivery of health products and medicines. The budget was also exceeded on the following categories Medicines and Pharmaceutical Products by 5%, infrastructure and other equipment as well as communication materials. Funds that were earmarked for NDSO for support for logistics very little was used, as a result the procurement and supply management spent below optimum level at 25%. However it is important to note that in general terms, good performance and high absorptive capacity of funds was achieved by end of year with 91% financial achievement. Below is summary on Service Delivery Areas financial analysis from November 2010 to October 2011 Expenditure Analysis by Service Delivery Area (SDA) Service Delivery Area Budget Expenditure Variance % on SDA Prevention -BCC-Community outreach 577, ,928 (235,626) 141% and schools Prevention - BCC-Mass media 209, ,449 1,359 99% Prevention Condoms distribution 131, ,887 (70,596) 154% HSS - Male Circumcision 75,057 75,057 0% Prevention - STI Diagnosis & treatment 733, , ,551 42% Prevention: Testing & Counselling 528, , ,002 22% Treatment - ARV treatment and 8,227,044 8,890,460 ( 663,416) 108% Monitoring Treatment -Prophylaxis and treatment 595, , ,130 18% for OI s HSS - Sexual & Reproductive Health 207, , ,442 51% Care & support for the chronically ill 827, , ,545 39% TB/HIV collaborative activities- 195,824 45, ,442 23% TB/HIV Strengthening National policy 104,370 43,641 60,729 42% Framework Supportive environment: Stigma 119,120 41,486 77,634 35% reduction in all settings Supportive environment: Strengthening 253, ,620 (86,548) 134% of civil society and institutional capacity building Supportive environment-program Management and administration 314, , ,517 61% 53

54 HSS: Health Workforce 9,832,735 9,456, ,252 96% HSS: Procurement and Logistics 415, ,563 (77,044) 119% HSS: Information System 949, , ,387 69% HSS: Service Delivery 878, , ,204 82% TOTAL 25,176,726 23,050,706 2,126,020 92% Most of the SDA performance as per financial analysis was good with the exceptional of five SDA that reached below optimum level. The SDA that have accomplished above the optimum or overspend are a results of invoices paid in Year 2 instead of Year 1 because of delays in the delivery of goods and services, or delays in the implementation of activities, deferred to and conducted in year 2. The Male circumcision activities were never performed because of the change in the target groups to benefit as against what was initially proposed during the initial development of the proposal, as a result o% of expenditure was achieved. With regard to Prophylaxis and TB/HIV interventions, low absorptive capacity was also attained due to non procurement of drugs for OI and STI. The reason for non procurement was the change in drugs that were required by health facilities and Patients. A rapid assessment was conduct to all health facilities to establish the required regime of drugs prescribed frequently, and diagnosed diseases. The report that contained the results and findings was only finalized towards end of the phase 1. The drugs required could not be procured because of necessary changed to be entered in the PSM plan that required the GF approval, as a result only 18% of funds allocated were spent. With regard to TB/HIV, the major part of funds was allocated to support for 18 TB/HIV personnel. However, these people were never engaged by the MOHSW, subsequently only 23% absorptive capacity was reached. Generally, spending as per SDA interventions improved during year 2 for majority of the activities, resulting into 92% utilization. The financial analysis summary as depicted below shows spending as per implementing agencies. Expenditure and budget analysis by implementing entity Implementing Entity Budget Amount disbursed to SR Ministry of Finance and Development Planning (PR) Ministry of Health and Social Welfare Lesotho Services Correctional Expenditure % Expenditure/Budget 314, , % 23,190,810 5,606,621 19,852, % 114, , % Ministry of Gender, Youth, 183, , % Sports and Recreation National Aids Commission 33,993 43, , % 54

55 Lesotho Mounted Police 107, , % CHAL 1,231,962 2,023, % Total 25,176,726 5,649,645 23,050,706 92% The Ministry of Health and Social Welfare and National Aids Commission were the only SRs which the received disbursement. The rest of implementing partners, arrangements were made that PR would pay suppliers on their behalf as per their request. This was because most of them were not willing to open specific bank account for the GF funds. Almost all implementers were able to spend their money as per allocation with exception of the PR whose absorptive capacity only reached 61%. The reasons may include funds not spend on travel outside the Country either for conference or short courses as stipulated by the workplan. Majority of the causes were not approved by the GF during the submission of the Training Action plan as stipulated in the approved budget. Those who overspend in Year 2 include CHAL, LMPS, LCS and MOGYR. As noted, most of the implementing agencies performed their activities in year 2 and this is reflected through overspending veruses budget allocated per the period under review. The major reasons for carried forward activities are result of late engagement of staff, delayed initiation of activities during Year 1, and delays in submission of payment of invoice which as a result had to be paid during year 2. In addition, the funds were released towards end of Year 1 by the GF due to condition precedent. However, spending level as indicated above has been improved during Year 2 of Phase 1 because of conditions fulfilled ROUND 9 HIV GRANTS: OVERVIEW AND BACKGROUND The support from Round 9 grant aims to increase access to quality education for OVC in and out of school, increase capacity for OVC program monitoring and evaluation and to strengthen the OVC legislative and policy environment. The first objective is comprised of one service delivery area (SDA) namely Support for orphans and vulnerable children. The main activity is the provision of bursaries to secondary school OVCs each year of the phase 1. Prerequisites to retain the pupil in school are to provide uniforms and hygiene kits for OVCs receiving bursaries. Furthermore, under this SDA the support is extended to strengthen Bursary Unit within MOET by increasing human resources and making available training for in order to increase the efficiency of the bursaries program. Other activities under this objective include expanding basic literacy training including HIV and AIDS information for out-of-school OVC. This activity entails support to the Lesotho Distance Teaching Centre (LDTC) to revise literacy curriculum to incorporate information on HIV and AIDs and to support this organization together with LANFE to scale up literacy program targeting young boys and girls out of school (herd-boys and domestic workers). The second objective supports ongoing strengthening of the national M&E system that is linked to the National OVC Strategic Plan. The funds under this grant complement activities supported under Round 7 to implement a robust and user-friendly M&E system to assess the ongoing impact of OVC initiatives. Activities include printing and distributing data collection tools, conducting data 55

