KINGDOM OF LESOTHO
REPORT ON THE QUALITY AND RESPONSIVENESS OF HEALTH SERVICES TO MEET THE NEEDS OF WOMEN IN CRISIS SETTINGS
CONDUCTED BY DR. MPOLAI MASAILA MOTEETEE
WHO JUNE, 2005
MMM Lesotho June 20005 i
Acknowledgements
I would like to foremost thank the Honourable Minister of Health and Social Welfare as well as the Management of the Ministry of Health and Social Welfare for allowing the study to go on as well as including some of the government health facilities in the study. My gratitude also goes to the Management of the Christian Health Association of Lesotho, for also allowing us to include their facilities in the assessment. To the District Secretaries of Maseru, Mokhotlong and Quthing, without whose support fieldwork would not have been possible I extend my deepest words of appreciation. The Chiefs of the involved villages were especially co-operative and flexible despite the short notice, to allow us entry and facilitate our village visits; I am thankful for their support.
The women (and some men) included in the sample, focus group discussions, key informant as well as exit interviews, were very patient and understanding; I thank them for their willingness to provide the entailed information. A special word of appreciation is extended to the Chairperson Ms. Ntilo Matela (May Her Soul Rest in Peace), and Members of PLOWA for their decision to share their experiences with us.
To the health workers who despite their busy schedule, spared time to hold discussions with us as well as organizing focus groups, I congratulate them for their willingness to serve and interest in the welfare of women of this country.
I also extend my appreciation and thanks to the Sampling Expert as well as the Programmer for their support; without you, this study would have not been what it is.
I thank the Supervisor and Interviewers for their dedication and understanding. Let us hope that, through you, more information will be available for decision making towards improved care and support of women in Lesotho. . As part of a regional study, let us hope that Lesotho’s contribution will add value to the objectives.
I also thank and express my appreciation to all the UN agency, bilateral partners, and NGO officers who spared their time to share information with me. My appreciation goes to the WR and the WHO Lesotho team for their support and encouragement. I am grateful to WHO Geneva for affording me the opportunity to lead this study in Lesotho.
I extend a special word of gratitude to the Honourable First Lady Mrs. ‘Mathato Mosissili and the Honourable Minister of Gender and Youth, Sports and Recreation Mrs. “Mathabiso Lepono, for finding time in their busy schedules to respond to my questions.
Finally yet importantly, I thank my husband, daughter, niece and nephew for their support and inspiration.
MMM Lesotho June 20005 ii
Table of Contents
Item Page i. Acknowledgements i ii. Table of Contents ii - vi iii. List of Tables and Figures vii - ix iv. Acronyms x - xi v. Concepts and Definitions xii - xiii vi. Executive Summary xiv - xxi
Chapter 1. Introduction 1 - 6
1.1 Background 1 - 5 1.2 Objectives of the Study 5 1.3 Structure of the Report 5 - 6
Chapter 2. Literature Review 6 - 15
Chapter 3. Methodology 15 - 17
3.1 Sampling 15 - 16 3.1.1 Probability Sampling Techniques 15 3.1.2 Stratification 15 3.1.3 Sample Size Determination 15 - 16
3.2 Description of Data Collection Methods 16 - 17
3.3 Data Processing and Analysis 17
3.4 Limitations of the Study 17
Chapter 4: Key Findings on Constraints and 18 - 48 Challenges to Women’s Access to Health and Basic Services
Community Level 18 - 33
4.1 Economic Factors and Impact of Health 18 - 23
MMM Lesotho June 20005 iii Care Financing
4.1.1 Affordability of Services 18 - 19
4.1.2 Penalties for Non-payment 19 - 20
4.1.3 Perception of Women of the Magnitude of Food 20 - 21 Insecurity and on Factors Contributing
4.1.4 Women’s Occupations and Level of Education 21
4.1.5 Opportunities Available for Women for Gainful 22 Employment
4.1.6 Women’s Capacity to Decide on Resource 22 - 23 Allocation
4.2 Socio-cultural factors 23 - 26
4.2.1 Socio-cultural Norms that Discourage or Inhibit 23 Health Services Utilization
4.2.2 Available Social/Legal Systems for Protection 23 - 26 of Women Against Sexual and Gender Based Violence
4.3 Physical Access Barriers 26 – 33
4.3.1 Average (mean) Distance to Nearest Health Centre 26 - 27
4.3.2 Average (mean) Distance to Nearest First Referral 27 - 28 Hospital
4.3.3 Average (mean) Distance to a Referral Health Facility 28 Offering Emergency (including surgical) Obstetric Services
4.3.4 Availability of Ambulance Services for Emergency 28 Obstetric Cases
4.3.5 Affordability of Ambulance Services 28
4.3.6 Average (mean) Waiting Time for Ambulance Services 28
4.3.7 Availability of Systems or Community Mechanisms 29 for the Provision of Transport for Emergency Cases
4.3.8 Range and Quality of Health/Social Services Available 29- 30
MMM Lesotho June 20005 iv to Women and Girls at Community Level
4.3.9 Proportion of Women who have Accessed Family 30 Planning Services
4.3.10 Availability of Trained Community Health Workers 31 or Volunteers
4.3.11 Access to Sanitary Facilities 31
4.3.12 Access to Safe Water Supply 32
4.3.13 Access to Food aid 32 - 33
National Level 33 - 38
4.4 Factors Related to National Health System 33 - 38 and Policies
4.4.1 Impact of Financial Resource Allocation Criteria 33 on the Quality and Availability of Services for Women 4.4.2 Effects of SWAP on the Quality of Women’s Health 33 Services
4.4.3 How the Issues of Contracting out Health Services 34 Affect the Quality and Availability of Service Relating to Women’s Health
4.4.4 Effect of Policies on Eligibility for Health Services 34
4.4.5 Effect of Policies on Eligibility for Exemption to User 34 Fees Payment on Women’s Access to Health Services
4.4.6 Fora (forum) for Participation (or voice) of Women 35 Concerning Issues Pertaining to Service Delivery including Women Living with AIDS
4.4.7 Availability of National For a (forum), Deliberate 35 Policies and/or Monitoring Bodies to Address Ills that Affect Women’s Health
4.4.8 Effectiveness of Statutory, Customary, and By-laws 36 - 37 Enforcement Meant to Offer Legal, Physical, and Social Protection to Women and Girls
4.4.9 Availability of Civic Education on Women’s (human) 37
MMM Lesotho June 20005 v Rights Related to Sexual and Gender Based Violence and Gender Related Inequalities
4.4.10 Access to Legal Representation in Matters Related to 37 Sexual and Gender Based Violence
4.4.11 Availability of National Policies, Guidelines and 37 - 38 Protocols for the Prevention, and Management of Sexual and Gender Based Violence Victims
4.4.12 Availability of Health Information Management Systems 38 that Capture Data for the Comprehensive Monitoring and Evaluation of the Status of Women’s Health Services including Sexual and Gender Based Violence (in addition to maternal morbidity and mortality records)
Facility Level 38 - 48
4.5 Factors Relating to Service Delivery Level 38 - 48 (policies, strategies and resources)
4.5.1 Existing Referral Service Policies that Prevent Women 38 - 39 from accessing Health Services 4.5.2 Barriers in accessing Health Services Pertaining to Opening 39 - 40 and Closing time
4.5.3 Health Facility Basic Infrastructure, Logistics And 40 Environment Embracing Concerns associated with
4.5.3.1 Availability of Privacy and Confidentiality 40 4.5.3.2 Availability of Life Saving Drugs 40 - 41 4.5.3.3 Availability of Basic Equipment 41 4.5.3.4 Availability of Sanitary Facilities 41 - 42 4.5.3.5 Availability of Communication Mechanism 42
4.5.4 Availability of, and Access Issues Related to Diagnostic 42 - 43 Facilities and Services
4.5.5 Availability of IEC Services such as HIV/AIDS 43
4.5.6 Scope and Quality of Health Services 44 - 45
4.5.7 Response of Health Care Providers to Socio-cultural Norms 45 - 46
4.5.8 Availability of Psycho-Social Counselling, Mechanisms 46 for Confidential Complaints and Other Support Services
MMM Lesotho June 20005 vi for Victims of Gender-Based Violence
4.5.9 Availability of Policies, Guidelines and Protocols for the 46 Prevention, and Management of Sexual and Gender-Based Violence Victims
4.5.10 Availability of Human Resources 46 - 47
4.5.11 Inhibition of Access due to Ills Pertaining to Health 47 Workers’ Attitudes
4.5.12 Availability of Health Information Management 47 - 48 Systems (HIMS) that capture Data for Monitoring and Evaluation of the Status of Women’s Health Services in Totality including Gender Based Violence
4.6 Observations and Conclusions 48 - 52
Chapter 5: Organizations Providing Health and Basic Social 53 - 54 Services to Women
Chapter 6: Recommended Components of a Health Assessment 55 - 56 Instrument that would be Considered Locally Relevant and Useful
Chapter 7: Recommendations for Action to Increase Women’s 57 - 60 Access to Health and Related Basic Social Services, in the Specific National Context
Chapter 8: References 61 - 63
Chapter 9: Appendices 64 - 87
9.1 Questionnaires 64 - 66 9.2 Tables and Figures 67 - 87 9.3 Other Relevant Materials 87
MMM Lesotho June 20005 vii
List of Tables and Figures
1) Tables on Respondents to structured Questionnaires
Table Number Title
1 Distribution of women by marital status 2 Distribution of women by urban and rural abode 3 Distribution of women by marital status 4 Distribution of women by school attendance 5 Distribution of women by level of education 6 Cross tabulation of women by level of education and ecological zone 7 Cross tabulation of women by urban/rural abode and level of education 8 Distribution of women by age 9 Distribution of women by employment status 10 Cross tabulation of women by employment status and ecological zone 11 Cross tabulation of women by employment status and urban/rural abode 12 Cross tabulation of women by age and employment status 13 Cross tabulation of women by level of education and employment status 14 Cross tabulation of women by level of education and type of employment 15 Cross tabulation of women by level of education and who decides on how money should be used in the family 16 Cross tabulation of women by their age and who decides on how money should be used in the family 17 Cross tabulation of women by occupation and who decides on how money should be used in the family 18 Cross tabulation of women by ecological zone and who decides on income use 19 Cross tabulation of women by urban/rural abode and who decides on income use 20 Distribution of women by income per month 21 Distribution of women by source of food 22 Cross tabulation of women by ecological zone and main source of food 23 Cross tabulation of women by urban/rural abode and main source of food 24 Distribution of women by their choice of where to seek care
MMM Lesotho June 20005 viii 25 Cross tabulation of women by ecological zone and where they usually go first to seek health care 26 Cross tabulation of women by urban/rural abode and where they usually go first to seek health care 27 Distribution of women by their choice of where to seek emergency pregnancy care 28 Cross tabulation of women by ecological zone and where they first seek emergency pregnancy care 29 Cross tabulation of women by urban/rural abode and where they first seek emergency pregnancy care 30 Distribution of women by reasons why they are not able to access services 31 Distribution of women by their knowledge/perception on service availability 32 Distribution of women by their experience of violence 33 Cross tabulation of women by perpetrator and type of violence. 34 Cross tabulation of women’s experience of the outcome of reporting violence by who the violence was reported to 35 Distribution of women’s response to witnessing a rape by who they would report to 36 Cross tabulation of women by witnessing rape of a family member by ecological zone and who they would report the rape to 37 Cross tabulation of women on witnessing rape of a family member by urban/rural abode and who they would report the rape to 38 Distribution of women’s mode of travel to health facilities 39 Distribution of the duration of women’s travel to health centre 40 Cross tabulation of women by ecological zone and duration to get to the nearest health facility 41 Cross tabulation of women by urban/rural abode and duration to get to the nearest health facility 42 Distribution of duration of women’s travel to hospital 43 Cross tabulation of women by ecological zone and duration to the nearest hospital 44 Cross tabulation of women by urban/rural abode and duration to the nearest hospital 45 Distribution of women by contraceptive method use 46 Cross tabulation of women’s use of Family Planning by ecological zone 47 Cross tabulation of women’s use of family planning by urban/rural abode 48 Distribution of women by source of family planning methods
MMM Lesotho June 20005 ix 49 Distribution of women by how they disposed of household solid and liquid waste 50 Cross tabulation of women’s disposal of solid waste by ecological zone and where waste was disposed 51 Cross tabulation of women’s disposal of liquid waste by ecological zone and where waste was disposed 52 Cross Tabulation of women’s disposal of solid waste by urban/rural abode and where waste was disposed 53 Cross tabulation of women’s disposal of liquid waste by urban/rural abode and where waste was disposed 54 Distribution of women by household possession of a toilet 55 Cross tabulation of household possession of a toilet by ecological zone 56 Cross tabulation of possession of a household toilet by urban/rural abode 57 Distribution of women by source of drinking water 58 Cross tabulation of source of drinking water by ecological zone and source 59 Cross tabulation of source of drinking water by urban/rural abode and source
2) Tables on Facility Interviews and Inspection
60 Distribution of health facilities by their normal opening hours 61 Distribution of health facilities by their opening outside normal hours 62 Distribution of health facilities by services offered 63 Distribution of health facilities by availability of emergency supplies stocks in hand 64 Distribution of health facilities by laboratory and other investigations services offered
MMM Lesotho June 20005 x
Acronyms
AIDS Acquired Immune Deficiency Syndrome ARV Anti Retro Viral BCC Behavioural Change Communication BOS Bureau of Statistics BSS Behavioural Surveillance Survey CBD Community Based Distribution CEDAW Convention on the Elimination of All Forms of Discrimination Against Women CHAL Christian Health Association of Lesotho CHBC Community Home Based Care CHWs Community Health Workers CWIQ Core Welfare Indicator Questionnaire CMR Child Mortality Rate CPR Contraceptive Prevalence Rate CSWs Commercial Sex Workers DATFs District Aids Task Forces DCI Development Cooperation Ireland DFID Department For International Development DHP District Health Package DHPS Department of Health Planning and Statistics DS District Secretary EOC Emergency Obstetric Care ESP Essential services Package FGDs Focus Group Discussions FP Family Planning GBV Gender Based Violence GNP Gross National Product GOL Government of Lesotho HBC Home Based Care HIV Human Immuno Virus HSA Health Service Area HTC HIV Testing and Counselling IGAs Income Generating Activities ILO International Labour Organisation IMO International Labour Migration IMR Infant Mortality Rate KIIs Key Informant Interviews LAPCA Lesotho AIDS Programme Co-ordinating Authority LB Live Births LBTS Lesotho Blood Transfusion Services LPPA Lesotho Planned Parenthood Association MCH Maternal and Child Health
MMM Lesotho June 20005 xi MDGs Mid-Decade Goals MOEL Ministry of Employment and Labour MOFDP Ministry of Finance and Development Planning MOHSW Ministry of Health and Social Welfare MTCT Mother to Child Transmission NGOs Non-Governmental Organisations OPD Outpatient Department PLWAs People Living With AIDS PMTCT Prevention of Mother to Child Transmission PRSP Poverty Reduction Strategy (Paper) PSCAAL Public Sector Coalition Against AIDS in Lesotho QE II Queen Elizabeth II RH Reproductive Health RSA Republic of South Africa SADC Southern African Development Council SH Sexual Health STI Sexually Transmitted Infections TBA Traditional Birth Attendant TEBA The Employment Bureau for Africa UNAIDS Joint United Nations Programme on HIV/AIDS UNCT United Nations Country Team UNICEF United Nations Children’s Fund UNFPA United Nations Fund for Population Activities USA United States of America USAID United States Agency for International Development VCT Voluntary Counselling Testing VHW Village Health Worker WHO World Health Organisation WLSA Women and Law in Southern Africa
MMM Lesotho June 20005 xii Concepts and Definitions
Aunt A woman usually older than the respondents who is a sibling of one of the respondent’s parents
Basotho Citizens of Lesotho regarded as indigenous to the country
Burial Society Organized group of community members with guiding rules and office bearers formed to cater for decent burial of the members’ family including in-laws
Chieftainess The wife of a Chief; acts as regent while the first son is still too young to rule following the death of her husband
Chobeliso Abduction of a girl for marriage either by consent of the girl or by force
Community Health An individual trained as a Village Health Worker or/and Worker Traditional Birth Attendant
Community Based A Village Health Worker further trained in Distributor and supplying Contraceptive Methods at village Level
Health Service Area Health district defined as per the set out catchment area not necessarily respecting government administrative districts
Key Informant A recognized member of a community, organization or institution acknowledged to be the authority whose opinions most likely represent and reflect those of the larger entity; an opinion leader
Maluti The currency of Lesotho; the mountain ranges that characterize the country
Mourning A period prescribed by the man’s family post his death during the bereaved wife wears special recognizable clothing that she has lost a spouse. Period duration may also relate to the season of death; the usual period for cessation is beginning or during winter. At the end, the woman then has to go to her parental family to be cleansed.
Nurse Clinician A diploma registered Nurse and midwife further trained for 18 months in diagnostic and treatment skills as well as working with and for communities. Cadre introduced at the inception of PHC.
MMM Lesotho June 2005 13
Nursing Assistant Secondary or high school graduate trained for 18 months in basic nursing skills as well as community approach,; deployed to health facilities as well as support for community health workers from the health center. A cadre also introduced with PHC.
Quality of Services: Poor The service not offered at all or only rudimentary education offered; the unit or facility not clean; waiting time longer than 2 hours Satisfactory The content of the service offered is as expected; facility structured such that and it offers privacy; most parts of the facility clean; waiting time 1 to 2 hours Good The content of the service offered is as expected; future discussed with client; facility offers privacy; facility clean all round; staff welcoming and ready to assist; waiting time less than 1 hour
Rooming In A specified period after delivery, commonly 3 months, during which the mother (and her baby) is restricted indoors and is excused from household and all other chores. She is also separated from and not allowed any private moment with her husband; she shares her room with female adult relatives
Scope of Services Below +Scope Only certain components offered; inadequate equipment and supplies; service provider only trained on the job At scope All components offered; equipment and supplies including relevant drugs available; service provider trained as part of basic training and/or received in- service training Above scope All components offered; equipment and supplies including relevant drugs available; requisite skills as expected per cadre; received in-service training; staff endeavour to ensure client satisfaction
Senqu The river that flows from the mountains of Lesotho into South Africa otherwise known as the Orange River
Sesotho The indigenous language of Lesotho
MMM Lesotho June 2005 14 iv. Executive Summary
• In March to April 2005, the WHO Geneva, through country-based consultants, conducted a regional study, including Lesotho, on the quality and responsiveness of health services to meet the needs of women in crisis setting. The specific objectives were to: • Identify local organizations providing health and basic social services to women • Indicate key constraints and challenges to women’s access to and quality of health and basic services • Recommend components of a health assessment instrument that would be considered locally relevant • Recommend concrete actions to increase women’s access to health and related basic social services, in the national context
Data collection tools used included structured questionnaires, interviews of key informants at sample sites/facilities as well as the central level, focus group discussions, and facility checks. The services of a sampling expert were sought and the sample size of the respondents for the structured questionnaires was based on multi-stage probability sampling. The first stage comprised a random selection of three (3) of the ten (10) districts within which enumeration areas were selected by ecological zone based on the probability proportional to population size, each enumeration area serving as the primary/first stage sampling unit. The decision was that the respondents would be women aged 15 to 49 years. The sample size was therefore determined as follows: Sample size = n = t^2pqdeff d^2 Where n = sample size t = standard normal deviate for 95% confidence limit = 2 p = proportion of the population that are women 15 to 49 years (population of interest) = 0.5 q = complement of p (1-p) = 0.5 deff = design effect = 2 d = tolerated margin of error for the confidence limit of 95% (D = 0.05 [(5%])
The total population of women 15 - 49 years to be interviewed was therefore determined to be 661. Given the average household size of 5 and that women aged 15 to 49 years comprise 24% (BOS) of such households the number of households to be visited was calculated to be 550 (661/5 x 0.24). The average cluster size was determined to be 20 and therefore 28 clusters had to be covered to teach the sample number of women. Within each of the selected enumeration areas households, the second stage-sampling units were then selected through random systematic sampling, to a total of 20 households per each of the 28 clusters. Given that 25% of the population is urban the clusters were subdivided into 25% urban and 75% rural.
The relevant respondents at the households at the time of the visit were 573 women aged 15 to 49 years. Serving these villages were 3 hospitals and 10 health centres but a hospital and health centres did not consent to be included in the
MMM Lesotho June 2005 15 study. A total of 2 hospitals and 7 health centres assessments and interviews, 9 focus group discussions and 39 key informant interviews were conducted. The key informants included respondents from the survey areas as well as central level individuals of varied social standing.
The conclusions drawn from the study are as follows:
Community Level • The Senqu valley lies within the mountains and both are predominantly rural; together with the foothills, these zones should be priority in easing financial accessibility to services, followed by the foothills and then the lowlands. • The user fee exemptions are inaccessible to women, further exacerbating the situation of the poor. • The higher dependency on food aid and hand outs in the rural areas, especially in the mountains and Senqu valley may be a reflection of higher food insecurity in these areas, aggravated by low agricultural potential. These are also the areas where finances are more a constraint to accessing health care. • The priority ecological zones for any food aid intervention are again reflected to be the mountains and Senqu river valley, followed by the lowlands and foothills last. • Food aid may not be accessible as required and target groups such as PLWHAs may, as per their report, not be receiving the required food aid. The lack of reliance on food aid in the foothills could be because of higher agricultural output but there also is the possibility that food aid has not yet targeted these areas. The situation may be worse in rural areas and zones where fewer women attain secondary and high school education as found in the foothills (14.6% and 4.3%) and mountain (17.5% and 10.9%) zones followed by Senqu river valley (23.3% and 26.1), hence lower purchasing power. The situation may also be similar in the rural compared to urban areas. • Women’s utilization of health services not only depends on their partners but also relates to their minority status as well as myths, taboos and misconceptions centred on sexuality and reproductive issues, as well as cultural practices during period and the mourning period. • Law enforcement in communities therefore primarily lies with police and chiefs. While there is a law (Sexual Offences Act 2003) that should protect women (and girls) against SGBV, the institutionalization of the minority status of women as per customary law, the preponderance of males in the legal and justice systems, the intimidating legal procedures, the limited legal aid, and lack of women’s awareness and civic education on these rights, result in poor implementation of such protection for women. • While up to over half of the population have physical access to a health facility, there was a significant proportion whose access was aided by vehicle transport and a proportion, especially in the mountains, for whom whatever the mode of transport, physical access was a problem. This problem was more so for hospitals that are the main providers of emergency services for women. The problem of physical access is more for hospitals that are the main providers of emergency services for women in the rural foothills, mountains and Senqu river valley. Access to EOC is not only affected by physical access but is further compromised by lack of transport for emergencies.
MMM Lesotho June 2005 16 • The community level services lean more towards providing home-based care than any other service provision. Given the high HIV prevalence, the bias may be reflection of the escalating numbers of seriously ill patients nursed from their homes, mainly due to HIV and AIDS, and therefore a felt community need. At the same time women’s perception that nursing is their natural role may be underlying reason for not mentioning care of the sick as a constraint to utilizing health care when in need. The issue needs to be further pursued. • While for the majority physical access may not be a constraint to FP, other factors may be contributory to non-use including the women’s decision making capacity whose lack of compares well with the lower use of FP by zone. Given the high prevalence of HIV, the proportion that used condoms was low (29.8%) and the dual protection accorded by condoms was probably not appreciated; more insight into and reasons for non-use is required. • While SGs and VHWs are a recognised resource for communities; TBAs are not. The quality and content/scope of the services may not be up to expectation due to human and other resource constraints. • Access to sanitary facilities is low and worst in rural areas as well as most of the zones except for the lowlands. Municipal waste disposal is very minimal even in urban areas. • While access to safe water supply was moderate to high, there was still 20% to 35% of the population, thence women that lacked such access. It was also noted that it was only for access to safe water where rural areas and mountains as well as Senqu river valley were better off compared to the lowlands.
National
• Budgetary allocations are not yet sufficient to ensure availability and quality of services including those for women. • Although eligibility for a specific service is only based on assessment at the time of the visit, there may individuals who do not receive services due to limited skilled human resources, their inadequate technical skills, and the paucity of guidelines and protocols as well as unreliable drugs and other commodity supplies. • ARVs are not available in rural areas and their availability is skewed to urban lowland areas. • The only way in which women may participate in service delivery is as providers. This is notable for support groups and PLWHA associations where the majority are women. • Although there may be institutions and policies in place, they are hardly monitored; there is neither a body nor effective systems to addressing ills affecting women. • Law enforcement in the protection of women against SGBV is weak and systems not conducive to use by women. At the same time legal aid is not easily accessible to a lot of women due to its geographical limitation while private lawyers are not affordable to most women. Women are also not empowered on their rights. • SGBV is not captured in the routine reporting from health facilities.
