Lesotho Nursing Initiative
Author: Ministry of Health and Social Welfare (MOHSW) and the Clinton Health Access Initiative (CHAI)
Approximately 75% of Lesotho’s population lives in rural areas, and poverty is widespread. The country has the third highest rate of HIV in the world with 23% of the population infected. The burden of health care provision has fallen on nurses – of the 180 public health centres in Lesotho, fewer than five have a doctor posted to the clinic. It is common for there to be only one or two registered nurses at a health centre, and in many cases at least one of these nurses is posted through the nursing initiative.
The Lesotho Nursing Initiative was established in 2006 to increase the number of healthcare workers (HCWs) in Lesotho in order to improve access to Anti-Retroviral Treatment (ART) and primary health care, with a particular emphasis on those living in rural areas. The initiative set out to find innovative, immediate solutions to the HCW shortage by applying basic principles of supply and demand to the problem. The initiative was intended to be a short-term solution in order to demonstrate and address an immediate need, giving the government and its partners enough time to scale up nursing positions.
The Ministry of Health and Social Welfare MOHSW advertised posts for 100 local nurses to be hired on a 3-year contract at a higher salary level than existing MOHSW nurses, in an attempt to encourage HCWs back to the public sector. Due to inadequate responses from Basotho nurses, the government of Lesotho approached the government of Kenya (which had a surplus of HCWs) and formulated a bilateral agreement that allowed Lesotho to advertise nursing posts in Kenyan newspapers. In the end 150 nurses were hired by the MOHSW: 40 Basotho, 60 Kenyans and 50 Zimbabweans.
District Health Management Teams (DHMTs) were approached by stakeholders to conduct a needs assessment in all of Lesotho’s 10 districts. This resulted in emphasis being placed on providing ART and PHC to rural communities. Nurses placed in hardship areas qualify for a “Mountain Allowance” of M 600. Nursing initiative nurses are also entitled to a pension gratuity of 38.5% of their contract earnings. Hiring of nurses was staggered to ensure that their contract expiration occurs in stages and that the initiative would be phased out rather than stopping abruptly. Nurses in the initiative were trained on the Integrated Management of Adolescent and Adult Illness (IMAI), which is necessary for nurses to be able to initiate patients on ART.
In 2006, 31 sites were initiating paediatric patients on ART; at the end of the year there were 1,042 children on treatment. By June 2010, there were 101 sites treating 4,224 paediatric patients. Adult treatment rates increased from 13,393 to 86,165 over the same time period, with 156 sites initiating adult patients on ART. Only 18 of these sites are hospitals – the remainder being health centres, many of which are partially staffed by nursing initiative nurses. Roll out on this scale would not have been possible without the nursing initiative nurses. All of this was accomplished while maintaining high nurse retention on the initiative. The success of the program allowed the MOHSW to convince the Ministry of Public Service (MPS) of the need for skilled nurses in Lesotho and led to the MPS increasing the number of nursing posts on the establishment list by 100. All these posts have been filled by Basotho nurses. Also the initiative succeeded in retaining skilled nurses on the continent, by absorbing excess Kenyan nurses. The Kenyan government has indicated that if Lesotho can no longer employ these nurses at contract end, the Kenyan healthcare system will be able to reabsorb them.
The initiative brought in local and foreign nurses to achieve the goal of ART scale up, whilst buying the MOHSW some time to identify funding to recruit locally, and to scale up domestic output. It identified a number of measures that can be taken to increase retention locally. It created a unique model of a government-to-government partnership that succeeded in keeping nurses within the region.