56 validation exercises and providing data management at district level. Additionally, funds have been earmarked for operational research programs designed to extend the impact of a revised OVC situational analysis. Finally, money is available for broad community sensitization activities at national, district and local levels on the Child Welfare and Protection act. Specific activities include supporting NGO to sensitise non-governmental partners and communities on the act and convening stakeholder consultation sensitization sessions and distributing copies of the legislature to the public as a whole. The next section will discuss the programmatic and financial performance for the period under review ROUND 9 HIV PROGRAMMATIC PERFORMANCE The programmatic performance presented in this report is based on the achievement as at September 2011, the third quarter since the implementation of this grant. The actual results per performance framework depict the performance for the first period of the grant which is January 2011 to June The period from July 2011 onwards, all activities were incorporated into consolidation of R9 and R7 to form Single Stream Funding which is yet to be signed. The programmatic performance will be presented by SDAs per objective SUPPORT FOR ORPHANS AND VULNERABLE CHILDREN Performance under objective one Increase access to quality education and training for orphans and vulnerable children in and out of school is assessed by indicators below that measures; improving implementation systems and evidence-base for OVC bursaries program, provide fees and educational requisites for OVC in schools, strengthen life-skills training and expand basic literacy training for outof school OVC. Indicator Target Results % achievement Jan 2011 June 2011 School drop-out rate among OVC at secondary school level 27% N/A N/A Number of OVC Bursary programme key % stakeholders trained on OVC Bursary operations manual Number of OVC in school provided with fees 1,075 1, % Number of OVC in school provided with educational requisites 0 0 0% Number of women reached with basic literacy % training including HIV and AIDS Number of herd-boys reached with basic literacy , % 56

57 training including HIV and AIDS The drop-out rate for 2010 academic year is one of the indicators in the MOET M&E plan that was developed in April Baseline survey was expected to be conducted by February 2011, to further measure this indicator. The survey could not be undertaken due non availability of funds because of consolidation process between R7/R9 into Single Stream Funding (SSF). The Survey will commence immediately when SSF is signed and funds disbursed. The poor performance on the trainings for OVC Bursary Programme Key Stakeholders on OVC Bursary manual was due to the delay in finalization of the Bursary manual. MOET is currently finalising the manual by including the Management Information system chapter and the trainings for all stakeholders in the districts such as principals, school bursars, chiefs, councillors and other community leaders. The trainings will only commence after signing of the SSF as funds not used by end of Quarter 2 will no longer be available. A total of 1,087 OVC were supported with schools fees for the year 2010/2011 in Form D and E from Round 7 Year 3 and R9 Q1. For support of 6,477 students in 2011 funds were not released because of the condition precedent that indicated that the M&E system should be in place which will be able to capture and generate information for beneficiaries, to ensure that there are no duplicated efforts and selection criteria for the beneficiaries. However, it is important to note that by end of September, 2011, the MOET borrowed funds to pay school fees for 7,511 students. Furthermore, the R7 and R9 grants consolidation had started and the cut off date which was April 2011 made impossible for the PR to receive further funds before signing off the new consolidated grant. It is therefore expected the funds will be disbursed by the Global Fund when the condition precedent is met. OVC in school were not provided with educational requisites during the reporting period because the identified service provider declined to accept the offer citing various reasons such as price for procurement of hygiene that he quoted was underestimated amongst others. The Service Provider provided the written withdrawal letter by 24 June Because of this, the tender panel of the MOET took a new decision to re-tender or to consider the second qualified service provider. The decision was undertaken in July 2011 that all bidders should be given another opportunity to retender on the revised specifications. The whole re- tendering process delayed procurement. However, by end of September 2011, the new supplier was engaged and delivery is expected to be complete by 2 nd December 2011 and the educational requisites will be distributed in January 2012 when the schools re-open. LANFE and LDTC contribute 30% and 70% respectively towards reaching women (domestic workers) and herd-boys with basic literacy including HIV and AIDS. However during the reporting period only LANFE reported while LDTC had to review its data collection system which delayed submission of data from the learning sites. LDTC contribution will therefore be reported at the end of December LANFE is operating in three districts Mokhotlong, MohalesHoek and Quthing and has engaged 63 animators, four roving animators and three district animators in all these districts to provide basic numeracy and literacy which include HIV knowledge in an effort to curb new HIV infections and to capacitate vulnerable children and youth to be able to read and write. 63 learning centres have been 57

58 established. The animators role is to facilitate learning on daily basis in all these learning sites. Supervision and monitoring is conducted by roving and district animators. During the reporting period the roving animators conducted 84 visits and district animators conducted 54 supervision visit. During the supervision visits, the animators assess learner s progress and advice the animators on challenges encountered during facilitation, checks availability of learning materials and replenishes if necessary. Since the commencement of this grant, 1,331 learners were revived and 227 new learners were enrolled into the programme thus making a total of 1,538 learners. To date 9% are in the pre-reading stage whereby the are guided on how to hold a pen and write and practices different sounds and vowels. 41% are studying book 1 of the programme which comprises of learning five different sounds and differentiating between vowels and consonants and starts writing. Book 2 which is being learned by 23% of the enrolled learners concentrates on sounds of difficult two letter phonetics and starts writing sentences and answering questions. 27% of the learners have progressed and are currently studying book 3 which include writing letters, listening comprehensions, learning idioms, writing and reading fluently. To date 1,356 herd-boys and 110 women have been reached with HIV and AIDS information depending on the stage they are presently at. Furthermore, all the animators conducts community campaigns where they sensitise the audience on the importance of education, children s rights and how to reduce children labour on monthly basis. To date 9,745 community members have been sensitised. Caption: Herd boys graduated after receiving LANFE education which include HIV and AIDS education. LDTC revised and printed 40,000 learning materials on literacy, numeracy and HIV and AIDS and 39,021 have been distributed to the learning posts to be used by the learners. Furthermore, 263 instructors have been trained by LDTC so that they can reach more learners with basic literacy including HIV and AIDS. The second objective under the same SDA that reads Support for Orphans and Vulnerable children SDA focus on achieving the following activities; strengthening monitoring and Evaluation systems for the OVC national response by enhancing the functioning of the national OVC M&E system at DSW, develop and implement a pilot database to support the Social Welfare Routine Information system (SWRIS) at national level and enhance knowledge base for OVC programs through operation research. One indicator is used to measure performance in this objective as shown below: 58