MMM Lesotho June 2005 17 Facility Level
• Even though patients and clients may self refer, the overall shortage of HRH and their limited skills, equipment and supplies as well as drugs shortages compromise the referral system as well as the quality of care. This is exacerbated by the lack of supervision. • Privacy and confidentiality are not adequately addressed in the infrastructure plans. • While drug shortages may not be a norm, the significant proportion of facilities that did not have emergency drugs in stock, the high proportion of facilities reported to have been without drugs for EOC, and that essential guidelines were only at hospitals is worrisome. The situation is made worse by equipment shortages that compromise the capacity of facilities to offer EOC. The claim that fewer and fewer women are delivering in hospitals, that the referral system is not adequate, including the lack transport translates into a health centres as the key centres for EOC for a high proportion of women. The likelihood that the health centres may not meet this expectation, even if not a high proportion may indicate that women unnecessarily die even if they do manage to reach a health facility. The situation should be worse for the rural and mountainous parts of the country for which physical access to hospitals is reduced. • The sanitary status of a recognizable proportion of health facilities is inadequate, even in delivery and ANC rooms. Such a situation may also deter facility utilization. • While the telephone and cell phone may be an option for urban areas, a large proportion of rural areas, often with inadequate infrastructure, may only be reached through two-way radio communication. The majority of the health facilities are therefore not adequately equipped for emergency communication. • Most health facilities, more for health centres, lack facilities for simple, basic and essential diagnostic tests including priority screening tests for women such as haemoglobin, urinalysis and HIV testing. • While health facilities conduct IEC activities they are not adequately equipped with locally relevant materials and are sometimes in a language that may not be understood by the majority of users. Other relevant materials were missing and most of the available were relevant only to HIV and AIDS. • The scope and quality of services are not optimal due to the inadequate number and skills of human resources; unreliable drugs supplies and equipment; inadequate supervision; poor maintenance of facilities and lack of infection prevention control systems. These are exacerbated by managerial and attitudinal deficiencies. At the same time in-service training is not sufficiently structured to address the inadequacies. • Health workers do not perceive customs that may deter utilization of health services a problem; it is more of nuisance. They may therefore not address the issues adequately in education and other related BCC activities. • Health facilities do not offer counselling nor adequate services for SGBV, including PEP. There are neither protocols nor guidelines for the prevention and management of SGBV. • The shortage of HRH is a barrier to women’s access to care and is exacerbated by insecurity at the health facilities as well as water shortage for services such
MMM Lesotho June 2005 18 as deliveries. At the same time their negative or non-supportive attitude further deters women from utilizing health facilities. • The HMIS does not cater for monitoring SGBV.
Recommendations
General • The MOHSW in its standardization of fees and accreditation with CHAL, should include an agreement on fee exemption criteria to guide health facility staff, while awaiting social welfare endorsement of their eligibility. Due consideration should be made to a total fee exemption for services specifically targeting women and girls. The zones and urban/rural differences should be considered in the prioritization of the intervention. • At the same time, the training of the social welfare cadre to effectively reach the community level should be accelerated. • Given the women’s low economic potential, their minority status and their food insecurity, the government sectors, especially the MOHSW, MOGYRS, and Ministry of Agriculture and Food Security, together with the relevant NGOs, the private sector and partners as well as UN agencies, should liaise and consult with a view to establishing uniform standards and systems for improved access to food aid and other assistance for women and girls. • Special attention and programmes should focus on young women and girls whose economic potential is further reduced due to drop out from school, ending in lowly paid and abusive jobs such as domestic work. Government should institute and monitor a legal mechanism for enabling the girls to pursue their education while instituting laws that would protect the women in domestic work and the informal sector from abuse. • Through advocacy and evidence based planning on the access of women and girls to health services, resource allocation for women’s services should be improved. Due differentials should be accorded the urban to rural divide, the zones, socio-economic status/employment, and special regard accorded to those affected and infected with AIDS and HIV. • The plans to have ART in all hospitals and VCT/HTC in all health facilities needs to be accelerated and be sensitive to ensuring equity between rural and urban areas as well as between topographical zones. • Programmes specifically targeting the male spouses and partners to be actively involved and support services for women should be instituted. The relevant socio-cultural and other underlying factors to reduced utilization of health services as well as avenues to community-organized inputs, specifically emergency transport, into the system, should be priority. • Given that human resource constraints are key at compromising the scope, quality and access to care, efforts at improving on the situation of human resources for health, including their retention, should be intensified. The working conditions that not only affect the service delivery, but the attitude of such workers, should be improved through improvements on the infrastructure, security, drugs, supplies and equipment at facility level. Deployment should place emphasis on equity and access especially to the difficult parts of the country. At the same time quality service should be rewarded and punitive measures transparently taken against those whose
MMM Lesotho June 2005 19 attitude not only deters service utilization but also compromises the human rights of the women and public. • Supportive supervision to facilities should be streamlined and integral to programme management at all levels. Appropriate checklists and guidelines should be developed prioritizing on equity to access and quality of care. • The development and dissemination of policies, guidelines, and protocols on women’s health issues, should be accelerated and expanded to include the prevention and management of SGBV. Through in-service training health workers should be appropriately equipped with the skills and trained on their use. Curricula of training institutions should be similarly updated. Such policies should be widely disseminated in a language that is easy for the general population to decipher. The women may then be able to decide on the adequacy of services delivered. • Health policies should be updated to reflect the current guidelines on access to quality health services e.g. physical access defined as 30 minutes and not 2 hours walk from a health facility for obstetric care. • Civic education on human rights, including their right to health (care), for women and men, should be expanded and be sensitive to issues that deter the protection of women from SGBV. Intensive education and social mobilization involving community leadership and structures is essential at specifically addressing issues that may be assessed contravening culture. • Relevant sectors, including the MOHSW, the Ministry of Gender and Youth, Sports and Recreation (MOGYSR), the Ministry of Agriculture and Food Security, as well as the Ministry of Education and Training (MOET), should closely collaborate and facilitate institution of fora at national and lower levels, for advocacy, education, monitoring the implementation of policies and laws that relate to women’s health, and ensuring compliance as well as taking corrective steps and action. • The implementation of the sexual offences act and other relevant laws should be closely monitored and the Ministry of Justice (through the Justice Sector Development Programme) in collaboration with the Ministry of Home Affairs (Police, Correctional Services and Immigration) reinforce and ensure compliance. Given that the majority of women’s occupations are mobile in nature, the Ministry of Labour and Employment should also be involved towards reduction of vulnerability of these women to HIV and abuse. • Justice and Legal enforcement agency human resources should be regularly updated of the laws and policies to foster improved appreciation of issues pertaining to SGBV, hence compliance. • Programmes should be deliberately designed to actively seek and involve as well as ensure women’s participation on issues relevant to their health. The empowerment of women in this regard should therefore be integral to the civic education on women’s rights. • Communities should then be mobilized in contributing resources to such as emergency transport etc. At the same time the formal sector should enhance road, radio and telephone communication of health facilities to further enhance access to services as well as ensure an effective referral system. • The community-based services should be improved to cater for the needs of women. The skills of such workers should thus be enhanced and accordingly expanded to also include prevention and management of SGBV as well as
MMM Lesotho June 2005 20 advocacy for protection of women against this violence. Their credibility should also be enhanced with appropriate support systems and avoid duplication or competition. • In support of these efforts and specific for IEC, specific materials addressing cultural and other practices that need to be changed for better health, encompassing SGBV and sanitation should be developed and disseminated to the health facilities. This should be appropriately backed up through other communication channels such as use of the radio. • Factors such as long duration of marriage and higher level of education (income earning) that significantly positively empower women to make decisions should be applied in identifying change agents in communities.
Defining the Crisis
• Given the low economic status of the women, fee exemption criteria should be updated and accord priority to women resident in the rural areas of worst off zones including PLWHAS. The government policy should be that the services for women are provided free of charge in public facilities. IGA activities should be similarly prioritized. • Food insecurity and higher level of dependence on food aid are worst off in areas where physical access to health facilities is also comparatively low. These should be the zones to which food aid is prioritized. The foothills zone where there was no reported dependency on food aid yet the other indices were poor needs to be further assessed to ensure equity of access to food interventions. • The preponderance of home-based care activities more than any other community based health service could be an implication of the burden of disease as well as the level of advocacy for such service delivery. PLWHAs appreciated the home-based carers more than those in health facilities. Care of PLWHAs therefore needs to be enhanced at facility level and the continuum of care maintained. • Similarly efforts at improved sanitation and universal access to safe water supply should be strengthened in contribution to reducing the burden of communicable diseases and improving on the care of PLWHAs. • The skilled health care providers should be appropriately trained to be HIV and AIDS competent; measures to address their high attrition should be taken as matter of priority. At the same time their capacity in client orientation should be improved including punitive measures for those whose attitude is not conducive to service utilization. • ART should be made available in all hospitals. Health centre staff should be trained and supported in screening and referral of patients, including for ART. • The skilled health care providers should be appropriately trained to be HIV and AIDS competent; measures to address their high attrition should be taken as matter of priority. At the same time their capacity in client orientation should be improved including punitive measures for those whose attitude is not conducive to service utilization. • Meantime recommendations for reducing the attrition of skilled human resources should be speedily implemented to facilitate access to care
MMM Lesotho June 2005 21 especially for ART and EOC; the quality of services for women should not be otherwise compromised. • Systems and mechanisms for the adequate protection of women against SGBV hence decreasing their vulnerability, including to HIV/AIDS, should be actively explored. Chiefs, politicians (parliamentarians) and other community leaders should be held accountable for such protection.
MMM Lesotho June 2005 22
1. Introduction
1.1 Background 1.1.1 Country Information
The Kingdom of Lesotho is situated between 28 to 30 degrees latitude and 27 to 30 degrees east longitude. The country area is 30,359 square kilometres and it is completely surrounded by South Africa. It is topographically divided into 4 zones based on altitude: Lowlands, Foothills, Mountains and the Senqu River Valley within the mountains demarcated by the line above which no winter wheat grows. The country lies between 1,500 and 3,500 metres above sea level in altitude. It is divided into ten (10) administrative districts.
Lesotho is patriarchal as well as patrilineal; women are minors according to the common and customary law. The Kingdom of Lesotho has an estimated population of 2.2 million with an estimated annual growth rate of 1.9%. Its demography is that of a developing country. According to the 2001 Demographic Survey (DS) the urban population is 17% of the total. Children below 15 years comprise 36% of the total population while 58% are 15 to 64 years, and 6% 65 years and above. The age dependent ratio is estimated at 0.72, with 4 out of 10 members of a household as the children of the household head. According to the 1996 census adolescents (10-19 years) comprised 21%, and Women of Child-Bearing Age (WCBA) 24%, of the total population. The orphan population is estimated at one third of the children 0 to 14 years. The study by the Department of Social Welfare estimated a total of 85,000 while UNICEF estimated the orphan population at 117,000. The road infrastructure covers a significant part of the country (tarmac and gravel) of the country and the lowlands are more accessible than the mountain areas. Household radio ownership is estimated at 63%. There is up to six (6) radio and 2 television stations. By 2002 it was estimated that there were 23,000 telephone main lines and 84,000 mobile cellular telephones (Ministry of Communications HIV/AIDS Strategic Plan 2002). The country is poor with a life expectancy at birth reduced from the previous low level of 60 years in 1996 to even lower at 52.5 years in 2001 due to the impact of the Acquired Immune Deficiency Syndrome (AIDS). It is estimated that the life expectancy at birth by 2005 is 35 years. The population below the poverty line is 43- 58%. The Gross National Product (GNP) per capita is estimated at US $ 423 and adult literacy at about 58% for males and 63% for females (Population Data Sheet 2002)
The demographic and health indicators for the country are currently as follows: Indicator Value Population 2.2 Million Life Expectancy at birth 52.5 (2001 Demographic Survey)
MMM Lesotho June 2005 23 Adult HIV Prevalence 28% Infant Mortality Rate 81/1000 Live Births Under Five Mortality Rate 110/1000 Live Births Maternal Mortality Ratio 419/100, 000 Live Births Population Living under US $1 per day Over 50% Estimated Number of Orphans 73,000 – 100,000 Proportion of 0 – 14 year olds who are 15% HIV infected Unemployment rate 43 – 58%
Lesotho adopted the Primary Health Care (PHC) strategy in 1979. The health care system comprises of Health Service Areas (HSAs) with the hospital as the pinnacle of care within the area. A total of 18 HSAs and about 158 Health centres are responsible for the health care. The community level services are delivered through community owned Village Health posts where they exist. Lesotho has 5639 Village Health Workers (VHWs) and 1423 Traditional Birth Attendants (TBAs) (Community Health Worker Inventory 2004). While Traditional Healers are not formally included they are integral to the system with a co-ordinating office aligned to the Director of Primary Health Care. The facilities are almost equally divided in ownership between the government (9 hospitals and about 50% of the health centres) serving 52% of the population, and the Christian Health Association of Lesotho (CHAL), a conglomerate of facilities owned by 6 churches, serving 48% of the mainly rural population. There are 3 referral hospitals, all in the capital Maseru: QE II Hospital where specialists are based, Mohlomi Mental Hospital, and Botsabelo Leprosy Hospital. A military and a private hospital are also located in Maseru. Two other privately owned mini-hospitals are located in the two urban areas of Leribe district. A myriad of privately owned facilities providing outpatient and other services, owned by medical doctors of varied cadres as well as nurses are scattered in all the 10 districts with the highest density in the capital Maseru. The structure of public health care delivery is represented as follows: 1.1.2 Context The gains that Lesotho had made in the late 1980’s to early 1990’s through its PHC programmes have been lost. Between 1996 and 2001, the Infant Mortality Rate (IMR) increased from 74 to 81 per 1000 Live Births (LB), while the Child Mortality Rate (CMR) increased from 82 to 113 per 1000 LBs. Twenty Eight (28%) of the population lack access to safe potable water while 46% lack access to a safe method of excreta disposal. Studies undertaken indicate that sexual debut is as early as 12 years. Early marriage and early pregnancy are common. The contraceptive prevalence rate is estimated at 30.4%, 50% of which service is through the private sector. The adult Human Immunodeficiency Virus (HIV) prevalence rate is estimated at 28.9% (sentinel surveillance report 2003) ; the third highest prevalence in the world. The sentinel surveillance report indicates a steady increase from 4% in 1993, 9.8% in 1998, to 31% in 2002,as indicated below.
MMM Lesotho June 2005 24
Figure 13: HIV Prevalence Trends by Site, 1991-2003
45 40 35 30 Leribe 25 Mafeteng 20 Maluti 15 Maseru Prevalence (%) 10 Mokhotlong 5 Quthing 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Year
The HIV prevalence is higher in urban (31%) than rural (27.6%) sites but the rate of increase is higher in the rural areas. Young people are worst off with the highest prevalence among 25 – 29 year olds at 39.1%; 30.1% among 20 – 24 year olds; and 14.1 % among the 15 – 19 year old. The 15 – 29 year old age group represents 25% of the HIV positive population and 10% of new infections. Women are particularly vulnerable representing 57% of all adult infections. The rate among mothers attending antenatal care was 28.9% in 2003. The PMTCT and exclusive breastfeeding each estimated at 22%. The facility reports also indicate a rate as high as 64% among the women that received HIV testing and Counselling (HTC) and women accounted for 55% of all AIDS admissions. UNAIDS estimates that there are 300,000 adults and 22,000 children living with HIV/AIDS. There were an estimated 29,000 AIDS related deaths in 2003 and the 3 x 5 plan of the MOHSW estimates there are 56,000 HIV infected individuals that require ART. The Maternal Mortality Ratio (MMR) has increased from 282 in the 1990s to 419 per 100,000 LB in 2001. A number of risk factors have been identified among which HIV/AIDS and unsupervised deliveries are key. With the estimated 46% of mothers delivering at home while only 34% attend post-natal care, the result is more increased maternal and child mortality. The maternal mortality, based on the 2003 facility reports, indicates a worrying picture of 21 maternal deaths out of the 6754 reported facility deliveries (310/100,000). Also reported were 728 stillbirths, 47% of them being fresh stillbirths. The two factors pose a challenge on the quality of obstetric services. The report indicated the top causes of female admissions as incomplete abortion, pneumonia, diarrhoea, and diabetes. Abortion accounted for up to 50% of adult deaths (above 12) among female inpatients. The underlying causes of such a high maternal mortality include the increasing level of poverty (more than 50 % living on less than M146.00 or $24 per month), poor nutrition and environmental sanitation, unhealthy lifestyles as well as weakened programme delivery. The latter is consequent to varied factors inclusive of a high attrition level of human resources for health and paucity of skills to deliver services, especially Emergency Obstetric Care (EOC) as well as post-abortion care. Early
MMM Lesotho June 2005 25 marriage and teenage pregnancy also contribute to the high proportion of at risk pregnancies as well as abortions. Because of late presentation, cancer of the cervix accounts for a high proportion of referrals to South Africa. While pap smears may be done throughout the country, the quality of the slides is often below standard and the laboratory capacity to read a high number of slides limited. Awareness among both the health workers and the women is very low. Cancer of the breast accounts for a high proportion of admissions to the female ward but screening and awareness are also very low. At the same time the health care system is faced with skilled human resources shortages as indicated below (Ministry of Health and Social Welfare Report). Population Public Doctor to Public Registered Population ratio and Staff Nurse to Population Ratio Government Health 1,525,763 1 for 13,600 (112) 1 for 4384 (348) Service Area CHAL Health 762, 628 1 for 27,300 (28) 1 for 4708 (162) Service Area Lesotho 2,288,391 1 for 16,400 1 for 4487 WHO 1 for 10,000 1 for 5,000 recommendation for LDCs ** With on-going attrition the numbers are expected much lower
With the high IMR, high CMR, and the high MMR, and in an effort to address the challenges faced, in 2000 the Government of Lesotho (GOL) through the Ministry of Health and Social Welfare (MOHSW), with the support of partners, developed and embarked on a Health Services Reform Programme (HSRP). The goal of the programme is to ensure equity and universal coverage of quality health services. The key areas of reform include decentralization; the district health package and essential care package; human resources; pharmaceuticals; infrastructure; social welfare, and Partner Co-ordination. The essential services package includes reproductive health services duly recognising the critical role of adolescent health care.
1.1.3 Rationale for the study
It is widely recognised that the health and well being of women and girls (and children) suffers most in disasters and conflicts (crisis setting) and that their additional needs do not receive due attention from humanitarian and other service providers. These special needs derive from the vulnerability of women and girls to sexual and gender based violence, reproductive morbidity, sexually transmitted infections including HIV, mental distress, and gender-related inequalities that impact on the health and nutrition of women. The WHO Geneva therefore commissioned the study to develop an appropriate instrument to assess the quality and responsiveness of health services to meet the
MMM Lesotho June 2005 26 needs of women in crisis setting. This would be preliminary to a potential interagency global programme with a goal of preserving and promoting the health of women and girls in crisis and post-crisis recovery situations. The focus on southern Africa is based on the fact that the countries in this region are faced by the crisis of a high level of poverty, high HIV prevalence, and food insecurity. The relative homogeneity of the selected countries of Botswana, Lesotho, Swaziland, Malawi and Zambia, makes the study feasible.
1.2 Objectives of the Study
Having defined the crisis as the triple threat of poverty and food insecurity, weakened governance capacity and high HIV and AIDS prevalence rates, the aim of the study is to provide the information towards development of an instrument that may be used to assess the quality and responsiveness of health services to meet women’s needs in crisis setting. The specific study objectives are: • Identify local organizations providing health and basic social services to women • Indicate key constraints and challenges to women’s access to health and basic services • Recommend components of a health assessment instrument that would be considered locally relevant • Recommend concrete actions to increase women’s access to health and related basic social services, in the national context
The specific outputs are therefore defined as follows: ¾ Specific analyses, directory/databases of resources, and recommendations that can be used by UNCTs and partners for follow up programmes to improve women’s access to health care ¾ A prototype health for women access assessment tool ¾ Insights for the design or evolution of the potential inter-agency global programme on women’s health in crisis situations
1.3 Structure of the Report
This report is organised into nine (9) chapters. Chapter one introduces the study in terms of the background on Lesotho, objectives of the study and how the report is organised. Chapter two comprises the literature review. Chapter three outlines the methodology for the study. Chapter four presents the results of the study while chapter five outlines the organizations that are providing health and basic social services to women. Chapter six presents the recommended components of a health assessment instrument relevant and useful to Lesotho. Chapter seven is a presentation of the recommendations for action, in the Lesotho context, to increase women’s access to health and related basic social services. Chapter eight is the references while Chapter nine is the appendices.
2. Literature Review 2.1 Introduction
MMM Lesotho June 2005 27 There is varied documentation, on access to services in the wider population context, and not specific for women. Several studies have however been conducted on specific issues pertaining to women’s health providing the baseline on which further inputs and follow up action may be made. The guiding principles may be drawn from the extensive publications of WHO and its sister agencies as well as other partners, and the conventions and declarations Lesotho is party to/has ratified including the Beijing Declaration, Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), and the Millenium Development Goals (MDGs).
In conformity with the MDGs, Lesotho’s goals include the promotion of gender equality and empowerment of women as well as improving maternal health (reduce by 2015 the Maternal Mortality ratio (MMR) by two thirds).
2.2 The key challenges and constraints to women’s access to health and basic services, in Lesotho, as per the literature review, are indicated below.
2.2.1 Economic Factors
The Poverty Reduction Strategy has, as one of its objectives, the promotion of access to quality and essential health care and social welfare services. It recognizes that issues of gender are cross cutting, especially that women are minors without the freedom to make decisions on their livelihood. By implication therefore women may only afford services should their spouses so decide. This is also implied in the Vision 2020.
The 2001 Demographic Survey results indicate overall high unemployment, more so for women, as per their low labour force participation. The 57% unemployment for women may be an indicator of the reduced capacity of women to afford services.
A 2004/2005 review report by the Department of Health Planning and Statistics (DHPS) of the MOHSW, highlights the high general unemployment rate of 42%. Linked to this is the differentials in user fees between the Five (5) and Ten (10) Maluti, paid by children and adults respectively, at government facilities compared with the higher fees at CHAL facilities, resulting in lower outpatient contacts at CHAL facilities. Given the reported higher unemployment among women they are therefore less likely to afford services.
The World Bank Core Welfare Indicators Questionnaire (CWIQ) core welfare indicators and tables also reveal that more women than men are unemployed with up to 38.37% of households finding it difficult to access food.
While no documented information on the penalties for non-payment could be found, the Strategic Plan of the MOHSW 2004/05 to 2010/2011 in one of its strategies envisages wider resources from the public and private sources and a review of user fees towards ensuring access to those who cannot afford. This intention, considered with that already mentioned on the differentials of utilization between government and CHAL facilities, may be interpreted to indicate that currently those who cannot afford to pay may be/are denied services.
The 2000 Baseline Study by the MOHSW also indicates that 4.8% of households were exempted from user fees. These included the destitute, very poor, poor and average
MMM Lesotho June 2005 28 socio-economic group. However 83% of the destitute did not use the nearest facility because of cost.
The draft National Adolescent Health Policy highlights that adolescents comprise 21.8% of the total population. While the primary school enrolment (nett) for girls is higher than that for boys at 72% compared with 66%, the drop out rate is 6.1% and 8.9% respectively, due to financial reasons.
2.2.2 Socio-cultural factors
The MOHSW in collaboration with WHO, in the Women’s Health Survey of 1996, reports that built on the premise of women as miners, infertility is blamed on women who therefore have to seek recourse to the problem. In cases of gender based violence women do not always seek help for they feel the law is not in their favour; so is their experience with disputes settled by families, based on the premise of their obligation to serve the needs of their spouses/partners. The male service providers are also not all in support of a different view. Women are also sympathetic to their husbands and would rather suffer abuse than desert their children, identified as belonging to the father’s family from birth (patrilineal society).
A MOHSW/WHO Study on Violence against Women in Lesotho corroborates this information and further highlights that there exist attitudes, myths, practices and values that legitimise violence against women. Women are therefore less likely to seek care if affected by such violence and consider it part of the norm.
The Behavioural Survey report by Sechaba Consultants for the Ministry of Employment and Labour, reports on the study undertaken by Kimane et al (1999). This study notes that sexual and reproductive beliefs and practices appear to be strongly influenced by the existing gender relations that are marked by a lot of inequalities. These findings include that sexual and reproductive issues are regarded as taboo and seldom discussed, the use of risky sexual and reproductive health practices such as dry sex, genital manipulation, and sex across age barriers such as sex with virgins as a cure for AIDS. Women in fulfilment of their service role for men also sometimes apply dangerous methods of sexual hygiene under the belief that it will increase sexual pleasure for the men. Kimane also notes the series of myths and misconceptions about sexual and reproductive health that apply to the population at large, including food taboos, to a large extent influenced by gender dynamics. In such situations, women will be less likely to seek services that are perceived contrary to the norms.
2.2.3 Physical Access Barriers
No information on the access by level of facility could be found.
However according to the Zicken - Sechaba Consultants Baseline Study 2000, 79.5% of the total population have access to a health facility defined as a walking distance of less or equal to 2 hours. Each hospital serves a total population of 100,000 (range 50 – 24,000).
No information on ambulance services could be found. Common knowledge among workers is that there is no organised ambulance service even for emergencies, including
MMM Lesotho June 2005 29 emergency obstetric care (EOC). Patients have to purchase such services from the few private ambulances in the capital and/or vehicle rental.
According to the Health Statistical Tables 2003, the doctor to patient ratio is 1 to 16,000 while the nurse to population ratio is 1 to 5000 with a nurse to patient ratio of 1 to 17. The outpatient (OPD) contact per capita is estimated at 0.5.There is a 20% of the population including women who have limited physical access to health facilities, further supporting the information in the baseline survey. Even among the 79.5% who have access, given the low level of skilled human resources, they may not always receive such services when in need.
The Lesotho Health and Social Welfare Sector Reform Programme Selected Indicators on the other hand indicate the human resource ratios of 1 to 14,013 for doctors and 1 to 1447 for nurses. The OPD contact per capita is estimated at 0.7-1 while facility utilization is 0.4.
The Selected Indicators also point to the fact that the average waiting time at health facilities, by 2002, was 5 to 6 hours. Client satisfaction with services was only 13.2%.
