LESOTHO'S reproductive health sector has been dealt a body blow after some of its key players suspended operations due to lack of funding.
Among the affected role-players is the Lesotho Planned Parenthood Association (LPPA) whose outreach programmes were targeting hard-to-reach areas with free contraceptives, anti-retroviral drugs and HIV-testing services. In recent times LPPA also downsized its operations from eight to five districts.
Sexual and reproductive health services are provided by both public and private facilities, with private pharmacies selling contraceptives mainly in the form of tablets.
The Ministry of Health is currently working to increase the country's contraceptive prevalence rate to 80 percent by 2019 from the current 60 percent, in addition to providing integrated sexual and reproductive health services. However, meeting the 80 percent and integrated service targets may not be easy considering the many odds stacked against Lesotho.
According to the Family Planning Programme Officer in the Ministry of Health, 'Mangose Sithole, in an ideal clinic, clients should be able to receive services that go beyond HIV-testing, contraceptives and anti-retroviral drugs.
Ms Sithole explained the clinics should also offer services such as cancer-screening, nutrition to deal with iron and calcium deficiencies mainly in women, as well as those that deal with hygiene-related challenges for women and girls.
However, fulfilling the integrated services strategy could be problematic in some areas which, for many years, have relied heavily on the LPPA's outreach and on-facility services.
The suspension of all outreach programmes is attributed to inadequate finances, a situation compounded by the United States' Mexico City Policy or the Global Gag Rule.
The Mexico City policy re-instated in 2017 is a United States government policy that blocks U.S. federal funding for non-governmental organizations that provide abortion counselling or referrals, advocate to decriminalize abortion or expand abortion services. Organizations such as the International Planned Parenthood Federation (IPPF) were directly affected by the Gag Rule and loss of funding.
Organisations dealing with sectors colliding with the Gag Rule are already feeling the pinch that is now hitting hard thousands of women and girls in the southern African region, who depended on free family planning, anti-retroviral treatment and other reproductive health services provided through funding by the American government.
Although each year the Government of Lesotho budgets up to M5 million for the procurement of modern contraceptives and millions more for anti-retroviral drugs and other sexual and reproductive health matters, collaboration with civil society was helping ensure a wider reach of services deep in the countryside.
In 2015, the LPPA signed a Memorandum of Understanding with the Ministry of Health, to receive and help distribute some contraceptives, including injectables, pills, condoms, implants, in addition to providing permanent contraceptive methods such as vasectomy and tubal ligation.
The LPPA operates in the five districts of Butha-Buthe, Maseru, Quthing, Mohale's Hoek and Mafeteng. In addition to the contraceptives, the organisation integrates ante-natal care, cancer-screening, ARVs including the prevention of mother-to-child treatment, HIV-testing and counselling, post-exposure prophylaxis, pregnancy-test and voluntary medical male circumcision.
The association came up with the outreach concept to close the gap caused by the incapacity to extend services to the rest of the country due to the mountainous terrain. Many women, in these areas, walk long distances to reach the nearest clinic which can be a day's walk away.
This kind of hardship is also attributed to the high teenage pregnancy rate in rural areas, compared to the urban communities.
However, what pushes the situation in Lesotho to the edge is the political instability that has taken focus away from serious developmental concerns in the health and other sectors.
When Lesotho was facing serious political and security challenges between 2014 and 2017, the country's HIV prevalence rate became second in the world at 25 percent while Tuberculosis incidence are currently at 724 per 100, 000 people.
Lesotho's problems are also reflected in the high maternal mortality rate where, of the 100,000 live births, more than 1, 100 women are dying during delivery or of ailments related to pregnancy and child-birth. Some of these are adolescents who include victims of child marriages, an old practice which continues to rear its ugly head in most parts of Lesotho.
Directly related to sexual and reproductive health are the worrying conditions created by patriarchy, which make it difficult for many people to boldly tackle cultural and religious norms that are fuelling teenage pregnancies at 19 percent, child marriages and the non-provision of modern contraceptives, in the case of some Christian health facilities, such as those belonging to the Roman Catholic Church.
Sex education has also remained a business of health facilities only, which are also limited when it comes to the provision of youth friendly services while sex education approaches in schools have not really focused on strategies aiming to change the behaviour of the students themselves.
One of the biggest challenges facing Lesotho is the non-provision of safe abortion services due to the laws that only allow medical abortion on health grounds and in the event of sexual assault.
The LPPA's Ms Phatŝoane said funds-permitting, there is a lot her organisation could contribute to ensure improved accessibility of integrated services, particularly in the hard to reach areas.
"We were doing a lot of outreach work to improve accessibility to family planning, HIV-services and education on sexual and reproductive health. We have since stopped outreach, which was supporting hundreds of women and girls, in addition to closing our other clinics in Leribe, Berea and Qacha's Nek," Ms Phatŝoane said.
The association's outreach programmes, she added, were appreciated in areas such as Roma, Semonkong and Leribe, where there are a number of Roman Catholic health facilities that do not provide contraceptives, including condoms.
Ms Phatŝoane further explained during some partnership forums, where discussions were recently held on the situation in the affected areas, nurses indicated women were at risk of having unintended pregnancies as they were struggling to access contraceptives.
"One of the ways we can manage the situation now is to encourage the use of long-acting and reversible contraceptive methods to deal with the problem of distance. The community-based distributors' system can also be strengthened to help cover the gap created by suspending our outreach programmes," Ms Phatŝoane said.
In Maseru, the LPPA operates three specialised clinics, one catering for men only, and the other the youth while the third provides mobile services for key populations particularly sex workers and men having sex with other men.
Following its MoU with the Ministry of Health, the LPPA's activities support the government to meet its strategic development targets such as increasing the contraceptive prevalence rate and tackling the high maternal mortality rate.
Ms Phatŝoane said while knowledge of modern contraceptives is high in Lesotho, there are still family planning needs that remain unmet particularly among people with disabilities, adolescents and women who no longer want to have more children and prefer permanent methods such as sterilisation. There is not much information about sterilisation or tubal ligation to meet the needs of women no longer wanting to have more children.
Better approaches aimed at tackling issues related to the unmet needs, poor messaging and sex education, she also said, were imperative if Lesotho is to meet its 80 percent target. This would include strengthening and supporting Comprehensive Sexuality Education for young people both in and out of school.
"The strategies we have been using over the years need to be improved if you look at the need for all public health facilities to embrace the integrated services approach. In terms of education, we have seen that the abstinence we have been focusing on in our sex education targeting mainly adolescents was not very effective.
"In addition, sex education remains a neglected or no-go area in many households because parents and guardians still view discussing sex as taboo or another person's job. On the other hand, those who can talk about it in most cases lack the capacity to deal with realities that have shown that some children as young as 15 were already having sex."
The LPPA Youth clinic in Maseru serves people below the age of 24 who visit to access services such as contraceptives, including the emergency pill, injectables and condoms as well as Ante- Natal Care and HIV services.
Ms Phatŝoane discouraged regular use of the emergency pill, which is quite popular among young women. "When it becomes regularly used, it ceases to be an emergency pill and can fail to protect against unintended pregnancies."