59 Indicator Target Results % achievement Jan 2011 June 2011 Percentage of stakeholder organisations submitting complete reports per quarter 36% 37% 103% During the reporting period the number of organizations that were able to submit complete reports is 16. There are 43 organizations that are expected to submit complete reports to the department of social welfare at national level. The M&E unit within the department of Social Welfare is intensifying data quality management at the district level. During the reporting period, 10,000 OVC monthly reporting forms have been printed under this grant and have been distributed to all the districts. 33 child welfare officers have been trained on HIV and OVC issues including Monitoring and Evaluation for OVC programmes in order to improve coordination of OVC programmes at district and national levels. Furthermore, in order to strengthen capacity three computers and one scanner were procured and delivered to Social Welfare in August The Computer Business solutions have been selected as the database consultant to set up the OVC database for the Ministry of Health and Social Welfare. The role of this company is to design the database, conduct feasibility for national roll-out and advise on other aspects such as installation of the server and other accessories to render the OVC management information system functional in Lesotho. The consultancy firm will work hand in hand with the database coordinator who has been engaged under the support of this grant in August 2011 at the Social welfare department to ensure sustainability and facilitate capacity building for district and national personnel in an effort to have good quality data. Data quality management mentoring, sensitization of the stakeholders on submission of complete reports to the department of social welfare on time, and validation exercises at all levels have been scheduled to start once the consolidated R&R9 grant have been signed as the funds were included in this grant. Implementation of these exercises will also be enhanced by availability of a new and a vehicle procured and was delivered to the DSW through the support of this grant SUPPORTIVE ENVIRONMENT NATIONAL POLICY FRAMEWORKS The second SDA centred around the objective 3 which aim to develop and implement public awareness program on the Child Protection and Welfare act of 2011.The activities under this objective included developing user friendly summary for the act, translating it and distributing it to the communities through media and by Non-governmental organisations such as FIDA and NGOC to sensitise other partners and the community. Activities under this SDA were not done due to the condition precedent which was set by Global Fund before disbursement of funds. This condition stipulated that the Child Welfare bill should be enacted as act before all activities can commence. The child protection and Welfare act was enacted and launched in August 2011 thus the condition was fulfilled. Since the condition was met 8 months following the commencement of this grant and consolidation of Round 7 and 9 grants had started, all the funds were shifted to this new grant. Implementation of all activities under this objective will be initiated once the grant has been signed by the Global Fund and the government of Lesotho. 59

60 2.3.3 ROUND 9 HIV FINANCIAL PERFORMANCE The implementation of activities started in January 2011 and the first disbursement to the tune of US$ 1,561, was received from Global Fund at the end of December In July 2011 the grant was consolidated with the Round 7 HIV grant to form the Round 7/9 HIV grant. Therefore, activities were implemented for the two quarters (January to June 2011) before consolidation of the grants. Expenditure by category for the period January to June 2011 in US$ is as indicated in the table below: Category Budget Expenditure Variance % on usage of funds Human Resources 107, , , % Technical Assistance 128, , % Training 57, , % Infrastructure and other equipment 155, , , % Communication materials 66, , , % Monitoring and evaluation 62, , % Living support to clients/target 758, , , % population Planning and administration 87, , , % Total 1,423, , , % The Financial Analysis above shows that funds have been absorbed satisfactory for human resource, communication materials and Living support to clients. This means that by this period all human resource that were to be engaged to strengthen The Bursary Unit of the Ministry of Education for the following positions: Bursary Manager, Data Officer, 10 Data Entry Clerks and 2 Drivers was completed. Furthermore staff for Ministry of Health and Social Welfare for the position of the Data Base Administrator was also in place, as well as payment of Stipend for the Animators to support distance teaching Programme under Lesotho Association of Non Formal Education was accomplished. Printing of the revised teacher literacy materials was also achieved during the period under review; however printing of the Bursary Manual is still outstanding due to delays in the finalization of the document. With regard to living support, the funds to the tune of $492,000 were used to pay school fees for 2010/2011 for Form D and form E. However funds were not used for hygiene kits due to challenges encountered with the selected supplier. Moreover, low absorptive capacity was experienced with infrastructure, M&E, the TA, and planning and administration. Two vehicles for the Ministry of Education and Training that were budgeted to be procured during the first quarter were not procured by the end of the second quarter, hence the under expenditure under the category. Office equipment for the Bursary Unit staff, three laptops, a scanner and server for the Department of Social Welfare that were budgeted in quarter were not procured during the period under review because there was a delay in the procurement processes. Payments for development of the policy including the workplace policy, development of user friendly summary and translation of the Child Welfare Protection Act to Sesotho and engagement of the NGO to sensitise the community about the Act could not be done as budget was included in the SSF grant, the feasibility study for the roll out of SWIRIS to districts and local level by the Department of Social welfare were not done hence the under expenditure on the category. 60

61 Financial Analysis of the budget and expenditure by SDA Service Delivery Area Budget Expenditure Variance % usage of funds Care and support: support for Orphans and Vulnerable Children 1,275, , , % Supportive environment: policy 147, , , % development including workplace policy Total 1,423, , , % School fees, equipment and furniture, remuneration of staff at all levels have been provided to strengthen SR under this grant by end of quarter 2. However, negative variance occurred due to delays in the delivery of vehicles for the MOET, and procurement of hygiene kits. Furthermore, no funds were used because of the condition precedent which was met after the first disbursement which was exclusive of funds to support any activities under Policy development including workplace policy. Financial Analysis of budget and expenditure by implementing entity is as shown in the table below: Implementing Entity Budget Expenditure Variance % of usage of funds by IP Ministry of Education and Training 1,117, , , % Ministry of Health and Social Welfare 257, , , % LANFE 47, , % MOFDP/GFCU , , Total 1,423, , , % Out of 79% budget allocated to the MOET, only 57% was used to build capacity for the bursary unit at central and district level through the engagement of personnel and procurement of furniture and equipment as well as payment of school fees for the 2010 period for Form E and D. The delays were experienced in terms procurement of vehicles, printing of bursary manual and training for key stakeholders on the usage of the bursary manual. LANFE is one SR that has managed to use its entire budget as allocated in support for the distance teaching of herd boys and domestic workers in the districts of Mokhotlong, Mohaleshoek and Quthing. With regard to Ministry of Health low absorptive capacity was experience due to non implementation of most activities. 61