The Health Sector Review Report 2005, also indicates that there has been slow progress in completion and adoption of policies and guidelines. This is coupled with persistent shortage of resources, including human and financial, negatively impacting on efficiency and effectiveness of services. The decline in the level of supervision is reported to further compromise the quality of health care. The quality assurance strategy is yet to be finalized. However, the Consultancy report for the MOHSW, on quality assurance and decentralization, points out that infection prevention and control are a known problem in health facilities.
According to Village Health Worker (VHW) Training Manual community level activities primarily comprise the promotive and preventive activities, covering a wide range of topics including disease prevention, nutrition education, reproductive health, and water and sanitation. Through the Community Based Distribution (CBD) of contraceptives, VHWs also improve on the access to Family Planning (FP) in underserved areas. Based on the Support Group Census of 2002by the Lesotho AIDS Programme Co- ordinating Authority (LAPCA) community home based care (CHBC) is gaining importance and recognition with the AIDS epidemic and volunteer support groups are spread countrywide providing care for all chronically ill patients. In the capital Maseru, the ARV programme initiated with support of Bristol Mayer Squibb (BMS) drug company, support for compliance with ARV therapy is fostered through the buddy programme involving support groups of People Living With AIDS (PLWAs). Community based mental health care is very limited in scope and coverage.
Based on the Community Health Worker Census of 2004, a total of 5369 VHWs and 1423 Traditional Birth Attendants (TBAs), actively provide services country-wide. The ratio to population is therefore 1 to 205 for VHWs and ratio to Women of Child Bearing Age (WCBA) 1 to 386 for trained TBAs.
2.2.4 Factors related to national health system and policies
MMM Lesotho June 2005 30 The Essential Services Package (ESP) document highlights that under the health reform programme the thrust of the ESP is improved coverage, at least cost. It further indicates that the level of the current public health expenditure estimated to be US$ 15.0 per capita (2001), cannot support the country’s health needs and that intra-allocations within the health sector have mainly focused on hospital care. Given the unsatisfactory/low level of utilization resource allocation has therefore been skewed to urban areas.
The MOHSW review report 2004/2005 states that there has been a skewed human resource allocation with a lower doctor to patient and nurse to patient ratio in CHAL hospitals that are mainly rural, compared to that in government hospitals. It may be presumed therefore that access to skilled care for women, in rural areas, is less that that in urban areas.
The ESP document further highlights that the hitherto centralised and vertical delivery of services has also translated into lack of fairness for delivery of services especially for the poor and vulnerable members of the population. It may therefore be deduced that the resource allocation has negatively affected the quality and availability of services for women.
The government and CHAL have not hitherto contracted out services.
No eligibility criteria, outside the decisions by professionals, could be found in the literature. In government as well as CHAL facilities the most criteria mentioned in several documents including the Health Strategic plan and review report is the capacity to meet the user fees. With the quality compromised as indicated before, especially delays in the adoption of guidelines, it may therefore be deduced that access to services may also be compromised.
The Baseline Study 2000, reported that 4.8% of households were exempted from user fees. While the criteria for exemption were not mentioned the procedure was that Social Welfare Officers first assess households. The HSRP report, on Social Welfare, however indicates that one of the key challenges facing the department is the shortage of professionals in the area. Long delays in assessment or never being assessed may therefore contribute to reduction of access to services for deserving women.
No information could be found on participation of women in issues pertaining to service delivery.
The country report of the UNSG’s Task Force on Women, Girls and HIV/AIDS in Southern Africa highlights the legal minority status of women. This is despite Lesotho being signatory to CEDAW. Men are culturally accepted to control decisions related not only to public life but also reproductive and sexual decisions. This information derives from the Women and Law in Southern Africa (WILSA) reports on Sexual Violence in Lesotho and In search of Justice Where do Women go in Lesotho.
The Vision 2020 recognizes that gender equity and equality, in line with CEDAW, demands efforts to eliminate discrimination. Included among the indicators are not only women’s health but their participation in high level decision making structures of the country as per the Southern African Development Community (SADC) resolution. Through its monitoring it is hoped the issues pertaining to women will also be catered
MMM Lesotho June 2005 31 for. The Poverty Reduction Strategy (PRS) also recognises gender as well as HIV and AIDS as cross cutting issues that need to be appropriately addressed.
**The draft Population Policy of the Ministry of Finance and Development Planning (MOFDP) indicates that the socio-cultural barriers make women inferior to men and results in the women’s inability to decide freely when to seek care. The consequences of early sex initiation include early pregnancy, early marriage, Sexually Transmitted Infections (STIs), high abortion rates and increased maternal mortality. At the same time, quality sexual and reproductive health is compromised due to shortage of staff and equipment as well as that service providers lack life saving skills that address Emergency Obstetric Care (EOC) while the referral system is insufficient. It further highlights that behaviour linked to disease leads to a fatalistic attitude to diseases such as AIDS. While 13% of youth get pregnant they cannot access reproductive health services and are expelled from some schools. The policy is therefore guided by the needs to promote women’s and other special groups’ rights, health, and well - being. It further recognises a comprehensive Sexual Health/Reproductive Health/Family Planning (SH/RH/FP) programme as a necessity and has developed targets in line with this intention. The MOHSW is entrusted with the role of designing appropriate sectoral strategies and interventions. It may be hoped that this will provide and facilitate future monitoring of women issues.
The Gender Policy of the Ministry of Gender and Youth, Sports and Recreation (MOGYSR) corroborates this information and its objectives include ensuring equal opportunities and participation by women and men, girls and boys in the development process; equal access to education, training and health services and mitigating and control of land and credit; mitigating negative aspects of culture, and enforcement of gender sensitive laws.
**Similarly the draft Reproductive Health and Adolescent Health strategies recognize these issues and those centred around Sexual and Gender Based Violence (SGBV) including rape, physical and psychological abuse, as well as sex coercion. The policies’ goals include advocacy for and wide covering intentions towards improving on the situation. Through monitoring of the policies it is intended that these issues pertinent to women will be addressed.
The National Health Strategic Plan has reproductive health as one of the output objectives. It has defined targets including policies supportive to this intent. It further highlights the relationship between reproductive and mental health.
In reference to GSBV, the draft Reproductive Health Policy indicates a growing problem such that of the 56% of cases reported and investigated by police only 40% of these were convicted. This lends a question to the effectiveness of the statutory mechanisms in enforcing legal support and protection for women.
The Sexual Offences Act 2003 is protective of women and children and violence such as rape is a capital offence.
The Women’s Health Survey 1998 reports that husbands or partners frequently perpetrate SGBV violence. However, women do not want to report their husbands since the statutory system is not conciliatory and they would not want to be separated from their
MMM Lesotho June 2005 32 children. The women also felt the law was against them as a consequence of the perceived superiority of the men. In the informal dispute settlement, usually presided by family elders, issues such as wife rape are never discussed since the women are culturally bound to serve their husbands. It is concluded therefore that the statutory, customary and common-law systems are not effective in protecting women (and girls).
The Study on the Violence against Women in Lesotho further reinforces this assertion and recommends that the strategies to address the problem should include gender equality in all education efforts, appropriate information on gender and human rights, and promoting access to legal and police services that protect rather than intimidate victims.
The WILSA clearly indicates that the increasing violence is a power rather than a sexual issue in its publications Sexual Violence in Lesotho and In Search of Justice Where Do Women Go in Lesotho. Not only are women discriminated against but the social and legal systems are both inaccessible as well as felt by women to be non-supportive.
WILSA in In Search Of Justice, indicates that there are three types of fora for resolving issues pertaining to women. These include the informal (family), semi-formal (Chiefs, NGOs, Ombudsman), and the formal (courts hierarchy). It further states that for Basotho (people of Lesotho) justice encompasses more than law and its administration, but also whether it has been fair. The study indicates a power hierarchy of the systems, each administering justice through specific systems and that women utilize each particular system to meet particular ends/needs at particular times. The higher the hierarchy, the more intimidating (language, procedure, male dominated) and non-supportive the women found the systems were. A lot of the formal structures are also based in towns and the capital, rendering them inaccessible to the majority of women. The costs of the formal courts are also reportedly exorbitant and unaffordable for an ordinary woman, especially where she has to obtain such money from her partner/spouse and/or earning low wages.
UNICEF/Mokuku in the Hear Us Shedding Light on the Plight of Child Domestic Workers in Lesotho, indicates that emotional bullying, physical abuse, and sexual abuse are common for domestic workers. Specifically with regard to sexual abuse of girl domestic workers, community members were reluctant to report or intervene even where they knew such abuse occurred. They however were of the opinion that such cases should be reported to police but were either not aware of the Sexual Offences Act 2003 or felt there was a discrepancy between the law and the way it is implemented. At the same time these children worked on the basis of verbal contracts (only 24% had written contracts), and are lowly paid: the 57% paid in cash earned 100 to 200 and few above 400 Maluti.
No information on access to legal representation in cases of GSBV could be found. It is however legal procedure that those who cannot afford their own legal representation receive legal aid.
No literature on civic education on women’s rights related to GSBV were found.
2.2.5 Factors Relating to Service Delivery Level
MMM Lesotho June 2005 33 According to the Review Report 2004/2005, the referral system is that health centres refer to hospitals that in turn refer to the referral hospital(s). The more complicated cases or for whom there are no facilities are then referred to the teaching hospital in Republic of South Africa (RSA). Clients and patients, especially in urban areas where the hospitals are situated, however self-refer to hospitals and are not turned away. The Maternal and Child Health (MCH) clinics attached to the hospitals also directly refer to the medical doctor. For all tiers a fee has to be paid. Health centres are also expected to defer and refer patients during the monthly doctor and Primary Health Care (PHC) team visit as well as consult through two-way radios or telephones where available. The review report indicates that communication with most health centres (40% with functioning radios) have broken down and is mostly in Christian Health Association of Lesotho (CHAL) Health Service Areas (HSAs) where monthly supervisory visits are still routinely conducted. This translates into a barrier for referrals especially of emergencies. Furthermore feedback on referred patients especially from the referral to the district/HSA hospitals is very poor. The information is however neither differentiated by gender nor age and therefore it may only be deduced that, especially rural women, entirely depend on the willingness and skills of the health worker for them to be appropriately referred. Emergency care is even more compromised. While there had been no guidelines the framework is included in the District Health Package (DHP) guidelines.
According to the MOHSW Selected Indicators the waiting time at the health facilities was 5-6 hours. All hospitals had functional emergency services and offered integrated services during the five working days. All health centres had integrated home based care into their activities. The CWIQ survey 2002 indicated a low client satisfaction of 13.2%. No information could be obtained on opening and closing times but it is implied that only emergencies and special service are served at weekends and public holidays. On the other hand according to the Review Report 2005, the waiting time for the eight (8) hospitals assessed ranged from 3.5 to 6.4 hours. A large proportion of the clients (82%) had indicated satisfaction despite the long waiting time; the 18% were not satisfied because of lack of medication or testing reagents and X-Ray, or because they were beyond the set quota for the day. The review report also indicates fewer and fewer health centres are conducting deliveries. Twelve of the twenty three (12 of 23) health centres assessed were not conducting deliveries due to lack of security, lack of appropriate human resources and poor water provision. This had limited women’s access to facility delivery and they are opting for home delivery.
While there is information on the Infrastructure Plan on on-going and planned rehabilitation, issues of privacy are not directly addressed. The selected indicators however reflect that there is no clear standard operating procedure (SOP) nor clearly documented system and procedures in drug procurement, distribution and storage; no information is given on drugs stock outs or on equipment.
The Review Report, under pregnancy and delivery, highlights that based on facility assessment conducted by the responsible unit only 21.7% (5 out of 23) had all the essential drugs for provision of EOC and that guidelines on management of hypertension in pregnancy were only at hospitals and not health centres. Drug stock outs were stated as rare. In an assessment of 8 hospitals an average of 93% of patients received the prescribed drugs; the 7% did not receive them because they were out of stock.
MMM Lesotho June 2005 34 The Infrastructure and Facility Typology Plan however indicates the planned equipment for all levels of care and it includes more that the basic RH package. ART has only been recently introduced in seven (7) hospitals and no ART stock outs are documented.
The selected indicators have not disaggregated access to safe water and sanitation by gender. However given that access to safe water is estimated at 78.9% and toilets 19.6%, it may be assumed that up to 50% of these are women as per the BOS estimates.
The demographic survey estimates that up to 64.7% of the population has access to safe drinking water while 54.9% of the households dispose of human waste unsafely (no toilet of any type). 11.3% of household also do not have any recommended facilities for disposal of household waste, 77.5% use their own dump-sites, and only 3.1% have access to waste collection. The situation is worse in rural compared to urban areas.
According to the reports by the Department of AIDS and STI as well as that of Laboratory Services all hospitals have the capacity for HIV testing and VCT is in all hospitals. There is 38 out of around 158 health centres that also provide VCT services. There are no guidelines on the testing of rape victims and it is up to the tending health worker or doctor to decide to test such an individual.
PSI has three VCT centres in 3 districts.
Mammography reportedly used to only at the referral hospital QE II, but is no longer available.
The Review Report however indicates that there is the capacity to perform the basic laboratory investigations: haematology including FBC (3 hospitals with CD4 count machines), clinical chemistry, microbiology and parasitology including VDRL, widal, urine analysis, ova and parasites, and Acid Fast Bacilli (AFB). The hospitals can also do ELISA and rapid HIV testing. No documents could be found on Pap smears, and pelvic examination. There is universal syphilis testing for all MCH attendances and for suspect cases of syphilis.
On education and information activities, the Review Report is specific on tobacco control, and commemoration of international days. The report indicates that other initiatives have not been undertaken due to resource constraints. The AIDS department, under Behaviour Change Communication (BCC), reports to have printed and distributed 50,000 ARV, PMTC, and HTC posters as well as 30,000 pamphlets countrywide.
The Scope of services as per the Review Report is broad covering all essential services for women including mental health care. The reproductive services reported on include the conventional MCH/FP as well as adolescent health. Not much is mentioned of SGBV. Mental health services are available from the 9 district hospitals as well as the referral hospital.
According to the Selected Indicators some of the coverage figures are as follows: Contraceptive Prevalence Rate (CPR) 27.6% (40.6% DS) Deliveries by trained human resources 60% Persons tested and counselled for HIV 6.9% Male to female ratio epilepsy 1:5
MMM Lesotho June 2005 35 Outpatient Department (OPD) contact females depression 14.4% OPD contacts female alcohol related disorders 2.2% OPD contacts all forms of mental problems 52.5%
Blood transfusion services are offered at all hospital provided it is available at the Lesotho Blood Transfusion Services (LBTS). No transfusion services are at levels below the hospital.
Psychosocial counselling, support and development of human resources is mentioned in the MOHSW Review Report 2005 in the context of HIV and AIDS. Social Welfare Officers also offer the service. It is not clear from the literature what type of services are available for victims of SGBV.
The Human Resources Strategic Plan 2005 to 2025 indicates the problem of shortage and high attrition of skilled health human resources. Except for Psychiatry data is not disaggregated by speciality but both this plan, and the selected indicators highlight the doctor to patient ratio of 1 to 16,000 while the nurse to population ratio is 1 to 5000 with a nurse to patient ratio of 1 to 17. The outpatient (OPD) contact per capita is estimated at 0.5. In psychiatry the ratios per population of 100,000 are Psychiatrist 0.05, Neurologists and Neurosurgeons 0, Psychiatry Nurses per 10,000 population 0.2, psychologists per 10,000 population 0.09, while social workers ratio per 100,000 population is 1.2.
While the information is not specific on women the Review Report indicates that the 18% of clients not satisfied with services also included those who felt the attitude of health workers was not supportive.
The Women’s Health Survey 1998 indicated that a large group of women reported they had problems with the care given at these hospitals and resorted to either ignoring the illness or to self medication; although they could adopt combination strategies.
The Baseline Study on the Magnitude of Abortion conducted by the MOHSW/WHO found out that while abortion was high (16% female admissions and 50% female inpatient mortality), such affected individuals had limited access to adequate, quality and humane post-abortion care services and appropriate enhanced technology. The conclusion was that service providers needed to change their attitude to ensure quality services. The study further indicates (based on Mohai et al, Factors associated with Teenage Pregnancy in Lesotho) that of teenagers aged 13 to 19 years, teenagers formed 14% of all hospital admissions and 27% of premature deliveries, while they formed 23% of all ANC first visitors.
The current Health Management Information System (HMIS) does not capture data for monitoring the status of women’s health services in totality. Data captured under reproductive health comprise the conventional MCH/FP. OPD data presents diagnoses and may be gender disaggregated. Information may also be obtained through inpatient data on causes of admission and mortality. Information on women who are victims of SGBV, other than rape, are reported as per diagnosis; only special record review studies would capture the cause.
3. Methodology
MMM Lesotho June 2005 36
3.1 Sampling
3.1.1 Probability sampling method
As the first stage of sampling three (3) of the ten (10) districts were randomly selected. Within each selected district, enumeration areas, as set out by the Bureau of Statistics (BOS), were selected by ecological zone (4 zones: Lowlands, Foothills, Mountains and Senqu River Valley, that experience significantly different climatic conditions). The enumeration served as the primary sampling units {PSU} (first stage sampling units), selected with probability proportional to size (PPS) with the number of households serving as a size measure. Within each selected enumeration area, the households were selected through systematic random selection as the second stage of sampling (Second Stage Sampling Units [SSUs]). The average cluster size was determined to be 20 households, thus 7 (137/20) urban and 21 (413/20) rural clusters.
3.1.2 Stratification
In order to cater for the urban and rural domains, given that the urban population is 25% of the total, the 550 households were then subdivided into 137 (550 x 0.25) urban and 413 (550 x 0.75) rural. At the time of data collection however the respondents were composed of 33% urban and 77% rural women.
3.1.3 Sample size determination
The target population selected was women of the age group 15 to 49 years. To determine the required sample size the formula used was: Sample size = n = t^2pqdeff d^2 Where n = sample size t = standard normal deviate for 95% confidence limit = 2 p = proportion of the population that are women 15 to 49 years (population of interest) = 0.5 q = complement of p (1-p) = 0.5 deff = design effect = 2 d = tolerated margin of error for the confidence limit of 95% (D = 0.05 [(5%])
The total population of women 15 - 49 years to be interviewed was therefore determined to be 661. If 661women were to be interviewed, given the average household size of 5 and that women 15 to 49 years comprise 24% of the population to be (1996 population census), the number of households to be visited was calculated to be 550 (661/5 x 0.24).
3.2 Description of data collection methods
MMM Lesotho June 2005 37
Ethical Issues and Consent
In order to adequately respond to the terms of reference it was decided that structured questionnaires, focus groups’ discussions, facility spot checks, as well as key informant interviews be used to collect the required information. The concept paper, tools and plan of the study were submitted and approved by the Ministry of Health and Social Welfare. Permission was sought from both the Ministry and CHAL for sampling their facilities. The Ministry of Health then wrote a supporting letter to the District Secretaries of the concerned districts; they in turn permitted and informed the chiefs of the sample villages, of the activity. The chief was the first point of call on entering the village and households only visited with their consent. The villages where the chiefs did not permit the study were excluded from the study; similarly the facilities where the proprietors did not consent. We went back only to the villages and facilities where an alternate date or time was suggested. At all stages the study rationale, objectives and expected outputs were explained and clarifications, including not raising community expectations, were made. Oral consent was sought from all those who participated in the study, including health facility staff.
3.2.1 Structured Questionnaires
Five Hundred and Seventy Three (573) Women aged 15 to 49 years, from 550 households, were interviewed at their abode using a structured questionnaire. Nine (9; 7 health centres and 2 hospitals) most senior health facility staff was also interviewed using a structured questionnaire. This questionnaire also included a facility check for specified items by the supervisor. The supervisor also conducted exit interviews with users found at the facility at the time of the visit.
3.2.2 Focus Group Discussions
Focus groups members were identified from the clientele found at the facilities and in the villages/neighbourhoods as well as from the identified women pressure groups. Associations of People Living with HIV and AIDS (PLWHAs) were specially sought. Focus groups’ discussions were conducted either at the health facility or a suitable location within the village or urban neighbourhood. A total of 9 Focus Group Discussions (FGDs) were conducted.
3.2.3 Key Informant Interviews
The key informants at village level included Facility Nurses, Chiefs, Village Health Workers, Traditional Birth Attendants, Traditional Healers, and Support Group members available at the time of the visit. Special recognition was given to women and girls living with HIV and AIDS. A total of Nine (9) of such informants were interviewed at the village and district level, utilizing an open-ended interview guide. At the central level, a listing of all known organisations serving or with interest in girls and women was prepared. These organizations were then grouped into functions: female parliamentarians, health service providers, legal, justice, gender, and pressure groups. A
MMM Lesotho June 2005 38 representative of at least one (1) of such organization was interviewed using a guide, after giving their oral consent. An exception in the selection was made for the Ministry of Health and Social Welfare and the second main health care provider, the Christian Health Association of Lesotho (CHAL), who were automatically included in the list of key informants. Similarly, the partners and UN organizations that support health care services were selected. A total of Twenty Four (24) such respondents were interviewed using an open-ended guide.
3.3 Data Processing and Data Analysis methods
Epi Info 3.3 was used in data processing and analysis. Dummy tables for analyses (frequency and cross tabulations) were developed to facilitate analysis. The focus group recordings were transcribed and the information together with that from key informants analysed manually. The two sets of information were then together further compared for consistency of information as well as similarities of findings. 3.4 Limitations of the study
The study has the following limitations • Although the sample was randomly selected and a representative sample used, the geographical spread of the source of information was relative to the size, composition and differentials in population exposure, as well as facilities that offer services not as wide. Issues of equity, especially for the remote rural populations, could therefore not be adequately addressed. This was due to time and financial resource allocation that limited the geographical spread of the sample for the study. • Due to short time allocated up to report submission, preparations were hurried and in some cases not all the intended interviewees could be met due to their own time availability and prior commitments. • The study had to be undertaken during working hours; in the towns the majority of the women interviewed were therefore most likely to be unemployed.
4. Key Findings on Constraints and Challenges to Women’s Access to Health and Basic Services
Community Level
Five Hundred and Seventy Three Women (573) 15 to 49 Years were interviewed; 46.9% urban and 53.1% rural. In ecological zones the women were 41.2% lowland, 9.4% foothills, 24.8% mountains and 24.6% Senqu River valley. The study showed that 55.3% were married, 3.9% separated, 1.9% divorced, 12.1% widowed (73.2% ever married), and 26.8% single. The age groups of the respondents, in years, were 2% less than 15,
MMM Lesotho June 2005 39 18.8% 15 to 19, 22.1% 20 to 24, 17.4% 25 to 29, 13.4% 30 to 34, 8.1% 35 to 39, 10.3% 40 to 44, 7.8% 45 to 49, and 0.2% 50 and above. Their levels of education were that 21% had never attended school: 54.9% had completed primary school, 18.7% had completed secondary school, 8.3% had completed high school, while 1.6% had completed tertiary education.
Six (6) focus group discussions were conducted at or in the neighbourhood of the 6 health facilities that were responsible for the villages visited. Threee groups were each composed of support group members, women living with AIDS, and community health workers. Three other groups were composed of women met at the time of the visit to three (3) of the Nine (9) health facilities.
4.6 Economic Factors and Impact of Health Care Financing
4.6.1 Affordability of Services
Only 32.1% (184) of the women were employed, mainly in the informal sector/ income generation activities, in occupations such as domestic worker, dress making, fruit and other commodities sales (including alcohol); only 15 were formally employed in low paying jobs such as returning officer, factory worker, and nursery teacher. Three (3) of the women were traditional healers, and one (1) a chief. Sixty One comma nine five percent (61.95%) of these women earned less than Five Hundred Maluti (M500) a month: 12 earned M10 to M110, 72 earned M111 to M310, while 31 earned M311 to M 500 a month. The women who lived in urban areas were also more likely to be employed (39.4%) compared with those living in rural areas (25.7%). The employment status by ecological zone was that more women living in the lowlands (47.8%) compared to the mountains (25%), Senqu River Valley (20.7%) and foothills (6.5%).
At all sites visited, people paid for health care. The main sources of health care were the health centre (55.96%) and the hospital (40.61%). While the health center was the first choice for all ecological zones there were significant variations with the lowlands the highest at 78.1%; in the foothills the rate was equal between the choice of a hospital and of a health center (48.1%); women in the mountains (52.1%) and Senqu river valley (62.3%) selected the hospital as their first choice for care. Rural women (64.1%) selected the health center as their first choice compared to the urban who selected the hospital (57.8%). Of the women who had sought emergency pregnancy care, 48.6% at either the hospital or health centre (34%), 6.6% (36) indicated they were not able to pay for the services. The first choice for emergency pregnancy care also significantly varied by ecological zones with more women in the lowlands selecting a health center (43.7%) while in the other zones more women selected the hospital: foothills 56.2%, mountains 47%, and Senqu river valley 64.8%. The rates for the rural area were similar at 41.2% and 42.3% but the choice of a hospital much higher for the urban women (55.8%). Of the 543 women who had ever sought health care, the majority indicated they had paid less or M20 and 93% were always able to pay the fee. The costs for curative care were 48.3% at the cost of ten (10) or less Maluti, probably indicating use of GOL facilities. Other costs were all less than 100 Maluti, 35.9% in the 20-40 Maluti range, probably indicating use of CHAL facilities. For those (19) who were not able to pay the fee 73.7% (14) indicated they had no money at the time. Only 39 of the 543 women had been sick in the past 3 months and 66.7% (26) of these women had not utilized health services due to shortage of money, 11% had other reasons and only 1 did not because she was caring
MMM Lesotho June 2005 40 for someone sick. A similar picture held for the maternal health services except for deliveries where 88.2% of the costs were above 40 Maluti, probably indicating less use of GOL facilities for deliveries.
