Healthcare workers' views on decentralized primary health care management in Lesotho: a qualitative study.

BACKGROUND: Lesotho experienced high rates of maternal (566/100,000 live births) and under-five mortality (72.9/1000 live births). A 2013 national assessment found centralized healthcare management in Ministry of Health led to fragmented, ineffective district health team management. Launched in 2014 through collaboration between the Ministry of Health and Partners In Health, Lesotho's Primary Health Care Reform (LPHCR) aimed to improve service quality and quantity by decentralizing healthcare management to the district level. We conducted a qualitative study to explore health workers' perceptions regarding the effectiveness of LPHCR in enhancing the primary health care system. METHODS: We conducted 21 semi-structured key informant interviews (KII) with healthcare workers and Ministry of Health officials purposively sampled from various levels of Lesotho's health system, including the central Ministry of Health, district health management teams, health centers, and community health worker programs in four pilot districts of the LPHCR initiative. The World Health Organization's health systems building blocks framework was used to guide data collection and analysis. Interviews assessed health care workers' perspectives on the impact of the LPHCR initiative on the six-health system building blocks: service delivery, health information systems, access to essential medicines, health workforce, financing, and leadership/governance. Data were analyzed using directed content analysis. RESULTS: Participants described benefits of decentralization, including improved efficiency in service delivery, enhanced accountability and responsiveness, increased community participation, improved data availability, and better resource allocation. Participants highlighted how the reform resulted in more efficient procurement and distribution processes and increased recognition and status in part due to the empowerment of district health management teams. However, participants also identified limited decentralization of financial decision-making and encountered barriers to successful implementation, such as staff shortages, inadequate management of the village health worker program, and a lack of clear communication regarding autonomy in utilizing and mobilizing donor funds. CONCLUSION: Our study findings indicate that the implementation of decentralized primary health care management in Lesotho was associated a positive impact on health system building blocks related to primary health care. However, it is crucial to address the implementation challenges identified by healthcare workers to optimize the benefits of decentralized healthcare management.

Effects of primary healthcare reform on routine health information systems (RHISs): a mixed-methods study in Lesotho.

BACKGROUND AND OBJECTIVE: The Ministry of Health of Lesotho and Partners In Health piloted the Lesotho National Primary Health Care Reform (LPHCR) from July 2014 to June 2017 to improve quality and quantity of service delivery and enhance health system management. This initiative included improvement of routine health information systems (RHISs) to map disease burden and reinforce data utilisation for clinical quality improvement. METHODS AND ANALYSIS: The WHO Data Quality Assurance framework's core indicators were used to compare the completeness of health data before versus after the LPHCR in 60 health centres and 6 hospitals across four districts. To examine change in data completeness, we conducted an interrupted time series analysis using multivariable logistic mixed-effects regression. Additionally, we conducted 25 key informant interviews with healthcare workers (HCWs) at the different levels of Lesotho's health system, following a purposive sampling approach. Interviews were analysed using deductive coding based on the Performance of Routine Information System Management framework, which inspected organisational, technical and behavioural factors influencing RHIS processes and outputs associated with the LPHCR. RESULTS: In multivariable analyses, trends in monthly data completion rate were higher after versus before the LPHCR for: documenting first antenatal care visit (adjusted OR (AOR): 1.24, 95% CI: 1.14 to 1.36) and institutional delivery (AOR: 1.19, 95% CI: 1.07 to 1.32). When discussing processes, HCWs highlighted the value of establishing clear roles and responsibilities in reporting under a new organisational structure, improved community programmes among district health management teams, and enhanced data sharing and monitoring by districts. CONCLUSION: The Ministry of Health had a strong data completion rate pre-LPHCR, which was sustained throughout the LPHCR despite increased service utilisation. The data completion rate was optimised through improved behavioural, technical and organisational factors introduced as part of the LPHCR.

High HIV prevalence and associated factors in Lesotho: Results from a population-based survey.

Despite extensive global efforts, sub-Saharan Africa remains disproportionately affected by the HIV epidemic. This generalized epidemic can be seen in Lesotho which in 2014 the HIV prevalence rate of those aged 15-49 years was 24.6%, with and incidence of 1.9 new infections per 100-person-year exposures. To better understand the impact of Lesotho's national HIV response and significant predictors associated with HIV infection, the Lesotho Population-based HIV Impact Assessment was conducted. This survey provided a nationally representative sample of individuals aged 15-59 years old in which participants were tested for HIV and given an individual questionnaire that included socio-demographic and behavioral risk questions. The association of factors between survey questions and HIV incident was assessed using logistic regression. Multivariate logistic regression models for men and women were constructed for each outcome using variables known to be or plausibly associated with recent or chronic infection. Overall annualized incidence among people aged 15-49 was 1.19% (95% CI 0.73-1.65) per year. The overall prevalence of HIV was 25.6% with women having significantly higher prevalence. Multiple variables, including decreased wealth status, lower education levels, marital status, condom use at first sex, and circumcision (men only) were identified as being significantly associated with HIV infection for both men and women. In combination with improving the awareness of HIV status, an increased focus is needed on AGYW and men 35-49 years old to prevent new infections. HIV education and prevention programs should focus heavily on younger age groups prior to and soon after sexual debut to prevent HIV transmission. The findings of the survey showed significant room for improvement in increasing awareness of HIV status and reinforcing the need for continued HIV prevention and treatment efforts in Lesotho to prevent new infections.