62 3. TB GRANTS PERFORMANCE Currently the Government of Lesotho is implementing two TB grants with the support of Global Fund. These are Round 6 and Round 8 TB grants. The Round 6 TB grant is in Phase 2 while the Round 8 TB grant relates to Phase 1. This section will discuss the overall performance of the grants over the past year from October 2010 to September ROUND 6 TB GRANT OVERVIEW AND BACKGROUND The goal as contained in the R6 grant is to reduce morbidity and mortality due to TB in Lesotho. There are two objectives to achieve the goal and these are (a) To empower people with TB and communities to provide treatment, care and support to TB patient( b) To address TB/HIV collaboratives activities. The goal and objectives were set in line with the national TB/HIVstrategic plan and the Stop TB strategy. The main activities under the first objective are; Strengthening of National TB Program Central Office and Health Education Division capacity to spearhead TB ACSM activities, improving and strengthening lab and health education infrastructure by procuring equipment, conducting countrywide sensitization activities in communities on TB issues, training of Health Care Workers on how to involve communities in TB Care, improving TB knowledge of community leaders through TB Education seminars, improving delivery of TB services to vulnerable populations by mapping populations and improving monitoring and evaluation, improving referral system of TB suspects by communities to TB services, establishing or upgrading infrastructure of laboratory services and providing laboratory equipment and supplies necessary for TB diagnostics for all HSA laboratories, strengthening capacity building for laboratory personnel and supporting TB operational research. The attaiment of the second objective was based on the following activities; providing HIV testing and counselling Services to all TB patients with all health centres, introducing HIV prevention methods and cotrimoxazole prophylaxis in TB clinics, training of Health Workers in TB Clinics to provide HIV/AIDS care and referral TB/HIV mechanisms. The grant consists of five service delivery areas(sdas) namely, Improving of diagnosis, High quality DOTs, Community TB care, Advocay, Communication and Social Mobilisation and TB/HIV collaborative activities ROUND 6 TB PROGRAMMATIC PERFORMANCE The programmatic performance on this grant covers October 2010 September 2011 and is presented based on the service delivery areas IMPROVING DIAGNOSIS The main activity under this SDA include strengthening the central NTP office and Health Education Division capacity to spearhead TB ACSM activities. Two indicators are used to monitor performance under this service delivery area. 62

63 Service Delivery Area Improving diagnosis Improving diagnosis Indicator description # of new smear positive TB cases detected every Proportion of PTB cases detected through smear microscopy Intended target by September 2011 Achieved results September , % 79% 76% 96% Percentage achievement The number of all new pulmonary TB cases reported as of september 2011 were 7955 and 2494 of those cases were new smear positive TB cases. The proportion of the smear positive cases constituted 31% of all pulmonary cases and the performance falls short of the 50% target from the WHO/StoP TB strategy. Performance in these indicators is influenced negatively by high TB/HIV co-mobidity in Lesotho. During this reporting period, 76% of the tested TB patients were HIV positive. However, it should be noted that this achievement still matches the 70% Global target of the detection rate. The bar chart above shows the performance of each facility including the PPP facilities. 13 health educators were recruited under the grant and placed in the ten dsitricts. The educators have deveoped ACSM plans that are articulating ACSM activities undertaken in each district. During the period under review, 37 social mobilisations have been reported, 8 in Berea, 24 in Qacha snek and 5 in Maseru.These gatherings empower the communities to know the signs and symptoms of TB, mode of transmission, prevention of TB, care and treatment of TB patient and TB/HIV collaborative activities. More importantly these interventions are intended to promote health seeking behaviour from the communities. 63

64 HIGH QUALITY DOTS Under this SDA one indicator was utilised to guide performance. Service Delivery Area Indicator description Intended target by September 2011 Achieved results September 2011 Percentage achievement High Quality DOTS # and % of new smear positive TB cases that successfully completed treatment among the new smear positive cases registered in a specified period 2441(85% of P13 cohort) 1850(67%) 67% By September 2011, 2726 smear positive TB cases were registered. 1851(67%) smear positive cases succesfully completed treatment. The performance falls short of the 85% target under the grant. The factors that might contribute to the low performance include; cases not evaluated which was 315 and this constituted 11.6% of all cases, the death rate of 9.8% while the defaulter rate of 7.5%. As an intervention measure to improve the performance, three high volume districts (Berea, Leribe, Mafeteng and Maseru) (whose performance was sub-optimal were identified and assisted in drawing action plans on how to address the under-achievement. This intervention proved worthy since the performance in these facilities improved in the July-September The action plans emphasized on strengthening defaulter tracking mechanisms and improving ART intake for TB patients. It should also be noted that the target, 2441, is actually higher than the 85% of P13 cohort-since 2138 were registered in P COMMUNITY TB CARE Under this SDA, the main activities to be carried out include conducting country wide community sensitization on TB issues, improving the referral system for the TB suspects to facilities, training of the health care workers and community health workers on how to involve communities in TB care. Three indicators were identified to measure performance under this service delivery area. Service Delivery Area Community TB Care Community TB Care Community TB Care Indicator description # of TB suspects referred by community health workers # of Community Health Workers trained on Community TB care # of Health Care Workers trained in Community TB care and TB/HIV collaborative activities Intended target by September 2011 Achieved results September ,250 1,378 61% % Percentage achievement % 64

65 The Ministry of Health and Social Welfare uses Community Health Workers to deliver various public health services at the community level. These services include promotion of good health practices in the community, provision of preventive and curative health care through education, referral of people to health facilities. Under this grant, provision has been made for training of CHW to strengthen referrals of TB suspects. As of September 2011, 1378 TB suspects were referred by the CHW and this translates into 61% of the planned target. The low performance is attributed largely to the high level of awareness of TB among the communities. Knowledge about TB among Basotho is recorded to be at ninety four percent (94%) base on the DHS It is believed that due to the high knowledge some suspects seek service directly without the involvement of the Community Health Worker and it is envisaged that performance is not going to improve much over time. The NTP programme placed a request to Global Fund for the deletion of the indicator based on the DHS 2009 findings. The request was not approved due to lack of evidence attesting that TB suspects do direct self referral to facilities. During the reporting period, 220 CHWs received training on community TB care. The training equipped the CHW on the following areas, the definition of TB, transmission of TB, prevention of TB, the signs and symptoms of TB, the role CHW and Treatment Supporters in the care of TB patient, referral of TB and HIV patients, the proper use of CHW reporting tools, side effects of TB drugs, HIV and AIDS and health promotion at the community level. These training are intended to empower the CHW to promote health seeking behaviour at the community. 229 health care workers have been trained on community TB and TB/HIV collaborative activities. These trainings equip the HCW with skills to manage TB/HIV collaborative activities and community TB care. The topics covered in these trainings include epidemiology of TB, diagnosis of TB, management of TB, TB treatment, TB/HIV co-infection, integration models and practices, paediatric TB/HIV co-infection, ACSM, MDR/XDR-TB, monitoring and evaluation, PMTCT in pregnant TB patients, TB infection control and policy, leprosy, supervision of CHW and the community treatment supporters, community involvement in TB care. These interventions are geared towards improved access to TB diagnosis and quality patient-centred care through community participation and better capacity of the health work force ACSM(ADVOCACY COMMUNICATION AND SOCIAL MOBILIZATION) The main activities under this SDA included improving the TB knowledge among the community leaders through trainings and education seminars. Two indicators were identified to monitor implementation of activities are. Service Delivery Area ACSM Indicator description Intended target by September 2011 # of community leaders trained on social mobilisation and communication ACSM # of districts with written social mobilisation and communication plans 65 Achieved results September % Percentage achievement 100%(10) 100%(10) 100%