The focus group discussions confirmed that most women are involved in the informal sector as an income generating activity. More and more husbands were retrenched from the mines. The focus groups also confirmed fact that all services were paid for and at Twenty Maluti (M 20.00) or less. The costs reported ranged from M5 for children and M10 for adults to a maximum of M45 per visit. While in the main the women indicated they would even borrow when in need of health care they indicated that there were those for whom the fee was a deterrent to utilization of health facilities. This was more emphasised by the PLWHAs than any other group.
The key informants were of the opinion that it is getting harder to access services of any type due to poverty consequent to the retrenchment of mineworkers and the high unemployment rate. Agriculture production has also been reduced by the drought, leaving little for sale. The little available income was sacrificed for the education of the children. The lack of capacity by women to decide on resource allocation was reported to aggravate the situation leading to late presentation at the facilities in some cases. Neither can they seek for jobs. Only the educated ones could decide on their own money. They considered the Government of Lesotho (GOL) facilities more financially manageable to households and women, compared to other providers of care.
The findings on the low economic capacity, limited decision-making capacity, and high unemployment rate of women, as well as reduced access to basic needs such as food, is corroborated in the literature. Although the fees are highly subsidized as per the indicated costs, there is still a proportion of women for whom service fees are a constraint to accessing care. The situation is aggravated by the women’s low employment and limited capacity to make decisions including on resource allocation. The situation would be expected worst off where the unemployment is worst off in the foothills followed by mountains and Senqu river valley, as well as in rural compared to urban areas. The first choice for these zones is also the further off hospital making it more expensive to access. The Senqu valley lies within the mountains and both are predominantly rural and should be priority in easing financial accessibility to services, followed by the foothills and then the lowlands.
4.6.2 Penalties for Non-payment
In the focus groups, the women indicated that only two (2) options if one were not able to pay the fees: most facilities would neither offer treatment nor services or in some cases one would arrange to pay later. The latter was only mentioned from one (1) rural health centre, out of the 9 visited.
Key informants were not aware of any fee exemptions except for emergencies where a patient would not be turned away. Health workers but not other community leaders were the only ones who mentioned this exemption criterion, probably indicating their clients’ lack of awareness of the exemption. The only other way for user fee exemption was if assessed deserving (destitute and poor), by the Department of Social Welfare. It was however noted that appropriate officers are few in number and cannot adequately meet the demands for their services.
MMM Lesotho June 2005 41
The literature (MOHSW Baseline Study 2000) indicates exemption from user fees for the poor and destitute (4%). This may only be after assessment by social welfare officers. On the other hand, a high proportion (83%) of the destitute had not utilized the nearest health facilities because of cost. This may be an indication that those likely to be exempted are not aware of the facility.
While the exemptions are limited, they also follow a bureaucratic system that may intimidate the deserving candidates as well as their not being aware of such exemptions. The exemptions are thus inaccessible to women, further exacerbating the situation of the poor.
4.6.3 Perception of Women of the Magnitude of Food Insecurity and on Factors Contributing
In this study 73.9% (393) had five or less dependants and 5.7% (342) of women had household members. Their main sources of food were purchase (64.1%) and farming (28.6%); 5.1% (29) depended on food aid and 1.8% (10) on hand outs. There were significant differences between the ecological zones in the extent of dependency: purchase ranged from 71.4% in the lowlands, 68.6% Senqu, 55.3% mountains, to 44.4% in the foothills. On the other hand more women depended on farm produce in the foothills (55%), compared to the lowlands (24.8%), mountains (37.6%) and Senqu (15.7%). Dependency on food aid and hand outs, while comparatively low, were significantly much higher respectively in the mountains (5% and 2.1%), and Senqu (12.1% and 2.9%) compared to the lowlands (2.1% and 1.3% respectively; these were not options in the foothills. While dependency on purchase and farming were comparatively similar in the rural areas (48% and 43% respectively), more urban dwellers relied on purchase (82.4%) than farming (12.4%). Reliance on food aid and hand outs were however more in the rural (7% and 1.3%) than urban (3% and 2.2%) areas.
Through the focus groups, women were of the opinion that there was increasing poverty that was made worse by increasing widowhood due to HIV and AIDS. All essentials were becoming more and more unaffordable making a balanced diet very difficult to afford. PLWHAs specifically complained that the food aid meant for them was not always accessible. Key informants reported that access to food was further exacerbated by drought negatively affecting agricultural production.
The literature review indicates an estimated 38.37% of households, by projection women, finding it difficult to access food.
It is generally known that there is less arable land in the mountains and Senqu river valley compared to the lowlands and foothills. The higher dependency on food aid and hand outs in the rural areas and mountains and Senqu may therefore be a reflection of higher food insecurity in these areas. These are also the areas where finances are more a constraint to accessing health care. The high level of food insecurity was explained to be secondary to the high levels of unemployment and therefore inability to purchase food, drought leading to poor agricultural production, and increasing widowhood due to AIDS therefore loss of breadwinners. Special groups such as PLWHAs as per their input may be worst off in
MMM Lesotho June 2005 42 the geographically disadvantaged rural areas of the mountains and Senqu river valley. The higher dependency on agriculture in the foothills coupled with no dependency on food aid and hand outs may not only be a reflection of the zone’s higher agricultural activity but could also reflect lack of access to food aid hence not a choice. The priority ecological zones for intervention are again reflected to be the mountains and Senqu river valley followed by the lowlands and foothills last.
4.6.4 Women’s Occupations and Level of Education
Most of the women interviewed had completed primary (54.9%) and secondary (18.7%) school level of education. 8.3% had completed high school education level while 1.6% had tertiary education. 16.5% had not completed even primary education. Lack of schooling was highest in the Senqu river valley (33%), while completion of all level of education was highest in the lowlands. The foothills were the lowest in all levels. No educational level completed was also higher in rural than urban areas. Employment levels were higher in the lowlands and lowest in the foothills as well as urban compared to rural areas. Of the 32.1% of the women employed, the majority were involved in IGA and low paying jobs. For the women who had not completed primary education their main occupations were IGA (60%) and domestic work (33.3%). A similar picture held for those with only primary school level of education of whom 71.3% were involved in IGA while 16% were domestic workers. While the proportion involved in IGA remained high (76.5% and 56.3%) a change from domestic to low paying civil service jobs (11.8% and 31.3%) was observed with those who had completed secondary and high school education, respectively. While the key occupations stayed similar the proportions were reversed at 66.7% civil service and 33.3 IGA for those with tertiary level education, but the numbers were too small (3). Notably, 20.8% of these were girls aged less than 20 years and all were domestic workers.
The majority of the women are therefore unemployed and not of a level of education high enough to facilitate employment. The majority are therefore involved in lowly paid jobs, rendering them economically dependent. Young girls who have to work are also commonly employed as domestic workers. The situation may be worse in of rural areas and zones where fewer women attain secondary and high school education as found in the foothills (14.6% and 4.3%) and mountain (17.5% and 10.9%) zones followed by Senqu river valley (23.3% and 26.1), hence lower purchasing power. The situation may also be similar in the rural compared to urban areas.
4.1.5 Opportunities Available for Women for Gainful Employment
Only 15 of the 184 women were formally employed in low paying jobs such as returning officer, factory worker, and nursery teacher. Three (3) of the women were traditional healers, and one (1) a chief. The others were all involved in IGA activities, not gainful employment. In the focus groups the women indicated that while there were opportunities for gainful employment for the educated, the common practices included consideration of personal knowledge or relative, political or denominational (Christian) affiliation, in addition to the skills. No specific criteria were applied to women but the practice applied to both men and women. The key informants’
MMM Lesotho June 2005 43 opinion was also that women were reported to be the least likely to gainful employment irrespective of level of education. The situation was reportedly accentuated by the closure of the garment factories. Some informants felt that the few who were highly educated got to senior positions but the very top echelon was still occupied by men. Where females are senior to men, the latter are always looking for opportunities to take over.
On the other hand women could be employed based on political affiliation, relationship with employer, or as a replacement for retired or dead mother/mother-in- law.
While the situation of educated women was reported as not bad/satisfactory, with women in senior positions such as Ministers, PS’s, and parliamentary members, the uneducated women have limited opportunities. They have to resort to low paying jobs such as domestic work, textile factories, street hawkers, and even moonlight as CSWS. Women who had attained a high level of education had gainful employment. There also were, although a minority, women in highly respectful jobs such as Speaker of Parliament, Judges, Ministers and Magistrates.
The literature finding was that girls’ primary school enrolment is higher (72%) compared to that for boys (66%) and so is the drop out at 6.1% and 8.9% respectively, due to financial reasons.
The determining factor for women’s gainful employment is therefore their level of education. Children that have to work, presumably dropping out of schools are more likely to be employed as domestic workers while at the same time with little or no control over the allocation of income earned.
4.1.6 Women’s Capacity to Decide on Resource Allocation
The proportion of decision on household resource allocation that included both partners was (31.8%), the woman/myself was (27.4%), the husband (12.2%), and relatives (28.1%); the other was only 0.5%. The significant relatives were members of the family, predominantly biological mother, and mainly for single women. The capacity of the women to decide significantly increased with their level of education: primary 23.3%, secondary 21.6%, high school 37%, and tertiary 44.4%. Women who were older and had been in marriage longer also made decisions more frequently. The next most frequent decision making was a joint one by both the husband and wife (30.4%) and the least was where the decision was only made by the husband (13.6%). More women (36.5%) in the urban areas could make decisions compared to those in the rural areas (28.2%).
It is therefore clear that women with a higher level of education and probably higher income earners as well as those who had a long time in marriage could decide on resource allocation within their households, especially if of urban abode. On the other hand, for young working women majority of whom were single and had dropped out of school, decisions were made by relatives.
MMM Lesotho June 2005 44 4.7 Socio-cultural Factors
4.7.1 Socio-cultural Norms that Discourage or Inhibit Health Services Utilization
The socio-cultural norms that inhibited utilization of services centred on adolescence, pregnancy, and mourning for a spouse. They were as follows: • Puberty/adolescence: abstaining from intake of protein-based food such as eggs and tripe for fear of early sexual maturation and increased libido. With increasing poverty the girls are therefore more at a disadvantage nutritionally and therefore in their development. The education at health facilities is contrary to this and girls may be deterred from utilizing facilities. • Pregnancy: abstaining from intake of eggs for fear of intact membranes at delivery (amniotic sac present first); wearing of special attire as per clan norms that sometimes discourages hygienic habits and prescribe walking barefoot. Not only does it embarrass the woman but in winter she also is exposed to the cold. She may then decide not to utilize health facilities. On the positive side the family assists the woman and she does not carry heavy weights; she is separated from her husband and is able to avoid unwanted sex. • Mourning: a woman in mourning is restricted in that she may not pay visits to other households, should not travel after sunset, should not shout even in need, should not sit in a chair, and should abstain from sex. The restrictions emotionally further traumatise the woman and she is left isolated. She at the same time cannot earn a living nor travel to a health facility for fear of reaching home late.
The Behavioural Surveillance Report by Sechaba Consultants indicates that there are myths and misconceptions, including taboos, about sexual and reproductive health, influenced by gender dynamics that render women less likely to seek services, if perceived contrary to the norms.
Women’s utilization of health services may thus not only depend on their partners but also relates to their minority status as well as myths, taboos and misconceptions centred on sexuality and reproductive issues, as well as cultural practices during period and the mourning period.
4.7.2 Available Social/Legal Systems for Protection of Women Against Sexual and Gender Based Violence
Eighty Eight (88) or 15.5% of the women had had experience of violence. The majority (54.8%) of the perpetrators were other people not related to the victim. Husbands accounted for 30.5% while brothers and relations accounted for 6% and 9.6% of the perpetrators, respectively. The major forms of violence were physical (45.1%), verbal and/or psychological (28%), and sexual (25.6%). While 5.8% of these women did not report for fear of the aggressor or the relatives, 43% reported to relatives, 29.1% to the local chief, 19.8% to police, and 2.3% to others. Nothing had followed 32.5% of the reports. Action had been taken for 20.5% that had been reprimanded by the chief, 25.3% reprimanded by the family, and only 15.3% of the aggressors charged. 56.8% of the victims reported to have been satisfied with the outcome but 43.2% were not.
MMM Lesotho June 2005 45
96.1% (547/569) of the women indicated they would report a rape outside the family if they witnessed one; primarily to the chief (50.2%), and police (41%). Fear of aggressors (23.5%) and relatives (23.5%) were the key reasons for not reporting by the 22 who would not. A similar response was received for family member rape where 98.8% (557/564) indicated they would report the rape. The chief (44.8%), police (38%) were again the ones who the report would be made to; relatives accounted for 13.4%. Similarly fear of relatives (50%) and other reasons (50%), were the reasons why the 7 respondents would not report a family rape. The other reasons were mainly fear of, or reluctance to, being called into court as a witness. Significant differences although following a similar pattern, were observed by ecological zone. In the lowlands such reports would be primarily made to the police (47.4%) and to the chief (53.7%); in the foothills the rape would be primarily reported to the chief (53.7%) and to the police (37%); and in Senqu river valley 50.5% would report to the chief while 32.4% would report to police. In the mountains the report would primarily either be made to the police (28.6%) or to the relatives (22.6%). While most (53.7%) of the rural women would report to the chief followed by police (28.7%), urban women significantly differed and would report more to the police (48.8%) followed by the chief (34.6%). Outside where the perpetrator was charged (15.3% of reported cases), the outcomes included remand by family (25.3%) and by the chief (20.5%). Nothing was done for a significantly high proportion of cases (32.5%), more with relatives (48.1%); but also significantly with the chief (33.3%) and police (18.5%).
Through the focus group discussions the women cited chiefs, police and family as the protectors. They however felt reporting husbands, even for incest was not often done due to stigma and fear of the husband. Quite often, police were reported to release husbands back and they would then beat the wives again. Men were also reported to abuse the Sesotho culture that a man is a head by taking advantage of their position for coercive sex. The women felt the chief and community were more effective in protecting girls against coercive marriage (chobeliso). Protection was not always effective as per reported cases where police directed the violated to bring the culprit to them and often informed women to make peace with their husbands. They reported that police only became serious where there was the likelihood of serious consequences (blood shed, destruction of property). The law was also slow even in cases of child expulsion from home by their father. At the same time the women were not sure of their human rights except that they may decide on sending children to school, what to buy, and who is welcome to their household. They did not think they had any sexual nor reproductive health rights because that was the discretion of the husband (and mother-in-law). They however indicated that the men abused the right of being household heads. They indicated the authority of the man is also reinforced in Christianity where sexual desires are with a man not a woman. Stigma especially attached to sexual issues was cited as an indication of lack of rights e.g. a girl coerced to marriage is usually first gang raped by the “prospective” husband and friends; she then is ashamed of going back home and her family would not accept her back and thus stays married to the eloper. The women indicated they had minimal access to a chief on issues of violence; the situation was only better with a Chieftainess. In cases of rape, the vulgar language and the humiliating as well as dehumanising questions asked at the courts, intimidated women. The courts were further not in favour of women since the males would hire lawyers that would be listened to better.
MMM Lesotho June 2005 46 On Sexual and Gender Based Violence (SGBV) key informants/respondents felt that although there were laws that protect women, their implementation had to be through men, the traditional/historical custodians; the law implementation has thus not been as easy and the laws continue to be violated with impunity. Customary practices and values also conditioned women to be subservient even in cases where behaving otherwise would be to the health benefit of herself and even her spouse. The respondents further indicated that men were also the family protectors and in their absence due to employment away from home (or death) women were rendered more vulnerable to such violence. Women would not decide on sex and were often forced to. Such women opted not to report this to anyone for fear of stigmatization including desertion by husband, especially in cases of rape. Where the family was not oppressive such cases were reported to the Chief, the police and to the courts for judgment. However the victim stayed stigmatized. The informants considered the policy of health facilities to only undertake certain procedures on women provided the husband consented as either abuse or a perpetuation of abuse.
At the same time, discussions also indicated that, in addition to conviction for abortion, women often end up in conflict with the law due to their physically abusing other women and spouses consequent to their spouses’ behavior.
While hardly anyone could identify specific fora addressing concerns and issues of women’s health some respondents indicated that support groups and other women’s organizations such as burial societies, church groups and home economics associations had extended their activities to include the health of women e.g. organized emergency transport and Home Based Care (HBC). The on-going social mobilization by the Department of Gender on women and politics; education through the Education Transformation Resources Centre (ETRC); the activities of Federation of Women Lawyers (FIDA) as well as Women and Law in Southern Africa Research Trust (WILSA), with regard to human rights; were the only civic education on women’s human rights that most respondents identified. Some respondents identified women occupying senior level government and other institutional positions (Commissioner of Police, Ministers, Priests, Magistrates) as a proxy indicator that women’s rights were being slowly understood and/or appreciated. Women were reported not to have access to legal representation unless they could afford fees of a private lawyer. The legal aid service through the Ministry of Justice was only available in Maseru and not mentioned outside the capital.
The information was supported by the MOH/WHO Women’s Health Survey 1998, MOH/WHO Study on Violence against Women in Lesotho, and WILSA’s Sexual Violence in Lesotho and In Search of Justice in Lesotho Where do Women Go. UNICEF/Mokuku in the Hear Us Shedding Light on the Plight of Child Domestic Workers in Lesotho, further highlights the plight of female domestic workers who are children. They are reported often subject to emotional bullying, physical abuse, and sexual abuse. At the same time, community members were reluctant to report or intervene even where they knew such abuse occurred. While such community members were of the opinion that such cases should be reported to police they were either not aware of the Sexual Offences Act 2003 or felt there was a discrepancy between the law and the way it is implemented.
MMM Lesotho June 2005 47 On women’s mental health, females accounted for 14.4% of the depression and 2.2% alcohol related disorders, while they accounted for 52.5% of OPD contacts for all mental problems. On the order hand psychosocial counselling is in the review report only mentioned in the context of AIDS. This may indicate that the women’s mental health needs are as yet to be accorded the priority they need.
Law enforcement in communities therefore primarily lies with police and chiefs. The differences by zone on whom the violence would be reported to may be an indication of less access to police in the mainly rural mountain, Senqu and foothills compared to the lowlands where access to towns and development centres may be easier; or may reflect the differences in the trust between police and chiefs. The fact that in some cases when cases are reported to the chiefs (33.3%) and to the police (18.5%) reinforces the FG reports that reports do not always end up with a supportive stance. It may be concluded therefore that while there is a law (Sexual Offences Act 2003) that should protect women (and girls) against SGBV, the institutionalization of the minority status of women as per customary law, the preponderance of males in the legal and justice systems, the intimidating legal procedures, the limited legal aid, and lack of women’s awareness and civic education on these rights, result in poor implementation of such protection for women.
4.8 Physical Access Barriers
4.8.1 Average (mean) Distance to Nearest Health Centre
The main modes of transport, to the nearest facility, were either public motor transport (42.2%) or on foot (56.5%); 0.4% used horses and 0.9% other means. The majority of the respondents (73.8%) took less than an hour to reach the nearest health facility; 25.5% took one to two hours; only 0.7% (4) took three to four hours. In the main (98.9%) there was no community-organized transport for emergencies. The duration it took to reach a health centre varied significantly between the zones. The highest proportion (87%) was in the foothills, followed by lowlands (82.4%), mountains (66.7%) and last Senqu (61.7%). For the minority 0.7% who took more than 2 hours to reach the nearest health facility, it was in the foothills (3.7%) and Senqu (1.4%); o.3% were rural and 1.1% urban.
While the majority of the key informants/respondents felt the spread of health facilities was wide and covered urban as well as rural areas, distance was reported a problem in the mountain areas. They however were of the opinion that there was a wide health facility distribution, hence physical access, was fair. The problem was that with increasing poverty most women could not afford the cost of transport as well as service fee plus the accompanying food away from home.
Although Village Health Workers (VHWs) had been in service for a longer period, most respondents’ opinion was that support groups were now the dominant group of service providers at community level. Co-operation and collaboration was however encouraged and fostered as far as it could, with VHWs sometimes leading or training the other support group members, but this varied from place to place. Traditional Healers were referred to as the first to be consulted, although often secretly, prior to visiting conventional health facilities. Traditional Birth attendants were hardly mentioned and reportedly most of these were VHWs as well.
MMM Lesotho June 2005 48
The physical accessibility of health facilities was corroborated by the focus group where facilities were reported to be less than an hour’s walking distance from the respondents’ homes. The exception was in the mountains where the women indicated that the health facilities were far and they sometimes had to walk for up to 5 hours.
The Baseline Study by Zicken-Sechaba Consultants corroborated that up to 79.5% of the population had to walk less than 2 hours to a health facility (MOH standard of physical access). The Health Statistical Tables further indicate that up to 20% of the population have limited physical access to health facilities.
The MOHSW defines access as less than 2 hour walking distance from a health facility. Therefore while up to over half of the population have physical access to a health facility, there was a significant proportion whose access was aided by vehicle transport and a proportion, especially in the mountains, for whom whatever the mode of transport, physical access was a problem. This problem was more so for hospitals that are the main providers of emergency services for women. More women n the foothills had problems of access to a health facility compared to the mountains and senqu that also faced the problem. The lack of physical access may further explain the lack of reliance on food aid in the foothills since the distribution is usually at health facilities. At the same time there was no organised transport for such emergencies.
4.8.2 Average (mean) Distance to Nearest First Referral Hospital
For the same mode of transport, the hospital facility was less than an hour away for 60.3%, one to two hours for 38%, and three to four hours away for 1.8%. A similar picture emerged for reaching the hospital with 60.3% taking less than an hour while 38% took 1 to 2 hours; only 1.8% took more than 2 hours. Similar to the health centre the duration differed significantly between zones and those who took more 2 hours were all in the mountains and Senqu, more in urban (1.9%) than in rural (1.7%) areas. There was a significant proportion whose access was aided by vehicle transport and a proportion, especially in the mountains, for whom whatever the mode of transport, physical access was a problem. This problem was more so for hospitals that are the main providers of emergency services for women
Focus group discussions similarly corroborated the information but in the mountains the women indicated hospitals were really too far to walk and could only be accessed if one went on horseback or by car if it could reach.
The problem of physical access is therefore more for hospitals that are the main providers of emergency services for women in the rural foothills, mountains and Senqu river valley. At the same time there is no organised transport for such emergencies.
4.8.3 Average (mean) Distance to a Referral Health Facility Offering Emergency (including surgical) Obstetric Services
The hospital was reported to offer emergency obstetric care (EOC) and was the same hospital for which 60.3% were less than one hour away driving. Through the focus groups discussions the women defined EOC mainly as caesarean section; others
MMM Lesotho June 2005 49 included myomectomy and assisted delivery. The key informants were of the opinion that EOC facilities are very limited. The low patient to doctor and patient to nurse ratios exacerbate the problem. The situation is made even worse by the inadequate skills of the human resources, the inadequate equipment and supplies, and closure of health centres outside working hours, translated into even lesser access to EOC.
The review report 2004/2005 indicates that a facility assessment found only 21.7% of health facilities with essential drugs for provision of EOC.
Hospitals are therefore the main providers of EOC. There is therefore a proportion of women who do not have access to such facilities; further exacerbated by that there is no organised transport for such emergencies as well as the inadequate human resources skills and numbers.
4.8.4 Availability of Ambulance Services for Emergency Obstetric Cases
The communities (98.9%) neither had any ambulance nor other community-organized transport for emergencies; only six (6) urban women could hire an ambulance if needed.
The focus group discussions further corroborated this and further indicated that even where health facilities transported a referred patient, the individual/family had to pay for such transport.
EOC is therefore not only affected by physical access but is further compromised by lack of transport for emergencies.
4.3.4 Affordability of Ambulance Services
This could not to a large extent be indicated since there was none. However in the focus group discussions, the costs to get to hospital through facility transfer by hospital ambulance ranged from M20.00 to M70.00 that the women assessed as inexpensive.
4.8.5 Average (mean) Waiting Time for Ambulance Services
This could not be indicated since there were none, except by facility transfer.
4.8.6 Availability of Systems or Community Mechanisms for the Provision of Transport for Emergency Cases
There were no community-organised mechanisms for emergency transport; individuals and families had to organize their own transport
4.8.7 Range and Quality of Health/Social Services Available to Women and Girls at Community Level The community level services comprised of activities undertaken at both the community level and at the nearest health centre. Health posts served as outreach for either the health centre or hospital outpatient services.
MMM Lesotho June 2005 50
Of the women interviewed, their primary source of services were the health centre (56%) and the hospital (40.6%); 1.3% sought services from the Village Health Worker (VHW), 0.9% from the Traditional Healer while 1.3% used other sources.. The services available at the health centre included curative care (99.5%), ANC (91.9%), Post-natal Care ([PNC] 91.2%), deliveries (67.4%), family Planning (61.5%), counselling (26.1%), and others (7.4%). The majority of the services offered by the health centres were assessed good (65.4%) while 21% were satisfactory, 11.1% poor, and 2.5% bad. The criteria for the classification of the services centred on quality, related to limitations of number of patients/clients consulted a day coupled with long waiting times in an endeavour for clients to be the first in the queue, as well as availability and unsatisfactory attitude of health workers attributed to heavy workload and frustrations at work.