Improving Sampling Efficiency for Determining Pediatric HIV Prevalence in National Surveys: Evidence From 8 Sub-Saharan African Countries.

BACKGROUND: Measurement of mother-to-child HIV transmission through population-based surveys requires large sample sizes because of low HIV prevalence among children. We estimate potential improvements in sampling efficiency resulting from a targeted sample design. SETTING: Eight countries in sub-Saharan Africa with completed Population-based HIV Impact Assessment (PHIA) surveys as of 2017. METHODS: The PHIA surveys used a geographically stratified 2-stage sample design with households sampled from randomly selected census enumeration areas. Children (0-14 years of age) were eligible for HIV testing within a random subsample of households (usually 50%). Estimates of child HIV prevalence in each country were calculated using jackknife replicate weights. We compared sample sizes and precision achieved using this design with a 2-phase disproportionate sample design applied to strata defined by maternal HIV status and mortality. RESULTS: HIV prevalence among children ranged from 0.4% (95% confidence interval: 0.2 to 0.6) in Tanzania to 2.8% (95% confidence interval: 2.2 to 3.4) in Eswatini with achieved relative standard errors between 11% and 21%. The expected precision improved in the targeted design in all countries included in the analysis, with proportionate reductions in mean squared error ranging from 27% in Eswatini to 61% in Tanzania, assuming an equal sample size. CONCLUSIONS: Population-based surveys of adult HIV prevalence that also measure child HIV prevalence should consider targeted sampling of children to reduce required sample size, increase precision, and increase the number of positive children tested. The findings from the PHIA surveys can be used as baseline data for informing future sample designs.

Correlates of HIV infection in adolescent girls and young women in Lesotho: results from a population-based survey.

BACKGROUND: HIV acquisition remains high among adolescent girls and young women (AGYW, aged 15-24 years) in sub-Saharan Africa. We aimed to estimate prevalence and incidence of HIV in AGYW and to identify correlates of HIV infection by using data from the Lesotho Population-based HIV Impact Assessment (LePHIA). METHODS: LePHIA was a nationally representative survey of adults and children based on a multistage cluster sampling method with random selection of enumeration areas and households. All adults aged 15 years and older who had slept in the household the night before were eligible for participation; participants completed an interview and HIV testing. We estimated incidence with the HIV-1 limiting antigen avidity enzyme immunoassay combined with viral load and examined the association between demographic and behavioural variables (including characteristics of cohabitating mothers and sexual partners, when available) and prevalence and incidence among AGYW using logistic regression, incorporating survey weights. FINDINGS: We interviewed 8824 households, including 2358 AGYW who were tested for HIV infection. Weighted HIV prevalence was 11·1% (95% CI 9·7-12·5) in the overall population (273 of 2358 AGYW), 5·7% (4·1-7·2) in adolescent girls aged 15-19 years (64 of 1156), and 16·7% (14·4-19·0) in women aged 20-24 years (209 of 1212). Annualised HIV incidence was 1·8% (0·8-2·8). Correlates of prevalent infection include reporting a history of anal sex (adjusted odds ratio [aOR] 3·08, 1·11-8·57), having lived outside Lesotho in the past year (1·86, 1·01-3·42), having a partner suspected or known to be HIV positive (11·7, 6·0-22·5), and having two or more lifetime sexual partners (1·84, 1·21-2·78, for 2-3 lifetime sexual partners; 2·44, 1·45-4·08, for ≥4 lifetime sexual partners). For the 570 AGYW living with their mothers, maternal education was negatively associated with HIV prevalence in their daughters (aOR 0·36, 0·15-0·82, per increase in level attended). For AGYW with a cohabitating partner, the factors associated with AGYW infection were partner age (OR 4·54, 1·30-15·80, for partners aged 35-49 years, although the OR was no longer significant when adjusted for HIV status of partner), HIV status (aOR 11·22, 4·05-31·05), lack of viral load suppression (OR 0·16, 0·04-0·66), and partner employment in the past year (aOR 3·41, 1·12-10·42). INTERPRETATION: The findings confirm the importance of improving the treatment cascade in male partners and targeting preventive interventions to AGYW who are at increased risk. A regional approach to prevention could mitigate the effect of migration on transnational spread of HIV. FUNDING: President's Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention.

Difficulties facing healthcare workers in the era of AIDS treatment in Lesotho.

Sub-Saharan Africa is most affected by the AIDS pandemic and Lesotho is no exception. In many countries, healthcare workers are at the forefront of the fight against AIDS. This study explores the difficulties facing healthcare workers in Lesotho using a combination of qualitative methods--focus group discussions and in-depth interviews. The findings suggest that healthcare workers are afraid of contracting HIV from their patients and this affects their delivery of services. In addition, the results revealed that poor infrastructure and shortage of supplies at the facilities hinder healthcare workers from performing their duties effectively. The other concern was the heavy workload and severe time constraints which puts enormous stress on healthcare workers. Stigma and discrimination emerged as major problems for healthcare workers. Addressing the challenges facing healthcare workers is essential in effectively managing the AIDS pandemic facing the continent.