66 During the period under review 287 community leadres were trained on community mobilization and social mobilization. The leaders trained include church leaders, teachers, nurses, CHW, counsilors and traditional leaders. The content of the trainings encampass signs and symptoms of TB, prevention methods of TB, treatment of TB, side effects of TB drugs, the role of CHW and TB treatment supporters.on HIV/AIDS the topics covered include HIV/AIDS prevention, HIV testing and counseling, adherence to ART treatment, side effects of ART drugs, referrals for both HIV and TB patients. The leaders are empowered to impart their knowledge to communities on TB and HIV/AIDS during the implementation of ACSM activities. All the ten( 10) districts have in place written ASCM plans articulating activities to be carried out at districts level by the health educators. In total, 37 social mobilisations have been reported this far, with 8 in Berea, 24 in Qacha snek and 5 in Maseru.These gatherings empower the communities to know the signs and symptoms of TB, mode of transmission, prevention of TB, care and treatment of TB patient and TB/HIV collaborative activities. More importantly these interventions are intended to promote health seeking behaviour from the communities. Advocay, Community and Social Mobilization and community participation in TB care consitutes important strategy in intensfying case finding of TB. The grant supports training of community leaders to empower them with knowledge on TB and HIV and AIDS. These trainings orientiate the community leaders on their role in influencing communities on BCC with respect to TB and HIV/AIDS using ACSM as a strategy. The ACSM activities endeavour to improve case detection, treatment adhrerence, combat stigma asoociated with TB and HIV/AIDS TB/HIV Five main activities were identified under this SDA and these include provision of HTC to all TB patients within the health facilities, introduction of HIV prevention methods in TB clinics, training of health care workers in TB clinics to provide HIV care and support, introduction of cotrimoxazole prophylaxis in TB clinics and training of health care workers on TB/HIV referral mechanisms. Three indicators were used to monitor the implementation of TB/HIV collaborative activities. Service Delivery Area TB/HIV TB/HIV TB/HIV Indicator description Intended target by September 2011 # of registered TB patients who received HIV testing and counselling # of HIV positive TB patients who received cotrimoxazole preventive therapy during TB treatment # of HIV positive TB patients who receive ART Achieved results September ,403 7, % 4,500 5, % Percentage achievement 2,073 2, % 66

67 The implementation of TB/HIV collaborative activities intensfied under the grant as demonstrated by three performance indicators. During the reporting period 7555 people received HIV counseling and testing HIV positive patients received CPT, 2183 HIV positive TB patients were put on ART. Trends in TB/HIV collaborative activities Year (up to September) Total number of all TB cases (all forms) Total number of TB patients tested for HIV Proportion of TB patients who tested for HIV 78% 84% 82% Total number of HIV positive TB patients Total number of HIV positive TB patients on CPT Proportion of HIV positive TB patients on CPT 94% 96% 91% Total number of HIV positive TB patients on ART Proportion of HIV positive TB patients on ART 28% 27% 38% HIV counselling and testing uptake within the TB patients has been increasing over the past two years. As revealed above, the number of people who received HTC in 2009 was 78% of TB patients received HTC and in 2010 the performance increased to 84%. As of September 2011, 82% of all TB patients received HTC. The performance is expected to be above 85% by December The main of NTP is to provide HTC to all patients by end of Enrolment of HIV positive TB patients on CPT is above 90% however below the 100% target. In 2009, there were 8084 HIV positives TB patients and 94% of them received CPT, in 2010 the recorded number of HIV positive patients was 8470 and 96% of them received CPT. The performance falls short of the 100% target but it is however improving. The proportion of HIV positive TB patients on ART is steadily increasing. As observed, for 2011 a much more significant progress in TB HIV positive patient put on ART will be achieved. This is proven by the fact that even though the statistics does not include the last quarter of the year, the results are already comparable to those attained in This performance owes to intensive approach applied at high volume sites like Leribe (Motebang), Berea government hospital and Mafeteng hospital. Since these are high volume sites, their performance has a large impact on the national figures. The grant made significant contribution in the scale up of the TB/HIV collaborative activities. 299 HCW received training of TB/HIV collaborative activities. These HCW encompasses nurses and doctors in public and private facilities. The trainings focussed on the implementation national guidelines which includes, routine HIV counselling and testing among TB patients, PMTCT in Pregnant in TB patients, initiation of TB patients on ART. These interventions are intended to reduce the burden of both TB and HIV/AIDS to people infected or affected as shown on the TB/HIV NSP

68 TB1: A poster used to promote proper cough etiquette, TB2: A poster outlining recommended timings and means of sputum collection In general, the grant had a very positive impact on the diagnosis and treatment of TB in Lesotho. The presence of microscopists within the laboratory system directly resulted in shortening the smear microscopy results turn-around time. It is with the same support that laboratories are continually supplied with reagents and consumables, crucial to the day to day operation of the laboratory. Furthermore, the programme and districts were capacitated to supervise their sub levels and ensure quality of treatment and care ROUND 6 TB FINANCIAL PERFORMANCE The grant is solely implemented by the Ministry of Health and Social Welfare. The PR received funding to the tune of US$ 707, from Global Fund during the period under review and disbursed US$ 781, to the Ministry of Health and social welfare. Funds were still available in PR account received prior to the period under review. Budget and Expenditure Analysis by category for the period October 2010 to September 2011 is as indicated in the table below: Category Budget Expenditure Varience % of usage of funds CR Human Resources 363, , , % Training 272, , , % Health Products and Health equipment 133, , , % Communication Materials 141, , , % Monitoring and Evaluation 50, , , % Planning and Administration 44, , , % 68