According to the FGDs, the services at community level were offered by VHWs, TBAs, Support Groups (SGs) and Clinic Staff. The services comprised of curative care, child welfare and Antenatal Care (ANC). The VHWs also dressed wounds, collected vital statistics (births and deaths), referred children for immunization, as well as educated on and advocated for ANC. The SGs mainly cared for the chronically sick with emphasis on People Living With AIDS (PLWHAs). SGs were regarded very helpful by the PLWHAs and offered not only care but also provided the PLWHAs with protective materials including gloves, food supplies, counselling and referral to a doctor. PLWHAs felt the SGs were more empathic to them compared with VHWs. On the other hand, the SGs felt that their patients were very irritable and did not want their care especially if they had been to an Anti-Retroviral Therapy (ART) centre, while at the same time very dependent for all their needs and unwilling to take care of their own welfare. Through the FGDs the services offered at health centre level included Information/Education/Communication (IEC) with emphasis on Maternal and Child Health (MCH) issues including Breastfeeding, as well as education and screening for the ART programme. PLWHAs felt they were discriminated against at health facilities and procedures such as that for treatment of STI one has to bring in a contact were deterrent to facility use. The state of sanitary facilities and/or lack of such facilities, the lack of confidentiality as well as privacy further negatively affected the care at facility level.
According to the VHW training manual the services a VHW should offer comprise of health promotion and preventive activities covering a wide range of services diseases, nutrition, reproductive health, and water and sanitation. Through the CBD programme they also distribute contraceptives in specific geographical areas and primarily where the religion of the proprietor does not allow for use and therefore distribution of contraceptives by such a health facility. With the advent of AIDS they also provide home based care. Services by TBAs were rarely mentioned. From the Community Health Census 2004 the ratio of TBAs to the population is 1 per 733 WCBA. Based on the review report 2004/2005 fewer and fewer health centres are offering deliveries due to the lack of appropriate human resources, poor water provision to facilities and lack of security.
The services offered at community level are broad in scope although some are very limited in coverage. The services also lean more towards providing home based care than any other service provision. The services specifically targeting women mainly
MMM Lesotho June 2005 51 centre on education and prevention but not service provision. The bias towards home based may be reflection of the escalating numbers of seriously ill patients nursed from their homes, mainly due to HIV and AIDS, and therefore a felt community need. It is interesting to note that caring for the sick was however mentioned by only 1 out of 39 women, on the reasons for not seeking care when they had needed it; financial and other constraints were the key reasons indicated
4.8.8 Proportion of Women who have Accessed Family Planning Services
Only 41.5% of the women were using a family planning method at the time. The highest proportion (35.8%) used Depoprovera, 29.8% used a condom, 21.8% the pill, and 11% IUCD. There were significant differences between zones with the highest proportion in the lowlands (51.5%), followed by the Senqu valley at 42.4%, foothills 29.6% and mountains the lowest at 28.6%, irrespective of whether urban or rural abode. The main source of the supplies was a health facility (76.7%), 7.0% from a pharmacy, and 4.7% from a VHW or Community Based Distribution (CBD) agent. 87.3% of the non-users indicated they would know where to obtain a method.
The 2001 Lesotho Population Data Sheet states that the Contraceptive Prevalence Rate (CPR) is 41% similar to the Demographic Survey’s 40.6% while the MOH selected indicators estimate the CPR at 27.6%.
The use of contraception and family planning is therefore not yet satisfactory. The proportions are significantly different between zones with women not using any method highest in the mountains (71.4% ), followed by foothills (70.4%) and Senqu (57.%), compared to 48.5% in the lowlands. Given that health facilities were the biggest source of supplies, this may not be convenient for the women for whom physical access is a problem although fewer. While for the majority physical access may not be a constraint to FP, other factors may be contributory to non-use including the women’s decision making capacity whose lack of compares well with the lower use of FP by zone. Given the high prevalence of HIV, the proportion that used condoms was low (29.8%) and the dual protection accorded by condoms was probably not appreciated; more insight into type (male or female) and reasons for non-use is required.
4.8.9 Availability of Trained Community Health Workers or Volunteers
Throughout the focus group discussions VHWs and SGs were indicated as the main sources of care at community level. While the women could not estimate ratios the national inventory indicates a total of 5369 VHWs and 1423 TBAs. With the total number of Women of Child Bearing Age (WCBA) estimated at 25% of the total (1.1 Million), the ratio of each worker to the target population is therefore 1 to 205 of the general population for the VHWs and 1 to 386 WCBA for the TBAs.
The women however indicated that the number of health workers at facilities was lately too small leading to heavy workload, long waiting times, and making workers irritable and sometimes de-motivated to deliver services (late coming on duty). They indicated the situation was accentuated by lack of supplies and equipment including poor equipment maintenance, as well as lack of transport (abuse by administrators).
MMM Lesotho June 2005 52 This is corroborated in the Review report 2005 where the shortage of resources, including human and financial, is reported to negatively affect service delivery. The situation is made worse by the lack of supervisory support to health facilities and to the communities.
While SGs and VHWs are a recognised resource for communities; TBAs are not. The quality and content/scope of the services may not be up to expectation due to human and other resource constraints.
4.8.10 Access to Sanitary Facilities
The majority of the household disposed solid waste in an unsanitary manner (67.7% heap, 22.7% ordinary pit, 3.9% in donga); only 4.9%, urban households had access to a municipality bin but indicated its disposal was erratic. A similar disposal mechanism held for liquid waste with only 10.4% of the household utilizing a soak away pit and 1.1% a septic tank.1.9% of the urban respondents owned a water system toilet facility while 15.3% owned a VIP latrine; 51.3% owned an ordinary pit latrine and 31.5% of the household did not own any toilets. The use of a heap for solid waste dominated the picture across the geographical zones as well as urban and rural areas but significantly varied in extent. The worst off zone was the foothills (83.3%) followed by the mountains (78.6%) and Senqu (73%); the lowlands were the least with 54.3 % usage. The use of ordinary pit was a reversal of the pattern with the highest use in the lowlands (32.3%) followed by Senqu (17%), the mountains (15.7%) and last the foothills (14.8%). Use of the heap was higher in the rural areas at 76.4% compared to 57.9% for the urban area; ordinary pit use was 25.9% in urban and 19.9% in rural areas. A similar pattern held for liquid waste but less significantly. Sanitary means of waste disposal were very low overall.
Access to sanitary facilities was thus low with the worst areas rural and outside the lowlands. Municipal waste disposal was very minimal even in urban areas. This may be a resultant of inadequate coverage of sanitation messages in the more difficult areas of the country, coupled with lower education levels therefore receptivity for health messages.
4.8.11 Access to Safe Water Supply
63.1% of household obtained water from a tap, while 4.9% obtained it from a borehole. Other sources of water included spring (14.1%), river (0.7%), and other (17.2%). Access to safe water (borehole and tap) however significantly varied by zones with the highest access to a tap in the mountains at 70.2% followed by the senqu at 69.5%; both were not using boreholes. On the other in the lowlands 57.1% obtained water from the tap and 9.4% borehole, followed by the foothills with 53.7% tap use and 11.1% use of a borehole. Access to safe water was also higher in rural (64.4% tap and 8.3% borehole) compared to urban (61.7% tap and 1.1% borehole)
Based on the selected indicators 78.9% of the population have access to safe water supply while the Demographic survey estimates the access at 64.7%.
Thus while access to safe water supply was moderate to high there was still 20% to 35% of the population, thence women, that lacked such access. It was also noted that
MMM Lesotho June 2005 53 it was only for this access that rural and mountains as well as senqu were better off compared to lowlands. Given that communities would rely more on authority provision of safe water as compared to waste disposal, the systems are yet to cover all beneficiaries.
4.3.12 Access to Food aid
Up to 64.1% of the interviewees relied on purchasing food for the households, 28.6% on farming, 5.1% on food aid, while 1.8% relied on handouts. Dependency on food aid and hand outs, while comparatively low, were significantly much higher respectively in the mountains (5% and 2.1%), and Senqu (12.1% and 2.9%) compared to the lowlands (2.1% and 1.3% respectively); these were not options in the foothills. Reliance on food aid and hand outs were also more in the rural (7% and 1.3%) than urban (3% and 2.2%) areas.
The focus groups also indicated increased food shortage consequent to the continued drought leading to reduced agricultural output. PLWHAs, however, indicated that the food aid was discriminatory, using screening indicators such as perceived place of residence and perceived economic status
The Demographic survey 2001 indicates that up to 57% unemployment for women while the MOHSW review report 2004/2005 mentions an overall unemployment rate of 42%. The World bank CWIQ core welfare indicators and tables also indicates that more women than men are unemployed with up to 38.37% of households finding it difficult to access food.
With the high level of unemployment the purchasing power of households will probably reduce especially negatively affecting the quality of their diet. If agricultural production has been reduced the household food security of those who rely on farming will also be negatively affected. A combination of these factors with inclusion of those that rely on handouts (another form of food aid) may probably render much more than the 5.1%, eligible for food aid, corroborating the CWIQ indicated 38.37% with difficulty in accessing food and the PLWA assertion. Food aid may therefore not be accessible as required and target groups such as PLWHAs may, as per their report, not be receiving the required food aid. The lack of reliance on food aid in the foothills could be because of higher agricultural output but there also is the possibility that food aid has not yet targeted these areas.
National Level
4.9 Factors Related to National Health System and Policies
Up to 25 key informants from government, non-governmental organizations, partners including UN and bilateral agency leaders/officers/representatives were interviewed.
4.9.1 Impact of Financial Resource Allocation Criteria on the Quality and Availability of Services for Women
According to the key informants financial resource allocation was based on the guidelines that indicate the line budget ceiling based on the history of allocations and
MMM Lesotho June 2005 54 expenditure, by the Ministry of Finance. Budgeting by objectives and the Medium Term Expenditure Framework (MTEF) are only at their infancy, introduced under the Health Sector Reform Programme (HSRP). Similarly human resources allocation is based on the history and discretion of the management of the MOHSW. No special consideration is accorded to services targeting women. With the adoption of PHC in 1979 the MOHSW adopted a decentralized system of health service management including budgetary utilization. This however encountered a lot of problems because the rest of government had not decentralized. Through the HSRP, the decentralization is being reactivated concurrent with the overall government decentralization. This is however at its infancy and too early to assess its impact.
The health sector review report 2005 indicates that there is persistent shortage of resources and negatively impacting on the efficiency and effectiveness of services. At the same time the level of supervision is very low and coupled with the long waiting times and paucity of guidelines, the quality of services is unsatisfactory.
The budgetary allocations are therefore not sufficient to ensure availability and quality of services including those for women.
4.9.2 Effects of SWAP on the Quality of Women’s Health Services
According to the key informants plans are neither based on needs nor are women afforded any special priority. Most plans are based on what is in vogue and level of available donor funding. Planning is to a large extent still vertical due to the lack of accountability, and support based on donor discretion. The MOHSW partner institutional requirements also do not facilitate for SWAP but attempts are made to ensure reciprocity and avoid duplication. Thus although the MOHSW would like to institute SWAP it is yet to take off.
4.9.3 How the Issues of Contracting out Health Services Affect the Quality and Availability of Service Relating to Women’s Health
No one was aware of any contracting out of services except for recruitment of Consultants in specific areas of expertise who function within the precincts set by the ministry.
4.9.4 Effect of Policies on Eligibility for Health Services
The key informants indicated there were no specific criteria used for deciding on service needs, patients/clients just present themselves for a service. The only determining criterion for access was the individual’s capacity to pay and to reach a facility that offers the service. The health worker or doctor met at the health facility finally decides on the individual’s eligibility for such a service. This extends to ART, currently only available at seven (7) sites. HIV screening is however available in all 17 hospitals and 38 health centers.
The Health Sector review however indicates the skewed human resources allocation on top of that in numbers, the lower doctor and nurse to patient ratios in the rural CHAL hospitals as well as their inadequate skills. This is coupled with a lack of all
MMM Lesotho June 2005 55 essential guidelines as well as drugs, supplies and equipment insufficiency. The Essential Services Programme document further highlights the centralised and vertical style of service delivery and the lack of fairness to the poor and vulnerable members of the population that include women.
A combination of the fore-mentioned translates into a high possibility that eligible individuals may in some cases not receive the required services. The situation may be more so in the rural areas served by CHAL hospitals as well as for the poor. Given the already indicated relative reduced access to hospitals and geographical disparities, ART is thus not yet available to a large number of deserving individuals and its availability skewed to urban areas.
4.9.5 Effect of Policies on Eligibility for Exemption to User Fees Payment on Women’s Access to Health Services
The key informants indicated that eligibility for exemption from user fees was dependent on assessment and certification by the Department of Social Welfare that the individual or family was destitute. At the same time the requisite officers are highly inadequate to meet all the needs.
The 2000 Baseline study indicated that 4.8% of the households were exempted from user fees but 83% of the destitute did not use the nearest facility because of cost.
The fact that the eligible did not benefit from the fee exemption may be a reflection of the limitations of the system of exemption and/or lack of information to the expected beneficiaries. There is the possibility therefore that services are not accessible to the poor, majority of whom are women.
4.9.6 Fora (forum) for Participation (or voice) of Women Concerning Issues Pertaining to Service Delivery including Women Living with AIDS
The key informants’ point of view was there were neither fora specific for women’s participation in issues pertaining to service delivery nor for addressing ills that affect women’s health. Most support group (SG) members for HBC were women and could be People Living with HIV/AIDS (PLWHAs). Women dominated all the support groups and Community Health Workers, primarily responsible for village based service delivery: IEC, HBC etc. They further indicated there was a need to empower health centre staff to support both the CHWs and the support groups. Other groups of service providers included traditional healers who have their own association that guides their practice, and legislation for control. These healers collaborated with PHC officers at all levels. Unlike the VHWS and support groups the traditional healers were not however directly answerable but could collaborate with the implementing agencies as well as the PHC at the central MOHSW level. The informants also indicated that women were also the majority in the nursing and related cadres of health workers, including those serving remote areas .
The gender policy indicates that hitherto women have not participated in relevant issues. One of its objectives therefore is ensuring equal opportunities in the development process.
MMM Lesotho June 2005 56
There are thus no fora for participation of women pertaining to service delivery. The only way they may participate is as service providers, especially in care where they are the majority of the members of PLWHA associations and other volunteers as well as nurses.
4.9.7 Availability of National Fora (forum), Deliberate Policies and/or Monitoring Bodies to Address Ills that Affect Women’s Health
No one at the national level was aware of any such bodies nor could any relevant literature be obtained, except with regard to issues pertaining to the MOHSW and CHAL as well as other specific sectors such as the MOET, Gender Unit of the Police and the MOGYSR.
Deliberate policies that affect women’s health included the Vision 2020, the National AIDS Policy, the National AIDS Strategic Plan, the Strategic Plan of the MOHSW 2004/5 to 2010/11, the Gender Policy, the Health Service Reform Programme, the HIV Testing and Counseling (HTC) Guidelines, ART Guidelines, and the Sexual Offences Act 2003. Other policies although still in draft form included the Reproductive Health Policy, the Adolescent Health Policy, the Population Policy, and the Married Persons Equality Bill (white paper).
While these policies and institutions policies may be in place their implementation and monitoring is yet to take effect. This translates into a lack of monitoring bodies and systems for addressing ills affecting women.
4.9.8 Effectiveness of Statutory, Customary, and By-laws Enforcement Meant to Offer Legal, Physical, and Social Protection to Women and Girls
The key informants indicated that services for victims of Sexual and Gender Based Violence (SGBV) were few and far between. There were no shelters for such abused women and only one center for alcohol rehabilitation. Post Exposure Prophylaxis (PEP) was dependant on the knowledge of the person consulted and the availability of ARV’s at such a facility (currently limited to the 9 (3x5) and 1 BMS sites). The social welfare services were limited to counseling for victims of abuse and referrals to appropriate justice/legal offices.
The Constitution of Lesotho of 1993 was recognised as the fundamental or the supreme law of the country. Below this is the Statutory law that comprises of 2 equal systems, the Customary and the Common or Received law. The Bill of Rights in the Constitution includes the right to equality before the law as well as the freedom from discrimination. It however indicates that such a right is inoperable in terms of the customary law on marriage and inheritance where women are minors. The Marriage Act of 1974 also recognizes customary and civil law. The assertion therefore was that the discrimination of women is constitutional; women were discriminated against on the basis of custom and culture rendering actions not offensive, e.g. the right of the man not to seek the wife’s consent for sex and number of children was irrevocable but physical violence was however excluded and a criminal offence.
MMM Lesotho June 2005 57 Laws such as the Sexual Offences Act of 2003, had been promulgated in support of women. Those in development included the married persons equality bill, children’s protection and welfare bill, and the draft penal code that would among others legalize abortion.
Lesotho was also reported signatory/had ratified several conventions and declarations including the Convention on the Elimination of all Types of Discrimination against Women (CEDAW).
The government through the Law and Justice Sector Development Programme (LJSDP) of the Ministry of Justice and Human Rights (MOJHR) was assisting the Justice sector institutions (police, prosecutors, lawyers, courts, prisons, and Directorate of Economic Offences) to deliver safety as well as security and access to justice. The institutions had together developed a vision and strategy for achieving their mandate
Legal aid was reportedly only available in the capital Maseru. The issue of rights while gaining momentum was reported not yet widely understood. A lot of times culture issues were reportedly brought to the fore to delay changes and men proactively guarded what they perceived as a threat to their authority. Even with the promulgation of laws their implementation remained a problem.
The Sexual Offences Act 2003 makes rape a capital offence. The Women’s Health Survey 1998 and the study on the Violence against Women in Lesotho indicate that husbands and partners are often the perpetrators. WILSA in the Sexual Violence in Lesotho as well as In Search of Justice Where do Women Go in Lesotho, indicates that such violence is often a power rather a sexual issue. The major hierarchy of the justice systems through which women seek recourse is such that the higher levels are more inaccessible, intimidating and non-supportive. Similarly, according to the study on Violence against Women, the women did not feel protected by the law nor the informal dispute settlement, centered on culture. Women also did not want to seek statutory settlement since they perceived this non-conciliatory and did not want to be separated from their children.
Law enforcement in the protection of women against SGBV is therefore weak and systems not conducive to use by women. At the same time legal aid is not easily accessible to a lot of women due to its geographical limitation while private lawyers are not affordable to most women. Women are also not empowered on their rights.
4.9.9 Availability of Civic Education on Women’s (human) Rights Related to Sexual and Gender Based Violence and Gender Related Inequalities
Civic education had mainly been through the Child and Gender Protection Unit (CGPU) of the police, The Women and Law in Southern Africa Research Trust (WILSA), and the Federation of Women Lawyers (FIDA). Their coverage is however still limited and to large extent not widely known.
MMM Lesotho June 2005 58 4.9.10 Access to Legal Representation in Matters Related to Sexual and Gender Based Violence The key informants indicated that legal aid through the Ministry of Justice, Human Rights and Rehabilitation (MOJHR) was available in the capital Maseru, these services were not widely publicized and essentially inaccessible to a large proportion of those in need. Women’s access to legal representation was to a large extent determined by their capacity to meet the cost of a private lawyer.
With the decentralization just being institutionalized it was hoped that improved skills would result in better promotion of rights of women and children. With communities getting more accountable for such as the high rate of maternal mortality, it was hoped that women’s rights would be addressed.
The recommendations of the study on Violence Against Women include promotion of access to legal and police services that protect rather than intimidate women. WILSA’s In Search of Justice indicates that the costs of the formal courts are exorbitant and unaffordable to ordinary women, especially since they have to obtain the money spouses who are the perpetrators and/or earning low wages.
Women’s access to legal representation in matters related to SGBV is therefore very poor due to relative inaccessibility of legal aid as well as the women’s minority status rendering them economically dependent.
4.9.11 Availability of National Policies, Guidelines and protocols for the Prevention, and Management of Sexual and Gender Based Violence Victims
While there were policies on other issues pertinent to women none were reported nor could be accessed specific to SGBV. Guidelines and protocols, unanimously recognised across all actors were non-existent but oral consensus existed among professionals in one area. The only tool used by all was the form provided by police that a doctor would be expected to fill in evidence of the violence inflicted, and used in court as evidence. Based on the Sexual Offences Act all suspect perpetrators of rape are also subjected to non-voluntary HIV testing and evidence given by the doctor to the presiding magistrate in camera.
4.4.12 Availability of Health Information Management Systems that Capture Data for the Comprehensive Monitoring and Evaluation of the Status of Women’s Health Services including Sexual and Gender Based Violence (in addition to maternal morbidity and mortality records)
The key informants indicated that information from the facilities is forwarded to the hospital/district level and then the central level, from where it is compiled, analysed and specific indices reported on. Efforts were on-going at strengthening the compilation and analysis capacity at facility level, including an integrated Health Information Management System (HIMS) as part of the HSRP. The HIMS was otherwise reported rudimentary.
The record reviewed indicated that the programme specific data collection tools and information could be sex disaggregated, based on need. This however did not capture
MMM Lesotho June 2005 59 SGBV except as a diagnosis identified through record review and not routinely reported on.
Facility Level
4.10 Factors Relating to Service Delivery Level (policies, strategies and resources)
Two (2) hospitals both government owned, and seven (7) health centres: 2 government, 3 CHAL, and 2 Lesotho Red Cross health centres were visited. A third hospital and tenth health centre which were visited, refused to respond because of lack of prior warning from their proprietors. The most senior staff member available at the facility was interviewed. The respondents included 1 Medical Doctor, 4 Nurse Clinicians, 3 registered Nurses and 1 Nursing Assistant.
4.10.1 Existing Referral Service Policies that Prevent Women from accessing Health Services
All the nine facilities visited (2 hospitals and 7 health centres) reported referring patients to a higher level of care. The reasons for referral included lack of resources (11.1%), and need for higher level/further management. The criteria followed were based on the workers’ skills and capacity; no policies deterrent to referral could be identified. The major problem with the referrals mentioned was that higher level facilities did not provide feed back.
The key informants at the level of the facility reported that women could self refer. Referral from lower levels of care was also undertaken as deemed fit by the person consulted. In all cases transport costs had to be borne by the woman. The transport was often expensive and patients/clients sometimes opted not to go. The Department of Social Welfare decided upon individuals that should be exempted based on their criteria for deciding that someone is destitute. However no emergencies were turned away although this to a large extent depended on who received such a patient.
At the national level, the key informants indicated the referral system was not effective because the individual is usually not assisted with transportation, from the community level up to the central referral hospital. Even where offered they have to pay for this transport. At the referral facility there are neither systems nor guidelines on how to deal with the problems, the outcome solely depends on the skills/and the first contact person met. The communication system (Radios) had also broken down. Coupled with the lack of ambulance services at the health center level, the referral system is even further compromised. This is also accompanied by supplies shortages, within an environment where the attitude of health workers not conducive to service utilization. The hours of service delivery are also restricted compared to the facility opening hours.
The services were further reported not user friendly, especially to the youth. Although Adolescent Reproductive Health (ADRH) corners had been opened in almost all hospitals, they were perceived more as antenatal clinics for the youth and not accessible to other youth. The quality of services delivered was also regarded as non-satisfactory. Waiting times were long, Human Resources for Health (HRH) and
MMM Lesotho June 2005 60 skills inadequate, while the attitude was not supportive, equipment insufficient, and supplies mix not meeting expected standards by level; stock outs were reported common due to managerial constraints.
A lot of facilities were also reported to be in disrepair (lack of water, electricity and security). Health facilities, especially components earmarked for women targeted services such as MCH, were reported to offer minimal or no privacy including providing services such as counseling.
Even though patients and clients may self refer, the overall shortage of HRH and their limited skills, equipment and supplies as well as drugs shortages compromise the referral system as well as the quality of care. This is exacerbated by the lack of supervision.
4.10.2 Barriers in accessing Health Services Pertaining to Opening and Closing time
The normal operating hours for the facilities were 8 hours (7) for the health centres, 9 hours and 10 hours each of the hospitals. 5 of the facilities (2 hospitals and 3 health centres) provided emergency and maternity services outside normal working hours. The hospitals also provided in-patient care. The reasons advanced by the 4 health centres for not providing services, outside normal hours, included poor security, lack of water and shortage of staff. The facilities offered the following services during normal working hours: curative (100%), ANC (100%), PNC (88.9%), deliveries 44.4%, family planning (77.8%), counselling (66.7%), and other (28.6%).
The key informants at the facility level reported that outside the hospital emergency services, health centers and filter clinics do not open outside normal working hours including weekends. Women therefore resort to self-management such as home delivery. They also reported that even where the patients and clients reached the health facilities, the shortage of doctors and nurses as well as supplies and equipment resulted in unwarranted referrals to higher-level facilities, increasing the women’s burden and cost for care.
The shortage of HRH again is a barrier to women’s access to care and is exacerbated by insecurity at the health facilities as well as water shortage for services such deliveries.
4.10.3 Health Facility Basic Infrastructure, Logistics And Environment Embracing Concerns associated with
4.10.3.1 Availability of Privacy and Confidentiality
The facilities’ spot check assessed 77.8% of the facilities as offering both confidentiality and privacy; 22.2 % were satisfactory on confidentiality while 11.1% were each satisfactory and poor on privacy.
When women were asked how they would classify services at their facilities, 65.4% thought they were good, 21% satisfactory, 11.1% poor and 2.5% bad. In addition to
MMM Lesotho June 2005 61 lack of money (11.4%), poor services (10.2%) and negative staff attitude were some of the factors that would discourage women utilizing the facility.
Issues centred on privacy and confidentiality therefore should be addressed and catered for in the infrastructure plans.
4.10.3.2 Availability of Life Saving Drugs
The availability of life saving drugs in the health facilities varied and was as follows:
Drug Proportion of Remarks Facilities (%) Adrenaline 77.8 Analgesics 44.4 Ergometrine 77.8 I.V. Fluids 66.7 Local Anaesthesia 55.6 Magnesium Sulphate 22.2 2 Hospitals only
55.6% (5 out of 9) facilities reported drugs were always available while 4 reported they are sometimes available. Supplies such as syringes and needles were however in supply
In the FGDs the women indicated that the shortage of drugs was one of the factors affecting utilization of the facilities.
The key informants at the national level corroborated the information and were of the opinion that it was regular and had become a norm that health facilities were out of stock of drugs and medical supplies.
The MOHSW review report 2005, under pregnancy and delivery, reports on a facility assessment whose finding was that only 21.7% (5 of 23) had all the essential drugs for provision of EOC; guidelines for the management of hypertension in pregnancy were only available at the hospitals but not health centres. In 93% of the hospitals patients received all the prescribed drugs and 7% did not because the drugs were out of stock. Drug shortages were however reported rare.
While drug shortages may not be a norm, the significant proportion of facilities that did not have emergency drugs in stock, the high proportion of facilities reported to have been without drugs for EOC, and that essential guidelines were only at hospitals is worrisome. The claim that fewer and fewer women are delivering in hospitals, that the referral system is not adequate, including the lack transport translates into a health centres as the key centres for EOC for a high proportion of women. The likelihood that the health centres may not meet this expectation, even if not a high proportion may indicate that women unnecessarily die even if they do manage to reach a health facility. The situation should be worse for the rural and mountainous parts of the country for which physical access to hospitals is reduced.
MMM Lesotho June 2005 62 4.5.3.3 Availability of Basic Equipment
All the facilities had the basic equipment inclusive of, sphygmomanometers and stethoscopes, foetoscopes, speculum and forceps. Oxygen was only available at hospital level. Delivery beds and examination couches were also in place in 7 facilities, 5 of which did and 2 did not conduct deliveries.
From the exit interviews x-rays and ultrasound were only available at 1 facility instead of both hospitals; delivery equipment was available in only 1 instead of 9 facilities. (IMCI in 2, PMTCT in 2, PNC in 2, VCT in 1, and SGBV in 1).
In the FGDs women reported that facility equipment was short and its maintenance poor.
The national level indicated a lot of equipment in facilities were not functional due to lack of maintenance was well as old equipment that needs to be replaced but funding was a problem.
The MOHSW review report supports this assertion of lack of equipment and its poor maintenance. The infrastructure and typology plan however includes adequately equipping all facilities and the equipment list includes the essential equipment for reproductive health, especially for EOC.
The equipment shortages further compromise the capacity of health facilities to provide the essential EOC; further implying inadequate maternal deaths at facility level.
4.10.3.3 Availability of Sanitary Facilities
On inspection of the facilities sanitary facilities were best in the ANC unit with 75% of the ANC rooms in good condition and 25% satisfactory. 57 % of the delivery rooms were clean (good) and 14% satisfactory; 29% did not conduct any deliveries although they could if they wanted. The condition of the patients’ bathrooms and toilets was good in only 38% of the facilities although 50% were satisfactory; 13% were kept in an unsanitary manner.
During exit interviews the clients of only 2 facilities considered the condition of the patients’/clients’ bathrooms and toilets good, 3 considered them satisfactory while 2 considered them poor; the other 2 were non-response.
Major complaints on the poor sanitary facilities were specially made by the PLWHAs during the FGDs. They reported that even where such facilities had been provided, they were inaccessible to patients because they stayed locked.
The sanitary status of a recognizable proportion of health facilities is therefore inadequate, even in delivery and ANC rooms. This may indicate inadequate infection control systems and may be a reflection of inappropriate human resources attitude and management. Such a situation may also deter facility utilization.
MMM Lesotho June 2005 63 4.10.3.4 Availability of Communication Mechanism
7 of the 9 health facilities were equipped with one of a two-way radio system (2), telephone (2), or cell phone (2). These were used to facilitate referral through consultations and seeking assistance where essential.
At the national level the reports were that the two-way radio communication system which had been a norm, linking hospitals to health centres, and facilitated referrals, had to a large extent broken down and needed replacement.
The infrastructure plan includes procurement and replacement of the radio system in all facilities. The review report indicates that only 40% of the facilities have functioning two-way radios.
While the telephone and cell phone may be an option for urban areas, a large proportion of rural areas, often with inadequate infrastructure, may only be reached through two-way radio communication. The majority of the health facilities are therefore not adequately equipped for emergency communication.
4.10.4 Availability of, and Access Issues Related to Diagnostic Facilities and Services
The diagnostic facilities at the 7 health centres and 2 hospitals that were assessed are indicated below.
Diagnostic Facility/Service Proportion (number) with Remarks Facility Urinalysis 77.8 (7) Full Blood Count 11.1(1) Hospital Pap smear 33.3 (3) 2 Hospitals and 1 HC HIV Testing Rapid 33.3 (3) 2 Hospitals and 1 HC HIV Test Rape Victims 22.2 (2) Hospitals only X-Ray 22.2 (2) Hospitals only Mammography 0 ** Health centres indicated transport blood and other specimen to hospitals for most tests.
The MOHSW review report 2005 indicates that all hospitals have the capacity to perform basic tests; 3 of the 17 hospitals can also do CD4 counts.
Most facilities, especially health centres, therefore lacked facilities for basic and essential diagnostic tests, including in relation to obstetric care/EOC. It is noteworthy that one hospital could not even do a full blood count. Despite the high prevalence of HIV (30% adult and 42% ANC), HIV testing was still limited. Cancer screening, especially for cancer of the cervix that is reported high and accounting for most referrals to South Africa, was also inadequate. Health centres, despite their being more physically accessible, lacked facilities for dealing with rape.
MMM Lesotho June 2005 64 4.10.5 Availability of IEC Services such as HIV/AIDS
All but 1 of the 9 facilities had conducted IEC activities over the past three months. The topics included ANC (100%), Family planning and emergency contraception (77.8%), deliveries (33.3%), ART (22.2%), post-exposure prophylaxis ([PEP] 22.2%), Prevention of mother to child transmission of HIV ([PMTCT] 44.4%), PNC (66.7%), sexuality (62.5%), and SGBV (33.3%).
From the facility checks and exit interviews IEC materials available included the following: ANC (6), deliveries (1), FP (6), IMCI (2), Immunization (6), PMTCT (2), PNC (2), SGBV (1), VCT/HTC (1). The materials had been obtained from varied sources including posters from South Africa and those in English.
The MOHSW review report was more specific on activities undertaken by the central health education unit mainly on tobacco control and commemoration of international days. Other activities had not been undertaken due to resource constraints. On the other hand the AIDS department had carried out material production on ARV, PMTCT, and HTC.
While health facilities conduct IEC activities they are not adequately equipped with locally relevant materials and are sometimes in a language that may not be understood by the majority of users. Other relevant materials were missing and most of the available were relevant only to HIV and AIDS. Despite the institution and unit responsible for health education, individual programmes also continue to develop materials making it difficult for facilities to know who to refer to as well. Supervisory support and monitoring of relevance and use of the materials may also be a problem.
4.10.6 Scope and Quality of Health Services
The scope of services offered, including RH, counselling, mental health and VCT was not satisfactory for up to 23% of the facilities. No facility provided any notable SGBV services. A similar proportion also provided services that were not of adequate quality.
Guidelines and/or protocols available at health facility level included family planning (3), IMCI (1), Immunization (7), Obstetrics (1), HTC (1), PMTCT (2), and other (5). Service records indicated varied levels of utilization of the services in the past month, with hospital figures larger than for health centres, in the following ranges: ANC 7 to 211 visits; deliveries 0 to 60 with 1 to 2 maternal deaths; 1 to 2 fresh and 1 macerated still births, 28 to 57 live births; 8 to 166 FP clients; 1 to 300 SGBV victims; 3 to 45 PNC clients; and 13 to 274 child welfare clients.
The average waiting time ranged from1 to 8 hours, 50% of which was 2 hours at both health centres and hospitals.
The national level’s opinion was that commodity/supplies shortages, within an environment of health workers whose attitude is not conducive to service utilization especially day services and limited time compared with facility opening hours, compromised the quality of service delivery. The services were further not user friendly, especially to the youth. Although ADRH corners had been opened in almost
MMM Lesotho June 2005 65 all hospitals, they were perceived more as antenatal clinics for the youth and not accessible to other youth. The quality of services delivered was also regarded as non- satisfactory. Waiting times were long, HRH skills inadequate, while the attitude was not supportive, equipment insufficient, and supplies mix not meeting expected standards by level; stock outs were reported common due to managerial constraints. Overall shortage of HRH was reported to further compromise the quality of care, exacerbated by the lack of supervision. Infection Prevention and Control (IPC) was hardly practiced and was faced with material shortages. Women were therefore opting for delivery at home.
Varied cadres of workers were undergoing basic training with donor support; several programs had conducted in-service training with similar support. The key in service training held by MOHSW, emphasizing on women included Reproductive Health (RH), Adolescent Reproductive Health (ADRH), Integrated Management of Childhood Illnesses (IMCI), Making Pregnancy Safer (MPS), Prevention of Mother to Child Transmission (PMTCT) and AIDS (ART, VCT/HTC, and Counseling). The training had mainly concentrated on staff at hospital level and/or PHC Supervisors, while health centers had either been ignored or were yet to be covered. The MOHSW did not have a sector wide training plan but was planning on developing one. The NGOs on the other have definitive plans for in service trainings, targeting capacity building in their area of focus.
A lot of facilities were also reported to be in disrepair (lack of water, electricity and security). Health facilities, especially components earmarked for women targeted services such as MCH, were reported to offer minimal or no privacy including in providing counseling services.
The partners however indicated that while they relied on guidelines such as the Millenium Development Goals (MDGs) and those from their headquarters or regional offices for deciding on areas for support, they relied on government collaboration in identifying local needs and priorities for support.
Although the number of facilities assessed was small, the assessment on the scope and quality compares well with the findings on the inadequacy of privacy and confidentiality (23%), emergency drugs shortages (22% to 78%), inadequate diagnostic facilities (30 to 70%) and the inadequate sanitation of the facilities (12.5% to 30%).
The MOHSW review report 2005 indicates the slow progress in adoption of guidelines coupled with a shortage of resources negatively impacting on effectiveness and efficiency of service delivery. The lack of supervision is reported to further compromise the quality of care. There also were 18% of the clients who were not satisfied with the services due to not obtaining prescribed drugs, lack of testing reagents, break down of x-rays, or because they were beyond the set quota for the day.
The scope and quality of services are therefore not optimal due to the inadequate number and skills of human resources; unreliable drugs supplies and equipment; inadequate supervision; poor maintenance of facilities and lack of infection prevention control systems. These are exacerbated by managerial and attitudinal
MMM Lesotho June 2005 66 deficiencies. At the same time in-service training is not sufficiently structured to address the inadequacies.
4.10.7 Response of Health Care Providers to Socio-cultural Norms
The health workers listed diet restrictions and application of ochre during pregnancy leading to embarrassment and restricted movement of widows during the mourning period, including not to be hospitalised, as the most common taboos and customs that may affect women’s utilization of services. While they sympathised with the mourning and indicated that women should be prioritised when they visit health facilities, they considered the practices around pregnancy a burden to women and that sometimes the hygiene practices made serving such women very uncomfortable.
The key informants’ opinion of the deterrent customary practices to women’s utilization of health services included forbidding women in mourning to be hospitalized nor traveling after sunset during the period of mourning for a spouse; restrictions of certain foods for girls (vitamin& protein); special attire worn during pregnancy that is degrading and results in the woman’s shyness to go to public places as well as exposure to extremes of temperatures. Other practices that could affect utilization of services by women included the opposition or imposition of conditions to scarification e.g. not sharing blades, as well as wife inheritance, due to the likelihood of HIV transmission. There also were customs regarded to facilitate utilization of health services that included the family support to a woman during the rooming-in period hence reduced workload, and abstinence from sex during the period of breastfeeding and therefore child spacing.
The practices are therefore more an inconvenience than of much concern to health workers.
4.10.8 Availability of Psycho-Social Counselling, Mechanisms for Confidential Complaints and Other Support Services for Victims of Gender-Based Violence
Neither counselling nor mechanisms for support of victims of SGBV were available at health facilities.
The policy of health facilities towards only undertaking certain procedures on women provided the husband consents were either classified as abuse or a perpetuation of abuse.
The on-going social mobilization by the Department of Gender on women and politics; education through the Education Transformation Resources Centre (ETRC); the activities of Federation of Women Lawyers (FIDA) as well as Women and Law in Southern Africa Research Trust (WILSA), with regard to human rights; were the only civic education on women’s human rights that most respondents identified.
Health facilities therefore do not yet offer any appropriate counselling nor support services for SGBV.
MMM Lesotho June 2005 67 4.10.9 Availability of Policies, Guidelines and Protocols for the Prevention, and Management of Sexual and Gender-Based Violence Victims
There were neither policies, nor guidelines, nor protocols, for the prevention and management of SGBV.
4.10.10Availability of Human Resources
Human resource capacity for the facilities were 1 to 7 counsellors per facility, 1 to 2 health assistants, 2 hospitals each with 1 health inspector, 1 to 3 medical doctors in the 2 hospitals, 1 to 2 nurse clinicians in 6 health centre facilities, 1 to 28 nursing assistants in all 9 facilities, 2 to 4 pharmacy technicians in 3 facilities, 1 to 21 registered nurses in 5 facilities. None of the facilities had a pharmacist. The human resources of all types were on duty at the time of the visit but were reported inadequate by 4 of the facilities. The human resources were distributed as follows:
Health Number per Number per Health Centre Worker Hospital Cadre #1 #2 #1 #2 #3 #4 #5 #6 #7 GOL GOL CHAL CHAL CHAL LRC LRC Medical 3 3 1 1 Doctor Dentist 1 1 Nurse 2 0 1 1 1 1 Clinician Public Health 2 2 Nurse Registered 19 21 2 1 1 Nurse Nursing 15 28 1 1 1 2 2 2 1 Assistant Counsellor 4 5 1 2 1 Pharmacist 0 0 Pharmacy 4 4 1 2 Technician Laboratory 3 Technician Health 1 1 Inspector Health 1 2 Assistant **Health Centres 1 and 2 are Filter Clinics for the central referral hospital
Thus while there are norms for facility staffing as per the initial original PHC plan, the current pattern is varied even for one proprietor. Specifically on the nursing cadre, there is an apparent pattern of professional nurse and a Nursing Assistant; only in one centre were there a Nurse Clinician, Registered Nurse and Nursing Assistant, the pattern closest to the fore-mentioned norm.
4.10.11Inhibition of Access due to Ills Pertaining to Health Workers’ Attitudes
MMM Lesotho June 2005 68
Through the exit interviews the long waiting times were reported to be due to the negative attitude of health workers. The other deterrent factor was restricted opening time.
The MOHSW sector review report 2005 indicates that in an assessment conducted 18% of the clients were not satisfied with the services due to not obtaining prescribed drugs, lack of testing reagents, break down of x-rays, or because they were beyond the set quota for the day. It further highlights that the 18% included those who felt the attitude of health workers was not supportive, but is not specific to women.
The attitude of health workers is therefore a deterrent factor to women utilizing health services.
4.5.12 Availability of Health Information Management Systems (HIMS) that Capture Data for Monitoring and Evaluation of the Status of Women’s Health Services in Totality including Gender Based Violence
The HMIS included the standard register in which diagnoses or service rendered is indicated by name, age and gender of the patient. Separate registers are used for curative care and the maternal and child health care services. SGBV is included in the curative service register. Specific services such as FP, VCT, and PMTCT are registered separate. The information from the facilities is then forwarded to the hospital/district level and then the central level, from where it is compiled, analysed and specific indices reported on. The MOHSW Health Statistical Tables had been compiled through this mechanism.
The key informants indicated that individual programmes, some more than others, at central level, found it difficult to be party to a unified system of reporting efforts were on-going at strengthening the compilation and analysis capacity at facility level, including an integrated HMIS system as part of the health sector reform programme. They regarded the HMIS as still rudimentary. SGBV had not been included in the discussions.
The HMIS therefore, even in the strengthening efforts, may not include SGBV.
4.6 The following observations and conclusions were therefore reached:
Community level • The findings on the low economic capacity, limited decision-making capacity, and high unemployment rate of women, as well as reduced access to basic needs such as food, is corroborated in the literature. Although the fees are highly subsidized as per the indicated costs, there is still a proportion of women for whom service fees are a constraint to accessing care. The situation is aggravated by the women’s low employment and limited capacity to make decisions including on resource allocation. The situation would be expected worst off where the unemployment is worst off in the foothills followed by mountains and Senqu river valley, as well as in rural compared to urban areas. The first choice for these zones is also the further off hospital, whose access is even lower. The Senqu valley lies within the mountains and both are
MMM Lesotho June 2005 69 predominantly rural; together with the foothills, these zones should therefore be priority in easing financial accessibility to services, followed by the foothills and then the lowlands. • While the health facility fee exemptions are limited, they also follow a bureaucratic system that may intimidate the deserving candidates as well as their not being aware of such exemptions. The exemptions are thus inaccessible to women, further exacerbating the situation of the poor. • It is generally known that there is less arable land in the mountains and Senqu river valley compared to the lowlands and foothills. The higher dependency on food aid and hand outs in the rural areas and mountains and Senqu may therefore be a reflection of higher food insecurity in these areas, aggravated by low agricultural potential. These are also the areas where finances are more a constraint to accessing health care. • The high level of food insecurity was explained to be secondary to the high levels of unemployment and therefore inability to purchase food, drought leading to poor agricultural production, and increasing widowhood due to AIDS therefore loss of breadwinners. Special groups such as PLWHAs as per their input may be worst off in the geographically disadvantaged rural areas of the mountains and Senqu river valley. The higher dependency on agriculture in the foothills coupled with no dependency on food aid and hand outs may not only be a reflection of the zone’s higher agricultural activity but could also reflect lack of access to food aid hence not a choice. The priority ecological zones for any food aid intervention are again reflected to be the mountains and Senqu river valley, followed by the lowlands and foothills last. • With the high level of unemployment the purchasing power of households will probably reduce, negatively affecting the quality of their diet. If agricultural production has been reduced the household food security of those who rely on farming will also be negatively affected. A combination of these factors with inclusion of those that rely on handouts (another form of food aid) may probably render much more than the 5.1%, eligible for food aid, corroborating the CWIQ indicated 38.37% with difficulty in accessing food and the PLWA assertion. Food aid may therefore not be accessible as required and target groups such as PLWHAs may, as per their report, not be receiving the required food aid. The lack of reliance on food aid in the foothills could be because of higher agricultural output but there also is the possibility that food aid has not yet targeted these areas. The majority of the women are unemployed and not of a level of education high enough to facilitate gainful employment. The majority are therefore involved in lowly paid jobs, rendering them economically dependent. Young girls who have to work are also commonly employed as domestic workers. The situation may be worse in rural areas and zones where fewer women attain secondary and high school education as found in the foothills (14.6% and 4.3%) and mountain (17.5% and 10.9%) zones followed by Senqu river valley (23.3% and 26.1), hence lower purchasing power. The situation may also be similar in the rural compared to urban areas. • Women’s utilization of health services not only depends on their partners but also relates to their minority status as well as myths, taboos and misconceptions centred on sexuality and reproductive issues, as well as cultural practices during period and the mourning period.
MMM Lesotho June 2005 70 • Law enforcement in communities therefore primarily lies with police and chiefs. The differences by zone on whom the violence would be reported to may be an indication of less access to police in the mainly rural mountain, Senqu and foothills compared to the lowlands where access to towns and development centres may be easier; or may reflect the differences in the trust between police and chiefs. The fact that in some cases when cases are reported to the chiefs (33.3%) and to the police (18.5%) reinforces the FG reports that reports do not always end up with a supportive stance. It may be concluded therefore that while there is a law (Sexual Offences Act 2003) that should protect women (and girls) against SGBV, the institutionalization of the minority status of women as per customary law, the preponderance of males in the legal and justice systems, the intimidating legal procedures, the limited legal aid, and lack of women’s awareness and civic education on these rights, result in poor implementation of such protection for women. • The MOHSW defines access as less than 2 hour walking distance from a health facility. Therefore while up to over half of the population have physical access to a health facility, there was a significant proportion whose access was aided by vehicle transport and a proportion, especially in the mountains, for whom whatever the mode of transport, physical access was a problem. This problem was more so for hospitals that are the main providers of emergency services for women. More women n the foothills had problems of access to a health facility compared to the mountains and Senqu that also faced the problem. The lack of physical access may further explain the lack of reliance on food aid in the foothills since the distribution is usually at health facilities. At the same time there was no organised transport for such emergencies. • The problem of physical access is more for hospitals that are the main providers of emergency services for women in the rural foothills, mountains and Senqu river valley. At the same time there is no organised transport for such emergencies. Hospitals are the main providers of EOC. A proportion of women do not have access to such facilities and the situation is further exacerbated by that there is no organised transport for such emergencies as well as the inadequate human resources skills and numbers. Access to EOC is therefore not only affected by physical access but is further compromised by lack of transport for emergencies. • The services offered at community level are broad in scope although some are very limited in coverage. The services also lean more towards providing home based care than any other service provision. The services specifically targeting women mainly centre on education and prevention but not service provision. The bias towards home based may be reflection of the escalating numbers of seriously ill patients nursed from their homes, mainly due to HIV and AIDS, and therefore a felt community need. It is interesting to note that caring for the sick was however mentioned by only 1 out of 39 women, on the reasons for not seeking care when they had needed it; financial and other constraints were the key reasons indicated. The reason for this may also be that the women’s perception of reasons may exclude those they perceive to be their natural role including care for the sick; the issue needs to be further pursued. • The use of contraception and family planning is not yet satisfactory. The proportions are significantly different between zones with women not using any method highest in the mountains (71.4% ), followed by foothills (70.4%) and Senqu (57.%), compared to 48.5% in the lowlands. Given that health
MMM Lesotho June 2005 71 facilities were the biggest source of supplies, this may not be convenient for the women for whom physical access is a problem although fewer. While for the majority physical access may not be a constraint to FP, other factors may be contributory to non-use including the women’s decision making capacity whose lack of compares well with the lower use of FP by zone. Given the high prevalence of HIV, the proportion that used condoms was low (29.8%) and the dual protection accorded by condoms was probably not appreciated; more insight into and reasons for non-use is required. • While SGs and VHWs are a recognised resource for communities; TBAs are not. The quality and content/scope of the services may not be up to expectation due to human and other resource constraints. • Access to sanitary facilities is low and worst in rural areas as well as most of the zones except for the lowlands. Municipal waste disposal is very minimal even in urban areas. This may be a resultant of inadequate coverage of sanitation messages in the more difficult areas of the country, coupled with lower education levels therefore receptivity for health messages. • While access to safe water supply was moderate to high, there was still 20% to 35% of the population, thence women that lacked such access. It was also noted that it was only for access to safe water where rural areas and mountains as well as Senqu river valley were better off compared to the lowlands. Rural water supply may have also been emphasised while lowland and urban supply lags behind. Given that communities would rely more on authority provision of safe water as compared to waste disposal, the systems are yet to cover all beneficiaries, worst off for those in the lowlands.
National
• Budgetary allocations are not yet sufficient to ensure availability and quality of services including those for women. • Although eligibility for a specific service is only based on assessment at the time of the visit, there may individuals who do not receive services due to limited skilled human resources, their inadequate technical skills, and the paucity of guidelines and protocols as well as unreliable drugs and other commodity supplies. This would negatively impact especially on the women for whom finance is a barrier to care. The situation would further exacerbated the by the limited system of exemption from user fees for the poor. • VCT and ARVs are not available in rural areas and their availability is skewed to urban lowland areas. • The only way in which women may participate in service delivery is as providers. This is notable for support groups and PLWHA associations where the majority are women. • Although there may be institutions and policies in place, they are hardly monitored; there is neither a body nor effective systems to addressing ills affecting women. • Law enforcement in the protection of women against SGBV is weak and systems not conducive to use by women. At the same time legal aid is not easily accessible to a lot of women due to its geographical limitation while private lawyers are not affordable to most women. Women are also not empowered on their rights.
MMM Lesotho June 2005 72 • SGBV is not captured in the routine reporting from health facilities.
Facility Level
• Even though patients and clients may self refer, the overall shortage of HRH and their limited skills, equipment and supplies as well as drugs shortages compromise the referral system as well as the quality of care. This is exacerbated by the lack of supervision. • Privacy and confidentiality are not adequately addressed in the infrastructure plans. • While drug shortages may not be a norm, the significant proportion of facilities that did not have emergency drugs in stock, the high proportion of facilities reported to have been without drugs for EOC, and that essential guidelines were only at hospitals is worrisome. The situation is made worse by equipment shortages that compromise the capacity of facilities to offer EOC. The claim that fewer and fewer women are delivering in hospitals, that the referral system is not adequate, including the lack transport translates into a health centres as the key centres for EOC for a high proportion of women. The likelihood that the health centres may not meet this expectation, even if not a high proportion may indicate that women unnecessarily die even if they do manage to reach a health facility. The situation should be worse for the rural and mountainous parts of the country for which physical access to hospitals is reduced. • The sanitary status of a recognizable proportion of health facilities is inadequate, even in delivery and ANC rooms. This may indicate inadequate infection control systems and may be a reflection of inappropriate human resources attitude and management. Such a situation may also deter facility utilization. • While the telephone and cell phone may be an option for urban areas, a large proportion of rural areas, often with inadequate infrastructure, may only be reached through two-way radio communication. The majority of the health facilities are therefore not adequately equipped for emergency communication. • Most health facilities, more for health centres, lack facilities for simple, basic and essential diagnostic tests including priority screening tests for women such as haemoglobin, urinalysis and HIV testing. • While health facilities conduct IEC activities they are not adequately equipped with locally relevant materials and are sometimes in a language that may not be understood by the majority of users. Other relevant materials were missing and most of the available were relevant only to HIV and AIDS. Despite the institution and unit responsible for health education, individual programmes also continue to develop materials making it difficult for facilities to know who to refer to as well. Supervisory support and monitoring of relevance and use of the materials may also be a problem. • The scope and quality of services are therefore not optimal due to the inadequate number and skills of human resources; unreliable drugs supplies and equipment; inadequate supervision; poor maintenance of facilities and lack of infection prevention control systems. These are exacerbated by managerial and attitudinal deficiencies. At the same time in-service training is not sufficiently structured to address the inadequacies.