69 Total 1,004, , , % Satisfactory absoptive capacity of funds has been realized with human resource category, while the rest of the categories usage reached below 50%. However training were conducted for Community Health Workers, community leaders as well as short courses for Laboratory staff. During the period under review health commodities such as frosted end slides, applicator sticks, gloves, sputum jars and mask box were procured. Delays have been experienced in terms of payments for health products due to setback in the delivery by end of the period. 300,000 TB treatment cards and 500 pins and sqeeze bottles with TB messages were also paid out. Lastly, only 12% of the budget has been spent by the National TB Programme who out of a budget of US$24, for operating cost allocated only US$3, was utilized. SDA Financial Analysis as per the budget and expenditure. Service Delivery Area Budget Expenditure Varience %usage of funds as per SDA Improving diagnosis 202, , , % Community TB care 76, , , % Improving diagnosis 211, , , % Timely detection and quality treatment of cases 16, ,000 0% Supportive environment: Laboratory 498, , , % Total 1,004, , , % The financial analysis as per SDA illustrate that large amount was spent toward communty TB Care where communities were sensitized and trained along with the, remuneration of staff for NTP and District health educators. On the other, under spending was incurred due to delays in the submision of invoices for printed IEC materials and health products such as frosted end slides and spatum jars. 69

70 3.2ROUND 8 TB GRANT OVERVIEW AND BACKGROUND The main goal of the grant is to reduce the burden of MDR/XDR-TB by providing universal access to high quality diagnosis and patient-centred services in line with Global Plan to Stop TB targets. The grant contributes in the provision of quality MDR-TB diagnosis and treatment to all patients regardless of HIV status, age, gender, sexual orientation, or country of origin in both the civilian and penitentiary sectors. Four(4) objectives are identified to guide implementation of activities and these are a) to pursue high quality DOTS expansion and enhancement through improved case detection, quality- assured bacterialogy and treatment for basic TB, b) to address MDR/XDR-TB, TB/HIV and other challenges to making management and prevention of drug resistant TB a routine component of TB control, c) to empower people with TB and communities and provide continuum of patient-centred care through community-based systems and d) to enable and promote research on MDR/XDR-TB to develop national capacity for evidence generation that will inform national and international policy and practices. Twelve(12) SDAs guide the implementation of interventions and these are; improving diagnosis for timely diagnosis and treatment of TB in general but specifically MDR/XDR-TB; patient support which entails provision of psychological support, food packages, transportation to help patients to overcome the barriers to care; procurement and suppy management of second line drugs, monitoring and evaluation for impact measurement, management and supervision, training of health care workwers on MDR/XDR-TB/HIV, prevention, management and control of MDR/XDR-TB, address high risk groups, infection control to prevent transmission of TB in health care and congregate settings, Advocacy Communication and Social Mobilization, community TB care and operational research. The interventions of the grant are geared towards strengthening MDR/XDR-TB diagnosis and treatment follow up through establisment of second-line DST at the national TB reference laboratory, detecting and managing 2562 MDR-TB cases according to WHO/GLC protocols, increasing awareness of policy makers and general population on TB, HIV and MDR-TB through ACSM and building the national research capacity to implement programme-based operations research ROUND 8 TB PROGRAMMATIC PERFORMANCE The programmatic performance of the grant covers the period from October 2010 to September 2011 and is based on the service delivery areas IMPROVING DIAGNOSIS The aim of this SDA is to increase access to timely and quality diagnosis for treatment of TB in general but specifically MDR/XDR-TB. Two performance indicators are used to monitor performance under this SDA. 70

71 Service Delivery Area Improving diagnosis Improving diagnosis Indicator description # of second line DST tests performed locally % of laboratories showing adequate performance among those that received external quality assurance for smear microscopy Intended target by September 2011 Achieved results September % 75%(12) 3(33%) 25% Percentage achievement By september 2011, two MGIT 960 analyzers were procured to develop national capacity for second line DST. Howevever installation of these analyzers is still awaiting completion of the construction of the new Multipurpose National Laboratory, which has the TB National Reference Laboratory as an intergral component. In addition two laboratory technologist have already underwent training on second line DST. The officers will be responsible for performing the tests when the laboratory is operational. Caption: One of MGIT analyzers procured under the grant. The procuremnet of reagents and consumables to perform second line DST was planned to be procured in the current year but this was not done due delays in procurement processes. The procurement process were initiated towards the end of year1 and it is envisaged that in year 2 all the reagents and consumables for second line DST will be procured. 71

72 Currently PIH is providing assistance to the Ministry of Health and Social Welfare to have 2 nd line DST done at South Africa Medical Research Council laboratory in Pretoria with high turn around time of up to three months. The establishment of second line DST capacity in the country is intended to enable effective monitoring for 2 nd line drug resistance, early diagnosis of XDR-TB and initiation of treatment. During the reporting period, the target was perform 864 second line DST tests locally however performance to date on the indicator is zero(0%). The unsatisfactory performance is attributed to the delay towards the completion of the Multipurpose National Laboratoty where the DST will be performed. Efforts were made to strengthen the national quality assurance microscopy and culture services in the Laboratories. During the reporting period QA supervisory visits were conducted for eight laboratories by the lab department within MOHSW. Three(3) facilities showed adequate performance from the eight(8) that received supervision. These supervisory visists are intended to strengthen QA system for AFB microscopy and culture services. Furthermore five Light Emitting Diode microscopes were procured and distributed to high burdened districts namely Leribe (2), Mafeteng(1) and Maseru(2). These miscroscopes are meant to increase detection of infectious TB and reduce diagnostic delays and the expected outcomes includes sustenance TB case detection rate above 70%, improvement of treatment success rate to 85 % for newly detected smear positive cases and achieve at least 60% treatment success rate for MDR-TB cases. Caption: LED Microscopes were procured to speed-up work in high burden hospitals PATIENT SUPPORT The SDA endeavours to ensure that support is provided to all patients on MDR/XDR-TB treatment to encourage adherence to treatment. Performance is assessed based on one indicator. 72