MMM Lesotho June 2005 73 • Health workers do not perceive customs that may deter utilization of health services a problem; it is more of nuisance. They may therefore not address the issues adequately in education and other related BCC activities. • Health facilities do not offer counseling nor adequate services for SGBV, including PEP. There are neither protocols nor guidelines for the prevention and management of SGBV. • Human resources are the key to adequate service delivery. The staffing of health facilities is not standard, the number of skilled ones inadequate, leading to long waiting times, allocation of quota per day and overwork. The shortage of HRH is a barrier to women’s access to care and is exacerbated by insecurity at the health facilities as well as water shortage for services such as deliveries. At the same time their negative or non-supportive attitude further deters women from utilizing health facilities. • The HMIS does not cater for monitoring SGBV.
5. Organizations Providing Health and Basic Social Services to Women
SECTOR ORGANIZATION SERVICE (S) THAT THE ORGANIZATION PROVIDES TO WOMEN Government Ministry of Health and Health and Social Welfare and Rehabilitation Social Welfare (MOHSW) Ministry of Finance and Population activities, donor coordination, national Development Planning planning, Financial regulation and management Ministry of Gender, Gender Advocacy and Empowerment Youth, Sports and Recreation (MOGYSR) Ministry of Justice and Correctional Services, Institution of Laws, Courts Human Rights Ministry of Law Law Formulation, Legal Aid, Prosecution Ministry of Home Affairs Immigration, Police including the Gender and Child Protection Unit Ministry of Employment Recruitment for Employment in South African and Labour Farms, Labour Laws, Relations and Court (garment factory workers) Ministry of Education and Civic Education, Formal Education including Training Vocational and Technical, Civic Education Ministry of Local Advocacy, Local Government Government Ministry of Public Service Management and development of human resources Office of the First Lady Home Based Care and Care for Orphans Parliament National Assembly Law Making, Budgetary Approval and ensuring Accountability through the Public Accounts Committee Senate Law making, Principal Chiefs Non- Lesotho Red Cross (LRC) Health Care, Vulnerability reduction especially in Governmental emergencies, Humanitarian services
MMM Lesotho June 2005 74 SECTOR ORGANIZATION SERVICE (S) THAT THE ORGANIZATION PROVIDES TO WOMEN Organizations Lesotho Planned Family Planning, STI management, HIV Parenthood Association Counselling and Testing (Voluntary), civic (LPPA) education for women Christian Health Health Care, Spiritual Care, Social Welfare Association of Lesotho (CHAL) Women and Law in Advocacy and Research on Women’s Rights, Civic Southern Africa Research Education, Legal advice Trust (WILSA) Federation of Women’s Advocacy and Legal Advice on Women’s Rights, Lawyers (FIDA) Civic Education Population Services VCT and Condom Distribution International (PSI) CARE International Peer Education, Home Based Care Clinton Foundation Human Resource Development For AIDS, ARVs Supply System World Vision (FBO) HIV/AIDS, social welfare Lesotho Association of Non-formal Education Non-formal Education (LANFE) National Council of Income Generating Skills Development Women (NCW) Community Support Groups Home Based Care, IGAs Based Women and AIDS in HIV and AIDS Organizations Africa Community Health Health Promotion, Education, Treatment of Minor Workers Ailments, Home Based Care Traditional Birth Care in pregnancy, delivery and post natal period Attendants Traditional Healers Traditional Healing Burial Societies Burial Ceremony Contributions CBOS of Varied Names IGAs and Home Economics Development Development Co-operation Support to Health and Education, Rural Water Partners Ireland (DCI) Supply, Rural Roads, HIV and AIDS, Gender Development Fund for Support to HIV and AIDS International Development (DFID) European Commission Support to HIV ad AIDS GTZ Support to HIV and AIDS KFW Support to Family Planning Logistics Ambassador USA/USAID In-Service Training, Local NGO/CBO Capacity Building, Capacity Building Health Sector (Capacity Project) UN Agencies WHO Support to the family health, adolescent health, health promotion, sanitation, nutrition, HIV/AIDS, social welfare
MMM Lesotho June 2005 75 SECTOR ORGANIZATION SERVICE (S) THAT THE ORGANIZATION PROVIDES TO WOMEN UNICEF Support to reproductive health, adolescent health, child health, nutrition, education, HIV/AIDS/PMTCT, social welfare/OVCs UNFPA Support to reproductive health, SGBV UNDP Economic empowerment women UNAIDS Support to HIV and AIDS FAO Support to nutrition education WFP Food distribution to vulnerable groups especially TB, HIV/AIDS, pregnant women GFATM Funding for TB, HIV and AIDS World Bank Capacity building for the health sector
6. Recommended Components of a Health Assessment Instrument that Would be Considered Locally Relevant and Useful
Asked
• Village Identification: District, Ecological Zone, Name, Chief, EA # • Personal info: age, marital status, education, employment • Number of Dependents: mandatory, optional • Source of food • Source of drinking water • Waste disposal mechanisms • Toilet facilities • Systems of payment that exist/are applied (Indicate facility name and type) • If not able to pay what are the penalties; any service received? Explain. • What are the women’s sources of income; how and who decides on the allocation for health care • What are the opportunities for gainful employment of women? (by level of education) • Beliefs, customs, and taboos that have implications on health service utilization and how • How far (distance in Km or walking time) from the nearest health centre • How far from the nearest hospital • Does this hospital offer Emergency obstetric care • If not how far is the nearest facility that offers this service • What transport is used for such cases (EOC) • If there is an ambulance how much does it cost and is it affordable? • How long does one wait for such an ambulance? • Is there community organized/owned means for transporting emergencies including EOC
MMM Lesotho June 2005 76 • What health services are available for women in the village and who is involved (indicate individuals, organizations etc) • Are there any protection mechanisms and systems for women against sex and gender-based violence • How effective are the means of legal enforcement • Elaborate on the human rights for women ESPECIALLY in relation to SGBV as well as gender related inequalities • What barriers are there to accessing health services **probe on closing and opening times, ease of referrals, physical infrastructure, gender, confidentiality, privacy, sanitary facilities, workers attitude • What is the availability of human resources for service delivery, especially for care of women and girls (cadre, numbers, attitude etc) • Programme strengths • Programme weaknesses • Key Challenges • Constraints and obstacles • Socio-Cultural and Economic Factors to service utilization • National Health Systems, Policies, and strategic plans etc available including guidelines and protocols in relation to women’s health and social services. • Systems of Health Service organization in relation to women’s • Health service delivery • Financial resources allocation criteria, quality and availability-financial allocation resources consideration for women. • Are services ever contracted out, when, why, any such contracting for women • Eligibility of women for service • Service fee exemption criteria with emphasis on women • Forum for participation of women in service delivery (probe for PLWHAs) • Referral systems for women • Any Support Systems for women • Women’s role and services received through the HBC • National fora and bodies for women’s health • Statutory, Customary and by-laws enforcement for protection of girls and women • Civic education on women’s rights in relation to school and GBV and gender related inequities • What Policies, guidelines and protocols are available on SGBV • Describe the HMIS on women health services • Health Facility type (Name, proprietor) • Health Facility Working hours: normal, outside normal hours • Services offered at health facility • Referral systems for health facilities • Inspection of health facilities: Cleanliness etc, infrastructure, equipment, drugs, IEC, policies etc • HRH pattern • Facilitating and deterrent factors to health facility utilization
Additional Questions Stakeholders considered Relevant and Useful in assessing access to services for women
• Equity of access by geographical zone and the urban rural divide
MMM Lesotho June 2005 77 • Condom usage: probe on type (assess utilization of the female condom) • General health habits • Mode of communicating that communities have an emergency from the community to the health facility in an emergency • Termination of pregnancy and guidelines • SGBV and complacency of neighbours • Other social sectors and the linkages e.g factory and health care • Maintenance problems and issue of biological father; the capacity to confirm paternity • Responsibilities that affect health seeking behaviour of women e.g care for the sick, work • Include assessment of access for women in institutions such as mental hospitals and prisons
7. Recommendations for Action to Increase Women’s Access to Health and Related Basic Social Services in Lesotho
The following recommendations, linking the three levels (community, health facility, national level) are made towards increased access of women to health and social services:
General • In order to ensure universal access of services to women, and to include those for whom user fees are a constraint to accessing services, the MOHSW in its standardization of fees and accreditation with CHAL, should include an agreement on fee exemption criteria to guide health facility staff, while awaiting social welfare endorsement of their eligibility. Due consideration should be made to a total fee exemption for services specifically targeting women and girls. The zones and urban/rural differences should be considered in the prioritization of the intervention. • At the same time, the training of the social welfare cadre to effectively reach the community level should be accelerated. Such access would also enhance support services for the poor and vulnerable including facilitating and monitoring their access to food and other aid, as well as IGAs. • Given the women’s low economic potential, their minority status and their food insecurity, the government sectors, especially the MOHSW, MOGYRS, and Ministry of Agriculture and Food Security, together with the relevant NGOs, the private sector and partners as well as UN agencies, should liaise and consult with a view to establishing uniform standards and systems for improved access to food aid and other assistance for women and girls. • Special attention and programmes should focus on young women and girls whose economic potential is further reduced due to drop out from school, ending in lowly paid and abusive jobs such as domestic work. Government should institute and monitor a legal mechanism for enabling the girls to pursue their education while instituting laws that would protect the women in domestic work and the informal sector from abuse.
MMM Lesotho June 2005 78 • Through advocacy and evidence based planning on the access of women and girls to health services, resource allocation for women’s services should be improved. Due differentials should be accorded the urban to rural divide, the zones, socio-economic status/employment, and special regard accorded to those affected and infected with AIDS and HIV. • The plans to have ART in all hospitals and VCT/HTC in all health facilities needs to be accelerated and be sensitive to ensuring equity between rural and urban areas as well as between topographical zones. • Programmes specifically targeting the male spouses and partners to be actively involved and support services for women as well as for men should be instituted. The relevant socio-cultural and other underlying factors to reduced utilization of health services as well as avenues to community-organized inputs, specifically emergency transport, into the system, should be priority. • Given that human resource constraints are key at compromising the scope, quality and access to care, efforts at improving on the situation of human resources for health, including their retention, should be intensified. The working conditions that not only affect the service delivery, but the attitude of such workers, should be improved through improvements on the infrastructure, security, drugs, supplies and equipment at facility level. Deployment should place emphasis on equity and access especially to the difficult parts of the country. At the same time quality service should be rewarded and punitive measures transparently taken against those whose attitude not only deters service utilization but also compromises the human rights of the women and public. • Supportive supervision to facilities should be streamlined and integral to programme management at all levels. Appropriate checklists and guidelines should be developed prioritising on equity to access and quality of care. • Health policies should be updated to reflect the current guidelines on access to quality health services e.g. physical access defined as 30 minutes and not 2 hours walk from a health facility for obstetric care. • The development and dissemination of policies, guidelines, and protocols on women’s health issues, should be accelerated and expanded to include the prevention and management of SGBV. Through in-service training health workers should be appropriately equipped with the skills and trained on their use. Curricula of training institutions should be similarly updated. Such policies should be widely disseminated in a language that is easy for the general population to decipher. The women may then be able to decide on the adequacy of services delivered. • Civic education on human rights, including their right to health (care), for women and men, should be expanded and be sensitive to issues that deter the protection of women from SGBV. Intensive education and social mobilization involving community leadership and structures is essential at specifically addressing issues that may be assessed contravening culture. • Parliamentarians should be empowered on women ‘s health issues. • Relevant sectors, including the MOHSW, the Ministry of Gender and Youth, Sports and Recreation (MOGYSR), the Ministry of Agriculture and Food Security, as well as the Ministry of Education and Training (MOET), should closely collaborate and facilitate institution of fora at national and lower levels, for advocacy, education, monitoring the implementation of policies and
MMM Lesotho June 2005 79 laws that relate to women’s health, and ensuring compliance as well as taking corrective steps and action. • The implementation of the sexual offences act and other relevant laws should be closely monitored and the Ministry of Justice (through the Justice Sector Development Programme) in collaboration with the Ministry of Home Affairs (Police, Correctional Services and Immigration) reinforce and ensure compliance. Given that the majority of women’s occupations are mobile in nature, the Ministry of Labour and Employment should also be involved towards reduction of vulnerability of these women to HIV and abuse. • Justice and Legal enforcement agency human resources should be regularly updated of the laws and policies to foster improved appreciation of issues pertaining to SGBV, hence compliance. • Programmes should be deliberately designed to actively seek and involve as well as ensure women’s participation on issues relevant to their health. The empowerment of women in this regard should therefore be integral to the civic education on women’s rights. • Communities should then be mobilized in contributing resources to such as emergency transport etc. At the same time the formal sector should enhance road, radio and telephone communication of health facilities to further enhance access to services as well as ensure an effective referral system. • The community-based services should be improved to cater for the needs of women. The skills of such workers should thus be enhanced and accordingly expanded to also include prevention and management of SGBV as well as advocacy for protection of women against this violence. Their credibility should also be enhanced with appropriate support systems and avoid duplication or competition. • In support of these efforts and specific for IEC, specific materials addressing cultural and other practices that need to be changed for better health, encompassing SGBV and sanitation should be developed and disseminated to the health facilities. This should be appropriately backed up through other communication channels such as use of the radio. • Factors such as long duration of marriage and higher level of education (income earning) that significantly positively empower women to make decisions should be applied in identifying change agents in communities.
Defining the Crisis
• Given the low economic status of the women, fee exemption criteria should be updated and accord priority to women resident in the rural areas of worst off zones as well as PLWHAS. The government policy should be that the services for women are provided free of charge in public facilities. IGA activities should be similarly prioritised. • Food insecurity and higher level of dependence on food aid are worst off in areas where physical access to health facilities is also comparatively low. These should be the zones to which food aid is prioritised. The foothills zone where there was no reported dependency on food aid yet the other indices were poor needs to be further assessed to ensure equity of access to food interventions.
MMM Lesotho June 2005 80 • The preponderance of home-based care activities more than any other community based health service could be an implication of the burden of disease as well as the level of advocacy for such service delivery. The women however did not mention caring for the sick as a constraint to seeking their own care. PLWHAs on the other hand appreciated the home-based carers more than those in health facilities. Care of PLWHAs therefore needs to be enhanced at facility level and the continuum of care maintained. Similarly efforts at improved sanitation and universal safe water supply should be strengthened in contribution to reducing the burden of communicable diseases and improving on the care of PLWHAs. • ART should be made available in all hospitals. Health centre staff should be trained and supported in screening and referral of patients, including for ART. • The skilled health care providers should be appropriately trained to be HIV and AIDS competent; measures to address their high attrition should be taken as matter of priority. At the same time their capacity in client orientation should be improved including punitive measures for those whose attitude is not conducive to service utilization. • Meantime recommendations for reducing the attrition of skilled human resources should be speedily implemented to facilitate access to care especially for ART and EOC; the quality of services for women should not be otherwise compromised. • Systems and mechanisms for the adequate protection of women against SGBV hence decreasing their vulnerability, including to HIV/AIDS, should be actively explored. Chiefs, politicians (parliamentarians) and other community leaders should be held accountable for such protection.
MMM Lesotho June 2005 81
8. References
1. (Draft) Government of Lesotho, National Adolescent Health Policy, November 2003 2. (Draft) National Reproductive Health Policy Kingdom of Lesotho, December 2002. 3. Facing The Future Together: Lesotho Country Report of the United Nations Secretary General’s Task Force on Women and Girls, and HIV/AIDS in Southern Africa draft 2005/2006. 4. FHI/Ministry of Health and Social Welfare/Sechaba Consultants/ USAID HIV/AIDS Behavioural Surveillance Survey Lesotho 2002 5. Government of Lesotho, Gender and Development Policy, March 2003. 6. Government of Lesotho/Ministry of Health and Social Welfare Final Draft Strategic Plan 2004/05 to 2010/11, March 2004. 7. Government of Lesotho/Ministry of Health and Social Welfare Lesotho Health Sector Reform Phase I: Capacity Building DHP Outfit: Display an Essential Service Package For The Lesotho Health Sectors Final the Report, June 2003. 8. Government of Lesotho, National Social Welfare Policy, December 2002 9. Government of Lesotho, Sexual Offences Act 2003 10. Health Planning and Statistics Department/Ministry of Health and Social Welfare, Health Sector Reform Phase I, Completion Report(PCR). 11. Health Planning and Statistics Department/Ministry of Health and Social Welfare, Lesotho Heath and Social Welfare Sector Reform Programme, Selected Indicators 2004. 12. International Organization for Migration, Partnership on HIV/AIDS and Mobile Populations in Southern Africa, April 2004 13. IOM, Sida, UNAIDS; Mobile Populations and HIV/AIDS in the Southern African Region, Recommendations for Action; Deskreview and Bibliography on HIV/AIDS and Mobile Populations; May 2003 14. Kingdom of Lesotho, Ministry of Health and Social Welfare, Human Resource Development Strategic Plan 2005-2025. 15. Kingdom of Lesotho, Ministry of Health Statistical Tables 2003 16. Kingdom of Lesotho, Poverty Reduction Strategy 2004/05 - 2006/07 17. Kingdom of Lesotho, Mental Health Policy (First Draft), February 2005.
MMM Lesotho June 2005 82 18. Kingdom of Lesotho, Strategic Plan For Mental Health (First Draft) February 2005.Mental Health Policy. 19. Lesotho AIDS Programme Co-ordinating Authority, Support Groups Census, 2002 20. Lesotho Government Gazette Extraordinaire, April 2003. 21. Lesotho Planned Parenthood Association, Gender Norms and Practices In The Heart of the HIV/AIDS Pandemic: Case Study of Ha -‘Manteko in Qacha’s Nek, December 2004 22. Ministry of Finance and Development Planning, Draft Population Policy 2004. 23. Ministry of Health, Community Health Workers Inventory, 2004 24. Ministry of Health, Village Health Worker Training Manual 25. Ministry of Health and Social Welfare/Health Planning and Statistics Department, Review Report 2004/05, January 2005 26. Ministry of Health and Social Welfare/Lesotho Health Sector Reform, Health Sectors Infrastructure Plan First Draft, July 2004 27. Ministry of Health and Social Welfare/Lesotho Health Sector Reform, Essential Service Package, 2005 28. Ministry of Health/World Health Organization, A Baseline Study On The Magnitude of Abortion among Women of Child Bearing Age in Lesotho, Maseru September 2003 29. Ministry of Health/World Health Organization, A Study of Adolescents’ Health Problems in Leribe, Maseru, and Mafeteng Districts of Lesotho, 1999. 30. Ministry of Health/World Health Organization, Lesotho Safe Motherhood Initiative, Women’s Health Survey 31. Ministry of Health/World Health Organization, National Adolescent Health Population and Development Programme for Lesotho December 1997. 32. Ministry of Health and Social Welfare/World Health Organization, Violence Against Women in Lesotho, December 2003. 33. SADC HIV/AIDS Strategic Framework and Programme 2003 – 2007; April 2003 34. Sechaba Consultants/ Ministry of Employment and Labour, Behavioural Surveillance Survey Report, August 2004 35. The World Bank, Core Welfare Indicator Questionnaire, Lesotho 2002 CWIQ Survey Core Welfare Indicators and tables.
MMM Lesotho June 2005 83 36. Ulla Idanpaan-Heikkela, Stakes, A Plan For a Quality Assurance System for The Decentralized Health Care in Lesotho, 2004 37. UNAIDS, The Global Coalition on Women and Aids, facing The Future Together: Report of the Secretary General’s Task Force on Women, Girls and HIV/AIDS in Southern Africa 38. UNICEF/Mokuku Selloane, Hear Us! Shedding Light on the Plight of Child Domestic Workers in Lesotho, November 2004 39. UNFPA/UNCT, Speaking Out! Views of Young Basotho on Gender, Sexuality, HIV/AIDS, Life Skills and Education In Lesotho, Volume 1 Quantitative Analysis, Maseru – Lesotho, March 2005 40. Vision 2020, National Vision for Lesotho. 41. What Other International Instruments Say on Prisoners Rights to Health Care (Prisons submission) 42. WHO/IOM/Mario-Negri Sud/ International Centre for Migration and Health/ILO/EGI/Office of United Nations High Commission for Human Rights; International Migration, Health and Human Rights, 2003. 43. WHO Regional Office for Africa, HI Package of The WHO Africa Report, Reproductive Health 44. WHO, The World Health Report 2004, Changing History 45. Wilson David (Project Support Group and FHI IMPACT Project); Lesotho and Swaziland HIV/AIDS Risk assessment at Cross Border and Migrant Sites in Southern Africa
46. Women and Law in Southern Africa, In Search Of Justice, Where Do Women In Lesotho Go, 2002 47. Women and Law in Southern Africa, Sexual Violence in Lesotho, The Realties of Justice for Women, 2002 48. Zicken- Sechaba Joint Venture, Lesotho Health Sector Reform Baseline Assessment, June 2001
MMM Lesotho June 2005 84 9. Appendices
a. Appendix I : Questionnaires
9.1.1 Structured Questionnaire Community Level (Attached)
9.1.2 Structured Questionnaire Health Facility Level (including spot check and exit interviews) (Attached)
9.1.3 Focus Group Discussion Guide
In your experience with the health services:
1. What systems of payment exist/are applied (Indicate facility name and type) 2. If not able to pay what are the penalties; do you still receive any service? Explain. 3. What are your sources of income; how and who decides on the allocation for health care 4. What are the opportunities for gainful employment of women? (by level of education • No education • Primary school completion • Secondary school completion • High school completion • Higher/tertiary completion • Vocational school completion 5. Indicate the beliefs, customs, and taboos that have implications on health service utilization and how 6. How far (distance in Km or walking time) are you from the nearest health centre 7. How far are you from the nearest hospital 8. Does this hospital offer Emergency obstetric care 9. If not how far is the nearest facility that offers this service 10. What transport is used for such cases (EOC) 11. If there is an ambulance how much does it cost and is it affordable? 12. How long do you have to wait for such an ambulance? 13. Is there community organized/owned means for transporting emergencies including EOC 14. What health services are available for women in your village and who is involved (indicate individuals, organizations etc) ** probe for RH,VCT/HTC, PMTCT,ART,IEC and mental health, CHBC,SGBV) 15. Are there any protection mechanisms and systems for women against sex and gender based violence/explain) 16. How effective are the means of legal enforcement through statutory, customary, by - laws means? 17. Elaborate on what you know of the human rights for women ESPECIALLY in relation to SGBV as well as gender related inequalities 18. What access is there to legal representation on SGBV? Elaborate
MMM Lesotho June 2005 85 19. What barriers are there to accessing health services **probe on closing and opening times, ease of referrals, physical infrastructure, gender, confidentiality, privacy, sanitary facilities, workers attitude 20. What is the availability of human resources for service delivery, especially for care of women and girls (cadre, numbers etc)
9.1.4 Key Informant Interview Guide
All questions relate to women and girls/adolescents and youth
1. Given that your Organization supports/implements programmes targeting women, would please in your own words indicate to me the following: • Programme strengths • Programme weaknesses • Key Challenges • Constraints • Obstacles
What are your views on/describe the following:
2. Socio-Cultural and Economic Issues: 2.1 Economic factors that relate to women’s utilization of Health services. • Affordability & Income • Female poverty • Food insecurity 2.2 Comparison of women’s employability and occupation to their level of education. 2.2 Decision making by women and resource allocation. 2.3 Known taboos, beliefs and customs that relate to women’s utilization of Health services. 3. Protection of women against sexual and gender based violence. 4. Perceived/Known physical access barriers for women to utilize health services, including the physical attribute (sanitation, water, food etc) 5. National Health Systems, Policies, and strategic plans etc available including guidelines and protocols in relation to women’s health and social services. 6. Systems of Health Service organization in relation to women’s health (positives and negatives) 7. Availability of services for women 8. Financial resources allocation criteria, quality and availability-financial allocation resources consideration for women. b. Are services ever contracted out, when, why, any such contracting for women ? 10. Eligibility of women for service: • Curative • ANC,PNC • Deliveries • FP • ART • VCT/PMTCT
MMM Lesotho June 2005 86 11. Service fee exemption criteria with emphasis on women 12. Forum for participation of women in service delivery (probe for PLWHAs) 13. Referral systems for women: • Scope • Criteria • Access • Infrastructure and logistics 14. Any Support Systems for women 15. Women’s role and services received through the HBC 16. National fora and bodies for women’s health. 17. Statutory, Customary and by-laws enforcement for protection of girls and women (Legal, Social, Physical) 18. Civic education on women’s rights in relation to school and GBV and gender related inequities 19. Describe the access to legal representation for women 20. What Policies, guidelines and protocols are available on SGBV 21. Describe the HMIS on women health services
MMM Lesotho June 2005 87 9.2 Appendix II: Tables and Figures
Table 1 Distribution of Women by Ecological Zone Ecological Zone Frequency Percent Lowlands 236 41.2 Foothills 54 9.4 Mountains 142 24.8 Senqu River Valley 141 24.6 Total 573 100
Table 2 Distribution of Women by Rural and Urban abode Urban/Rural Frequency Percent Rural 304 53.1 Urban 269 46.9 Total 573 100
Table 3 Distribution of Women according to Marital Status Marital Status Frequency Percent Divorced 11 1.9% Married 316 55.3% Separated 22 3.9% Single 153 26.8% Widowed 69 12.1% Total 571 100.0%
Table 4 Distribution of Women by Attendance of School School Frequency Percent Yes 545 96.1% No 22 3.9% Total 567 100.0%
Table 5 Distribution of Women by Level of Education Level of Education Frequency Percent None 91 16.5 Primary 303 54.9 Secondary 103 18.7 High 46 8.3 Tertiary 9 1.6 Total 552 100
MMM Lesotho June 2005 88 Table 6 Cross Tabulation of Women by Education Level and Ecological Zone Level of Ecological Zone Education Lowlands Foothills Mountains Senqu Total River Valley None 30.8 9.9 26.4 33.0 100 Primary 41.9 8.9 27.4 21.8 100 Secondary 44.7 14.6 17.5 23.3 100 High 58.7 4.3 10.9 26.1 100 Tertiary 55.6 0 22.2 22.2 100 Total 42.2 9.6 23.9 24.3 100 Chi-squared df Probability 21.8608 12 0.0391
Table 7 Cross Tabulation of Women by Urban/Rural abode and Level of Education Urban/Rural Level of Education None Primary Secondary High Tertiary Total Rural 21.0 55.9 16.9 5.5 0.7 100 Urban 11.5 53.8 20.6 11.5 2.7 100 Total 16.5 54.9 18.7 8.3 1.6 100 Chi-squared df Probability 17.9231 4 0.0013
Table 8 Distribution of Women by Age Age (Years) Frequency Percent <15 11 2.0 15 – 19 104 18.8 20 – 24 122 22.1 25 – 29 96 17.4 30 – 34 74 13.4 35 – 39 45 8.1 40 –44 57 10.3 45 – 49 43 7.8 >/50 1 0.2 Total 553 100
Table 9 Distribution of Women by Employment Status Employment Frequency Percent Yes 184 33.1% No 372 66.9% Total 556 100.0%
MMM Lesotho June 2005 89 Table 10 Cross Tabulation of Women by Employment Status and Ecological Zone Employment Ecological Zone Status Lowlands Foothills Mountains Senqu Total River Valley Yes 47.8 6.5 25.0 20.7 100 No 38.0 10.8 24.7 26.5 100 Total 41.2 9.4 24.8 24.6 100 Chi-squared df Probability 7.0516 3 3 0.0703
Table 11 Cross Tabulation of Women by Employment Status and Urban/Rural abode Urban/Rural Employment status Yes No Total Rural 25.7 74.3 100 Urban 39.4 60.6 100 Total 32.1 67.9 100 Chi-squared df Probability 13.3722 0.0004
Table 12 Cross tabulation of Women by Age and Employment Status Age Business Civil Domestic IGA Private Traditional Total (years) Service worker Sector Healer employee <15 0 0 1 0 0 0 1 15 – 19 0 1 7 12 1 1 22 20 – 24 0 2 5 22 0 0 29 25 – 29 1 3 4 18 2 0 28 30 – 34 1 3 4 23 1 1 33 35 – 39 0 2 0 18 1 0 21 40 – 44 1 3 6 15 1 0 26 45 – 49 0 2 2 15 1 1 21 >/50 1 Total 3 16 29 123 7 3 181
Table 13 Cross tabulation of Women by Level of Education and Employment Status Level of Employed Not Employed Total Education Number Percent Number Percent Number Percent None 30 33 61 67 91 16.5 Primary 94 31 209 69 303 54.9 Secondary 34 33 69 67 103 18.7 High 16 34.8 30 65.2 46 8.3 Tertiary 3 33.3 6 66.7 9 1.6 Total 177 32.1 375 67.9 552 100
MMM Lesotho June 2005 90 Table 14 Cross tabulation of women by Level of Education and Type of Employment
Level of Type of Employment (%) Education Business Civil Domestic IGA Private Traditional Total Total Woman Servant Worker Sector Healer (%) (#) Employee None 3.3 0 33.3 60 0 3.3 17.0 30 Primary 2.1 5.3 16 71.3 4.3 1.1 53.1 94 Secondary 0 11.8 2.9 76.5 5.9 2.9 19.2 34 High 0 31.3 6.3 56.3 6.3 0 9.0 16 Tertiary 0 66.7 0 33.3 0 0 1.7 3 Total (%) 100 100 100 100 100 100 100
Total 3 16 27 121 7 3 177 (#)
Chi-squared df Probability 41.6276 20 0.0031
Table 15 Cross tabulation of Women according to their Level of Education and Who Decides on How Money should be used in the family Level of Joint Husband The woman Relative Total Education Decision woman and husband Number % Number % Number % Number % Number % None 22 24.2 14 15.4 37 40.7 18 19.8 91 16.6 Primary 109 36.3 40 13.3 70 23.3 80 26.7 300 54.8 Secondary 33 32.4 11 10.8 22 21.6 34 33.3 102 18.6 High 7 15.2 2 4.3 17 37 20 43.5 46 8.4 Tertiary 3 33.3 0 0 4 44.4 2 22.2 9 1.6 Total 174 31.8 67 12.2 150 27.4 154 28.1 548 100
Chi-squared df Probability 35.8831 16 0.0030
MMM Lesotho June 2005 91 Table 16 Cross tabulation of Women by Age and Who Decides on How Money should be used in the family Age Who decides (%) Both Husband Wife/self Relative Other Total husband and wife <15 0 0 10.0 80.0 10.0 100 15.19 10.2 10.2 12.2 65.3 20.0 100 20-24 33.1 13.2 23.1 30.6 0 100 25-29 37.9 15.8 34.7 11.6 0 100 30-34 37.8 20.3 33.8 8.1 0 100 35-39 37.8 15.6 46.7 0 0 100 40-44 28.1 14.0 56.1 0 1.8 100 45-49 28.6 11.9 57.1 2.4 0 100 >/50 100 0 0 0 0 100 Total 29.5 14.0 32.4 23.4 0.7 100 Chi-squared df Probability 218.5607 3.2 0.0000
Table 17 Cross tabulation of Women according to their Occupation and Who Decides on How Money should be used in the family Occupation Who Decides (%) Both Husband Wife/self Relative Other Total husband and wife Business 100 0 0 0 0 1.6 Woman Civil 31.3 12.5 50 0 1 8.7 Servant Domestic 17.2 3.4 69 10.3 0 15.9 Worker IGA 28 3.2 61.6 6.4 0.8 68.3 Private 28.6 0 57.1 14.3 0 3.8 Sector Employee Traditional 0 0 100 0 0 1.6 Healer Total 100 100 100 100 100 100 Total # 50 7 112 13 1 183
Chi-squared df Probability 16.7374 20 0.6700
MMM Lesotho June 2005 92 Table 18 Cross tabulation of Women by Ecologic Zone and Who decides on income use Ecological Who decides (%) zone Both Husband Self Relative Other Total Husband and wife Lowlands 27.4 12.2 32.2 27.4 0.9 100 Foothills 39.6 16.7 20.8 20.8 2.1 100 Mountains 33.3 15.6 36.2 14.2 0.7 100 Senqu 29.1 12.8 31.9 26.2 0 100 Total 30.4 13.6 32.1 23.2 0.7 100 Chi-squared df Probability 15.9889 12 0.1917
Table 19 Cross tabulation of Women by Urban/Rural abode and Who decides on income use Urban/Rural Who decides (%) Both Husband Self Relative Other Total husband and wife Rural 34.0 15.6 28.2 21.1 1 100 Urban 26.3 11.3 36.5 25.6 0.4 100 Total 30.4 13.6 32.1 23.2 0.7 100 Chi-squared df Probability 9.6525 4 4 0.0467
Table 20 Distribution of Women by Income per Month (Maluti) Income per Month Frequency Percent (Maluti) Less than 10 1 0.5 10 – 110 11 5.9 111 – 210 42 22.7 211 – 310 30 16.2 311 – 410 13 7.0 411 – 500 18 9.7 > 500 70 37.8 Total 185 100
MMM Lesotho June 2005 93 Table 21 Distribution of Women by Source of Food Source of food Frequency Percent Farm 163 28.6% Food Aid 29 5.1% Handouts 10 1.8% Other 2 0.4% Purchase 365 64.1% Total 569 100.0%
Table 22 Cross tabulation of Women by Ecological Zone and Main Source of food Ecological Main source of food (%) zone Farm Food aid Handouts Purchase Other Total Lowlands 24.8 2.1 1.3 71.4 0.4 100 Foothills 55.6 0 0 44.4 0 100 Mountains 37.6 5.0 2.1 55.3 0 100 Senqu 15.7 12.1 2.9 68.6 0.7 100 Total 28.6 5.1 1.8 64.1 0.4 100 Chi-squared df Probability 58.2742 12 0.0000
Table 23 Cross tabulation of Women by Urban/Rural abode and Main Source of food Urban/rural Main source of food (%) Farm Food aidHandouts Purchase Other Total Rural 43.0 7.0 1.3 48.0 0.1 100 Urban 12.4 3.0 2.2 82.4 0 100 Total 28.6 5.1 1.8 64.1 0.4 100 Chi-squared df Probability 79.5104 4 0.0000
Table 24 Distribution of Women by their Choice of Where to seek care Where do you usually go first to seek health care? Frequency Percent Health Center 310 56.0% Hospital 225 40.6% Other 7 1.3% Traditional healer 5 0.9% VHW 7 1.3% Total 554 100.0%
MMM Lesotho June 2005 94 Table 25 Cross tabulation of Women by Ecological Zone and Where they usually go first to seek health care Ecological First seek care (%) zone Health Hospital Traditional VHW Other Total center Healer Lowlands 78.1 18.3 0.4 0.4 2.7 100 Foothills 48.1 48.1 0 3.8 0 100 Mountains 43.6 52.1 2.1 1.4 0.7 100 Senqu 35.5 62.3 0.7 1.4 0 100 Total 56.0 40.6 0.9 1.3 1.3 100 Chi-squared df Probability 96.8573 12 0.0000
Table 26 Cross tabulation of Women by Urban/Rural abode and Where they usually go first to seek health care Urban/rural First seek care (%) Health Hospital Traditional VHW Other Total Center Healer Rural 64.1 31.9 1.0 2.0 1.0 100 Urban 38.4 57.8 0.8 0.4 1.6 100 Total 56.0 40.6 0.9 1.3 1.3 100 Chi-squared df Probability 23.0296 4 0.0001
Table 27 Distribution of Women by their Choice of Where to seek to Emergency Pregnancy Care
Where do you usually go first to seek emergency pregnancy Frequency Percent care Health Center 175 34.0% Hospital 250 48.6% Other 66 12.8% TBA 8 1.6% Traditional healer 7 1.4% VHW 8 1.6% Total 514 100.0%
MMM Lesotho June 2005 95 Table 28 Cross tabulation of Women by Ecological Zone and Where they first seek Emergency Pregnancy Care
Ecological First seek care (%) zone Health Hospital Traditional VHW TBA Other Total center Healer Lowlands 43.7 37.9 1.0 0 0.5 2.7 100 Foothills 33.3 56.2 0 0 0 10.4 100 Mountains 34.8 47.0 2.3 3.0 2.3 10.6 100 Senqu 18.0 64.8 1.6 3.1 3.1 9.4 100 Total 34.0 48.6 1.4 1.6 1.6 12.8 100 Chi-squared df Probability 46.8141 15 0.0000
Table 29 Cross tabulation of Women by Urban/Rural abode and Where they first seek Emergency Pregnancy Care Urban/rural First seek care (%) Health Hospital Traditional VHW TBA Other Total center Healer Rural 41.2 42.3 1.8 1.5 1.8u 11.3 100 Urban 25.8 55.8 0.8 1.7 1.2 14.6 100 Total 34.0 48.6 1.4 1.6 1.6 12.8 100 Chi-squared df Probability 16.0080 5 0.0068
Table 30 Percentage Distribution of Reasons why Women are not able to access services Reason Frequency Percent Caring for someone sick 1 2.6% Did not have money 26 66.7% No drugs in facility 1 2.6% Other 11 28.2% Total 39 100.0%
MMM Lesotho June 2005 96 Table 31 Distribution of Women by their Knowledge/Perception on Service Availability Service Service Available Number Percent Number Percent Total Total Yes Yes No No Number Percent ANC 519 91.9 46 8.1 565 100 Deliveries 381 67.4 184 32.6 565 100 PNC 515 91.2 50 8.8 565 100 FP 346 61.5 217 38.5 563 100 Counselling 147 26.1 417 73.9 564 100 Curative 562 99.5 3 0.5 565 100
Table 32 Distribution of Women by their Experience of Violence Ever been a victim of any form of violence Frequency Percent Yes 88 15.5% No 481 84.5% Total 569 100.0%
Table 33 Cross tabulation of Women by Perpetrator and Type of Violence Perpetrator Type of violence Physical Psychological/ Sexual Total Verbal Number % Number % Number % Number % Husband 21 84 2 8.0 2 8 25 100 Brother 2 50 2 50 0 0 4 100 Relation 2 25 5 62.5 1 12.5 8 100 Other 12 26.7 14 31.1 18 40 45 100 Total 37 45.1 23 28 21 25.6 82 100 Chi-squared df Probability 29.3651 9 0.0006
MMM Lesotho June 2005 97 Table 34 Cross tabulation of Women’s Experience of the Outcome of Reporting Violence by Who the violence was Reported to Outcome Who the violence was reported to( %) Not Local Police Relatives Other Total Reported Chief Perpetrator 0 0 90.9 9.1 0 15.3 charged Perpetrator 0 82.4 5.9 11.8 0 20.5 remanded by Chief Perpetrator 0 5 0 85 10 25.3 remanded by family Nothing 0 33.3 18.5 48.1 0 32.5 Other 14.3 14.3 14.3 57.1 0 8.4 Total 1.2 30.5 20.7 45.1 2.4 100 Total # 1 25 17 37 2 82
Chi-squared df Probability 87.1774 16 0.0000
Table 35 Distribution of Women’s Response to Witnessing a Rape by Who they would report to Who would Witnessed rape outside Family member raped report to family Number % Number % Local Chief 278 50.2 251 44.8 Police 227 41.0 213 38.0 Relative 19 3.4 75 13.4 Other 30 5.4 21 3.8 Total 554 100 560 100
MMM Lesotho June 2005 98 Table 36 Cross tabulation of women on witnessing rape of a family member by ecological zone and who they would report the rape to Whom they would report to (%) Ecological Zones Chief Other Police relative TOTAL 53.7 1.9 37.0 7.4 100.0 Foothills
Lowland 39.1 4.3 47.4 9.1 100.0
Mountain 5.3 3.6 28.5 22.6 100.0
Senquvalley 50.4 3.6 32.4 13.7 100.0
44.8 3.8 38.0 13.4 100.0 TOTAL
Chi-squared df Probability 27.3922 9 0.0012
Table 37 Cross tabulation of Women on Witnessing Rape of a Family Member by Urban/Rural abode and Who they would report the rape to Who they would report the rape to (%) Urban/Rural Chief Other Police relative TOTAL 53.7 3.0 28.7 14.7 100.0 Rural
34.6 4.6 48.8 11.9 100.0 Urban
TOTAL 44.8 3.8 38.0 3.4 100.0
Chi-squared df Probability 27.9430 3 0.0000
MMM Lesotho June 2005 99 Table 38 Distribution of the Women’s Mode of Travel to reach health facilities Mode Frequency Percent By car/bus/taxi 237 42.2% By foot 317 56.5% By horse 2 0.4% Other 5 0.9% Total 561 100.0%
Table 39 Distribution of the duration of women’s travel to the health centre Duration (hours) Frequency Percent 1 to 2 145 25.5% 3 to 4 4 0.7% Less than one hour 420 73.8% Total 569 100.0%
Table 40 Cross tabulation of women by ecological zone and duration to get to nearest health facility HOW LONG IT TAKES TO THE NEAREST FACILITY (%) Ecological Zones 1 to 2 3 to 4 Less than one hour TOTAL Foothills 9.3 3.7 87.0 100.0
Lowlands 17.6 0.0 82.4 100.0
Mountains 33.3 0.0 66.7 100.0
Senqu valley 36.9 1.4 61.7 100.0
TOTAL 25.5 0.7 73.8 100.0
Chi-squared df Probability 39.8189 6 0.0000
MMM Lesotho June 2005 100 Table 41 Cross tabulation of Women by Rural/Urban and Duration to get to Nearest health facility
HOW LONG IT TAKES TO THE NEAREST FACILITY (%) Urban/Rural 1 to 2 3 to 4 Less than one hour TOTAL Rural 30.8 0.3 68.9 100.0
Urban 19.5 1.1 79.4 100.0
TOTAL 25.5 0.7 73.8 100.0
Chi-squared df Probability 10.5181 2 0.0052
Table 42 Distribution of the Duration of Women’s Travel to the Hospital Duration (hours) Frequency Percent 1 to 2 216 38.0% 3 to 4 10 1.8% Less than one hour 343 60.3% Total 569 100.0%
Table 43 Cross tabulation of Women by Ecological Zone and Duration to get to Nearest Hospital Duration in Hours (%) Ecological Zones 1 to 2 3 to 4 Less than one hour TOTAL
Foothills 29.6 0.0 70.4 100.0
Lowland 29.2 0.0 70.8 100.0
Mountain 48.9 2.8 48.2 100.0
Senqu Valley 44.7 4.3 51.1 100.0
TOTAL 38.0 1.8 60.3 100.0
Chi-squared df Probability 33.4379 6 0.0000
MMM Lesotho June 2005 101 Table 44 Cross tabulation of Women by Rural/Urban abode and Duration to get to the Nearest Hospital Duration in hours (%) Urban/Rural 1 to 2 3 to 4 Less than one hour TOTAL Rural 50.7 1.7 47.7 100.0
Urban 23.6 1.9 74.5 100.0
TOTAL 38.0 1.8 60.3 100.0
Chi-squared df Probability 44.3341 2 0.0000
Table 45 Distribution of Women by Contraceptive Method Use Method Proportion (%) Condom 29.8 Pill 21.8 IUCD 11.0 DMPA 35.8 Abstinence 0.4 Traditional Medicine 0.4 Total 100.0
MMM Lesotho June 2005 102 Table 46 Cross tabulation of women’s use of FP by ecological zone Use of FP (%) Ecological Zones Yes No TOTAL
Foothills 29.6 70.4 100.0
Lowland 51.5 48.5 100.0
Mountain 28.6 71.4 100.0
Senqu valley 42.4 57.6 100.0
TOTAL 41.5 58.5 100.0
Chi-squared df Probability 22.3697 3 0.0001
Table 47 Cross tabulation of Women’s Use of FP by Urban/Rural abode Use of FP (%) Urban/Rural Yes No TOTAL Rural 41.6 58.4 100.0
41.4 58.6 100.0 Urban
TOTAL 41.5 58.5 100.0
Table 48 Distribution of Women by Source of Family Planning Method Source Frequency Percent CBD 5 2.3% CHW 5 2.3% Health 165 76.7% facility Other 25 11.6% Pharmacy 15 7.0% Total 215 100.0%
MMM Lesotho June 2005 103 Table 49 Distribution of Women by How they Disposed of Household Solid and Liquid Waste Solid waste Liquid waste Disposal Frequency Percent Frequency Percent In donga 22 3.9% 20 3.5% In Soak away pit 59 10.4% In ordinary pit 129 22.8% 230 40.4% Municipality bin 28 4.9% On heap 384 67.7% 245 43.1% Septic Tank 6 1.1% Other 4 0.7% Total 567 100.0% 569 100.0%
Table 50 Cross tabulation Disposal of Solid Waste by Ecological Zone and Where Waste Disposed of Ecological Where dispose of solid waste in/at(%) zone Donga Ordinary Municipality Heap Other Total Pit Bin Lowlands 1.7 32.3 11.2 54.3 0.4 100 Foothills 1.9 14.8 0 83.3 0 100 Mountains 4.3 15.7 0.7 78.6 0.7 100 Senqu 7.8 17.0 0.7 73.0 1.4 100 Total 3.9 22.8 4.9 67.7 0.7 100 Chi-squared df Probability 68.9939 12 0.0000
Table 51 Cross tabulation Disposal of Liquid Waste by Ecological Zone and Where Waste Disposed of Ecological Where dispose of liquid waste in/at(%) zone Donga Soak Ordinary Heap Septic Other Total away Pit Tank Pit Lowlands 3.0 13.3 47.2 32.6 1.7 2.1 100 Foothills 1.9 11.1 48.1 37.0 0 1.9 100 Mountains 4.3 9.9 33.3 49.6 0.7 0 100 Senqu 4.3 9.9 33.3 49.6 0.7 2.1 100 Total 3.5 1`0.4 40.4 43.1 1.1 1.6 100 Chi-squared df Probability 31.1158 15 0.0085
MMM Lesotho June 2005 104 Table 52 Cross tabulation of Disposal of Solid Waste by Urban/Rural abode and Where Disposed of Urban/rural Where dispose of solid waste in/at(%) Donga Ordinary Municipality Heap Other Total Pit Bin Rural 3.0 19.9 0.3 76.4 0.3 100 Urban 4.9 25.9 10.2 57.9 1.1 100 Total 3.9 22.8 4.9 67.7 0.7 100 Chi-squared df Probability 39.5298 4 0.0000
Table 53 Cross tabulation Disposal of Liquid Waste by Rural/Urban abode and Where Waste Disposed of Urban/Rural Where dispose of liquid waste in/at(%) Donga Soak Ordinary Heap Septic Other Total away Pit Tank Pit Rural 3.0 7.6 39.9 47.9 0.3 1.3 100 Urban 4.1 13.5 41.0 37.6 1.9 1.9 100 Total 3.5 10.4 40.4 43.1 1.1 1.6 100 Chi-squared df Probability 12.5799 5 0.0299
Table 54 Distribution of Women by Household Possession of a Toilet Type of toilet Frequency Percent None 179 31.5% Pit latrine 292 51.3% VIP latrine 87 15.3% Water system 11 1.9% Total 569 100.0%
MMM Lesotho June 2005 105 Table 55 Cross tabulation of Household Possession of a Toilet by Ecological Zone Type of Toilet (%) Ecological Zones None Pit latrine VIP latrine Water system TOTAL 16.7 74.1 9.3 0.0 100.0 Foothills
Lowlands 18.9 58.8 17.6 4.7 100.0
Mountain 61.0 27.0 12.1 0.0 100.0
Senqu valley 28.4 54.6 17.0 0.0 100.0
31.5 51.3 15.3 1.9 TOTAL 100.0
Chi-squared df Probability 98.7909 9 0.0000
Table 56 Cross tabulation of Household Possession of a Toilet by Urban/Rural abode Type of toilet (%) Urban/Rural None Pit latrine VIP latrine Water system TOTAL Rural 38.9 50.5 10.6 0.0 100.0
Urban 22.9 52.3 20.7 4.1 100.0
TOTAL 31.5 51.3 15.3 1.9 100.0
Chi-squared df Probability 33.6388 3 0.0000
Table 57 Distribution of Women by Source of Drinking Water Source of drinking water Frequency Percent Borehole 28 4.9% Other 98 17.2% River 4 0.7% Spring 80 14.1% Tap 359 63.1% Total 569 100.0%
MMM Lesotho June 2005 106
Table 58 Cross tabulation of Sources of Drinking Water by Ecological Zone and Source Ecological Source of drinking water (%) zone Borehole River Spring Tap Other Total Lowlands 9.4 0.4 16.7 57.1 16.3 100 Foothills 11.1 0 3.7 53.7 31.5 100 Mountains 0 2.1 15.6 70.2 12.1 100 Senqu 0 0 12.1 69.5 18.4 100 Total 4.9 0.7 14.1 63.1 17.2 100 Chi-squared df Probability 53.3336 12 0.0000
Table 59 Cross tabulation of Sources of Drinking Water by Urban/Rural and Source Urban/rural Source of drinking water (%) Borehole River Spring Tap Other Total Rural 8.3 1.3 18.8 64.4 7.3 100 Urban 1.1 0 8.6 61.7 28.6 100 Total 4.9 0.7 14.1 63.1 17.2 100 Chi-squared df Probability 66.0410 4 0.0000
Table 60 Distribution of Health Facilities by their Normal Opening Hours Opening hours Frequency Percent 10 1 11.1% 8 7 77.8% 9 1 11.1% Total 9 100.0%
Table 61 Distribution of Health Facilities by their Opening Outside Normal Hours Opening Frequency Percent Yes 5 55.6% No 4 44.4% Total 9 100.0%
MMM Lesotho June 2005 107 Table 62 Distribution of Health Facilities by Services Offered Service Frequency (out of 9) Percent ANC 9 100 PNC 8 88.9 Deliveries 3 33.3 Counselling 6 66.7 Family Planning 7 77.8 Other 2 28.6 **2 Hospitals and 1 of 7 Health Centres (2 Filter clinics)
Table 63 Distribution of Health Facilities by Availability of Emergency Supplies Stocks in Hand (7 health centers and 2 hospitals) Type Number with supplies Remarks Adrenaline 7 Ergometrine 7 Magnesium Sulphate 1 1 hospital Analgesics 4 IV Solutions 6 Foetoscope 9 Sphygmomanometer and 9 stethoscope Speculum 9 Forceps 9 Needles and syringes Local Anaesthesia 5
Table 64 Distribution of health facilities by laboratory and other investigations services offered Test available Number Remarks Urinalysis 7 FBC 1 1 hospital HIV 3 Pap Smear 3 X-Ray 2 Mammography 0 Other 2
9.3 Other Relevant Materials: Sexual Offences Act 2003
MMM Lesotho June 2005 108