73 Service Delivery Area Patient Support Indicator description # of MDR-TB patients receiving treatment adherence food packages Intended target by September 2011 Achieved results September % Percentage achievement During the reporting period 213 patients received treatment adherence food packages. The package of food consists of mealie meal (25 kg), Salt (5kg), sugar (5kg), full cream milk (500mg), Cooking oil (2L), peas and beans (2kg) and mabele, flour (10) kg. The food packages are aimed at ensuring that all patients adhere to treatment as required. The target was to reach 368 MDR-TB patients. Performance is still below the target due to the fact that enrolment of new patients is lower than projected number of patients. The MDR-TB/XDR TB treatment being a long therapy is normally plagued with many side effects which affect treatment adherence of many patients. Poverty and malnutrition are factors that make treatment more difficult to patients and families. Caption: Above are food package distributed to patients with MDR In addition temporary accommodation and transport reimbursement is provided for patients travelling long distances to the health facilities. By the end of September 2011, 187 patients were given transport fees and these are patients who come on monthly for follow up and routine check up. Transportation fare is provided to needy patients to enable them come for follow up at the hospital. The assistance is critical in ensuring that patients are able to attend follow up sessions continuously and consistently. Sixteen (16) of these patients were provided with accommodation due travelling long distance between home and the public facility PROCUREMENT AND SUPPLY MANAGEMENT This SDA endeavours to ensure un-interrupted supply of quality assured drugs and supplies for effective MDR/XDR-TB management. One indicator was used to measure performance under the SDA Service Delivery Area Indicator description 73 Intended target by September 2011 Achieved results September 2011 Percentage achievement Procurement # and % of units reporting no stock 85% 100% 118%

74 and supply management (second line drugs out of 2nd line anti-tb treatment drugs on the last day of the quarter During the reporting period there were no stock outs of 2 nd line anti-tb treatment drugs. In addition, The central MDR/XDR-TB pharmacy was refurbished to increase storage capacity. Medicines bags were not procured due to sufficient supply in stock in this period they will be procured in year two of the grant MONITORING AND EVALUATION By September 2011, Six (6) desk top computers and six printers were procured. These computers are intended to strengthen routine MDR-TB surveillance system. The computers are to be distributed to the three regional MDR-TB wards namely, Motebang, Mohale s Hoek and Mokhotlong Hospitals when construction work on these facilities has been completed. Currently the TB Officers are using TB Register.net to record data TB patients and report and report it to the next level. This software is installed on computers in the public hospitals and DHMTS. The TB Officers at the facility level enter data and TB Coordinators view and run reports for their respective districts. The intervention constitutes an important development towards building the monitoring and evaluation capacity at the facility and district level MANAGEMENT AND SUPERVISION The main aim of the SDA is to ensure quality TB/HV care including MDR/XDR-TB through improving health workers knowledge, efficiency and motivation through routine supervision. One indicator was used to guide implementation of activities Service Delivery Area Management and supervision Indicator description Number of supervisory visits conducted out of planned for the period Intended target by September 2011 Achieved results September % Percentage achievement By September 2011 the NTP program in collaboration with Laboratory department was able to carry out 10 supervisory from the 40 that were planned. The main reason for the low performance is attributed to other competing activities that are implemented by the Laboratory department. As part of strengthening national TB programme management on MDR-XDR-TB, essential positions were filled under the grant. A TB Advisor was engaged from 01 st September The Advisor will strengthen NTP S technical and managerial capacity, support to the GFATM grant processes, 74

75 oversee the MDR-TB programme, support TB laboratories activities, participate in resource mobilization for the programme, support to NTP policy, strategy and M&E system. An additional Programme officer was engaged on the 01 st July The Programme officer main duties include overseeing the effective implementation and coordination of all components of the Global Fund R6 and R8 TB activities. A TB/HIV Medical Officer has been engaged since August 2011 to be the focal point for TB/HIV at central level. Five Drivers have also been engaged since September Two drivers are assisting PIH, to transport officers during support supervision to the districts. The other three drivers are allocated in other departments within the Ministry Of Health and Social Welfare. The recruitment of Medical officer for Central MDR/XDR TB Hospital, four Nurses and four Nurse Assistants could not be done due under budgeting on human resource. The Ministry took a decision to reprogramme the funds for refurbishment of the three regional MDR/TB wards. The reprogramming was approved by the Global Fund. The renovation for three regional wards (Leribe, Mohale s hoek and Mokhotlong hospitals) is scheduled to be completed by September 2012 when phase 1 of the Grant ends. The renovation entails expansion of rooms where MDR-TB services are provided. By September 2011, six meetings were held to strengthen programme coordination and accelerate implementation of activities under the grant. Three district meetings were held in Mafeteng, Leribe and Berea. The three districts were identified as hot spots districts in terms of reduced notification rates and poor treatment outcomes, the rationale to hold these meetings was to discuss the underlying factors for the poor performance and to draw action plans for remedial actions. The fourth meeting was with all GFATM TB implementing partners, the main objective of the meeting was to discuss implementation and find ways to identify bottle necks that might impact on the implementation of the grant. The fifth meeting was with all TB technical partners and the main objective of the meeting was to strengthen partnership and discuss any updates within the National TB Programme. The sixth meeting was held with the Private Practitioners, the main objective of the meeting were to discuss ways to improve the treatment outcomes and ways to improve on TB medicines management in their facilities HUMAN RESOURCES DEVELOPMENT The SDA strives to ensure the availability of competent and motivated programme staff to effectively deliver quality TB/HIV services including MDR/XDR-TB. One indicator was identified to monitor implementation of activities under this SDA Service Delivery Area Human Resources Development Indicator description # of health care workers trained on MDR/XDR-TB/HIV management Intended target by September 2011 Achieved results September % Percentage achievement During the reporting period, 21 health care workers were reached with training under the grant. The training focused on MDR/XDR TB Management, TBHIV Management, Intensified Case Finding, Isoniazid Preventive Therapy and Infection Control. 75

76 In addition, training was conducted in Berea District for 35 uniformed staff (Correctional Service staff, Police Officers and Military Personnel). The main Objective of the training was to equip the uniformed staff with knowledge about TB, TBHIV and MDR-TB and the training focused mainly on the following topics, definition of TB, Mode of spread, Signs and symptoms, roles of a DOTS Supporter health education in TB Management, MDR/XDR TB and TB/HIV Co Infection MDR-TB: PREVENT, MANAGE AND CONTROL MDR/XDR-TB The specific objective of the SDA is to prevent deaths from TB/HIV co-infection and interrupt transmission of drug resistant forms of TB. One indicator was identified to guide implementation of activities under this SDA Service Delivery Area MDR-TB Indicator description # and % of laboratory confirmed MDR-TB patients enrolled in 2nd line anti-tb treatment Intended target by September 2011 Achieved results September % Percentage achievement By September 2011, the number of laboratory confirmed MDR-TB patients enrolled in 2 nd anti-tb treatment was only 4 and the target was to put 368 on treatment. The low performance has been attributed to delay on the completion of the new Multipurpose National Laboratory in Lesotho where both culture and DST will be performed. The targets were done based on the assumption that the new laboratory will be operational by Currently PIH is providing assistance to the Ministry of Health and Social Welfare to have 2 nd line DST done at South Africa Medical Research Council laboratory in Pretoria with high turn around time of up to three months which is quite a long period. Two MGIT 60 analyzers were procured during the reporting period and awaiting installation on the new facility once completed. In addition two officers who will be responsible for the undertaking the DST have already received training. In addition, basic equipment (29 weighing scales, 29 thermometers and 29 BP apparatus) were procured and distributed to the 17 hospitals for basic TB and MDR/XDR-TB management. The regular laboratory monitoring tests that are performed on all enrolled MDR/XDR-TB patients, include full blood count (FBC, Electrolytes especially potassium (K+), Urea and serum Creatinine, Liver function tests (LFTs) and Thyroid function tests). 76

77 ADDRESS HIGH RISK GROUPS The SDA aims to increase access high quality MDR/XDR-TB prevention and care services to high risk groups such as migrant workers and prisoners. Two indicators were used to monitor performance under the SDA. Service Delivery Area High groups High groups risk risk Indicator description % of prisoners screened for Tuberculosis # of contacts of smear positive miners and ex-miners screened for TB Intended target by September 2011 Achieved results September 2011 NA NA NA % Percentage achievement Prisoners constitute high risk groups since they are in congregate settings. The Lesotho Correctional Service has thirteen (13) health centres within its institutions and prisoners are already being screened for TB within the LCS health facilities. During the reporting period it was planned that 288 contacts of smear positive miners and ex-miners were going to be screened or TB. By the end of September 2011 result reported under the indicator was zero. The PR requested the Global Fund to modify the indicator after it was established that data for the indicator would not be available. In addition it was also found out that all the activities to be implemented focussing miners and ex-miners were not contributing to the indicator. However as Part of accelerating implementation of activities under the SDA, ICAP was identified as Sub-Sub Recipient to the GF R8 TB Grant. The activities they are implementing include; undertaking stakeholders consultation meetings on high risk groups (Prisons, Workplace, detention units), Conduct mapping of MDR/XDR-TB in miners and ex-miners. Undertaking field visits for mapping activity and holding a dissemination workshop INFECTION CONTROL The SDA aims to prevent transmission of TB in health care and congregate setting. The infection control requirements are high due to the high burden of both TB and HIV. Performance under the SDA is monitored through one indicator. Service Delivery Area Infection Control Indicator description % Of health facilities with functional infection control procedures for TB transmission according to National Policy Intended target by September 2011 Achieved results September 2011 Percentage achievement 50% 100% 150% By the end of September 2011 all the 18 (100%) hospitals had functional infection control procedures for TB according to the National Policy. Despite the good performance on the indicator some 77

78 activities under the SDA were not implemented by the end of year one of the grant. These included group meetings to develop national infection control guidelines, contracting of consultant for development of infection control policy and printing of the infection control guidelines. MOHSW took a decision to make ICAP Sub-Sub Recipient to the GF R8 TB Grant to carry out these activities as an endeavour to accelerate implementation. During the reporting period some equipment for infection control was procured and these included 1100 waste sharp disposal containers which were distributed to Botshabelo MDR/XDR-TB Programme and TB central Laboratory. These waste sharp disposal containers are used at the MDR/XDR TB Clinic and Central TB Laboratory to minimize the risk of infection. Equipment that was not procured in year one included eight(8) ventilation system with HEPA filtration that are to be installed in bot sabelo hospital and the three regional centres, N95 or N100 respirators for doctors, nurse, ancillary staff and CHW, 10 UV lights, N95 and 3600 N100 masks. All these equipment will be procured in year 2 of the grant ACSM (ADVOCACY COMMUNICATION AND SOCIAL MOBILIZATION) The main purpose of the SDA is to engage society and community at large in TB control and provide treatment nearer to the patient s home. One performance indicator was identified to guide implementation of activities. Service Delivery Area ACSM Indicator description Number of advocacy meetings held out of the planned Intended target by September 2011 Achieved results September % Percentage achievement One meeting was held on the 09 th March 2011 through Health Education Division for Correctional Services personnel. The objective of these meetings is to discuss infection control in congregate setting like prisons, MDR/XDR TB and TBHIV management. A Consultant to support Health Education Division in designing IEC messages for MDR/XDR- TB/HIV has been deferred and will be recruited in Year 2. The IEC material will be written in local language( Sesotho). The IEC material will be disseminated during the outreach programmes at the community level COMMUNITY TB CARE The SDA endeavours to promote patient centred continuum of care at the community level. Provision of treatment support at the community level is critical and community health workers form the cornerstone of the community based MDR/XDR-TB treatment programme. Two performance indicators are utilized to monitor performance under the SDA. Service Delivery Area Community TB care Indicator description # of treatment supporters trained on MDR/XDR-TB/HIV care Intended target by September 2011 Achieved results September % Percentage achievement 78

79 Community TB care # of community treatment supporters receiving incentives % During the period under review 57 treatment supporters were equipped with skills to support MDR Patients, a 7% of the intended target. The low performance on the indicator is attributed to underreporting on trainings that were conducted as well as delayed implementation of the trainings. The performance is expected to improve in year two of the grant. The training of treatment supporters is an important part of the MDR/XDR-TB programme since they are oriented to provide adherence support to MDR/XDR-TB patients while on treatment. The training also includes basic treatment of MDR-TB, the early identification of potentially life-threatening adverse events, and the treatment of common adverse events. Because of the high rate of HIV co-infection among patients with MDR-TB, the treatment supporters also receive training in the delivery of HIV care and the identification of other illnesses. Caption: Community treatment supporters at Botsabelo central MDR and on the left treatment supporters receive training facilitated by PIH. By September 2011, 205 community treatment supporters were receiving incentives and this constituted 56% of the intended target. The low performance is attributed to the low number of patients currently on MDR-TB treatment. The actual number MDR/XDR-TB patients enrolled in treatment is lower than the projected targets under the grant and according to the MDR/XDR TB programme one treatment supporter looks after one patient. The treatment supporters complement the efforts of physicians and nurses as extension of the health care services providers at the community level. Part of their responsibilities include accompanying patients for routine monthly check ups, assisting the patient to take medication as prescribed from the health facility OPERATIONAL RESEARCH The SDA focuses on creating a system for guiding programme performance through collection of reliable and accurate data on TB management in Lesotho. One indicator is used to monitor implementation of activities under this SDA. 79