1. Executive Summary
The Global Fund is a key partner to Lesotho in the fight against HIV and TB, with cumulative investments of over US$300 million since 2003.
The country has made noteworthy progress against HIV, evidenced by a 15% decline in AIDS-related deaths and a 35% reduction in new infections since 2010. TB deaths have decreased by 17%, and incidence by 35%, since 2010. Notwithstanding these achievements, the country continues to have the second highest HIV prevalence in the world at 23.6%, reaching 71% in key and vulnerable populations. The country’s TB incidence rate, at 611 per 100,000 population, is the highest in the world.1 As such, Global Fund investments are heavily invested in HIV prevention to reduce the number of new infections and control the epidemic, and in HIV/TB collaboration for active TB case finding and treatment. These areas account for approximately 59% of the grant in the past two funding cycles, NFM 1 and NFM 2.
Various exceptions were identified for the performance of TB screening and testing, and of contact tracing, contributing to the high percentage of missing cases in the country. Inadequate mechanisms are in place to identify and treat MDR-TB. Duplications in prevention activities and geographic locations were noted in HIV prevention programs implemented at sub-recipient level. In addition, there is a lack of coordination between implementers promoting HIV prevention services such as Voluntary Medical Male Circumcision and those providing the services, with substantial gaps between the number of patients referred for HIV prevention services and those actually receiving the service. The adequacy and effectiveness of controls to ensure access to quality services, including prevention programs, are therefore partially effective.
Multiple challenges exist around governance and oversight. The audit identified a number of issues related to the Government of Lesotho fulfilling its commitments towards procuring HIV and TB medicines and funding Human Resources for Health. This has contributed to stock-outs of key commodities and a failure to initiate HIV patients on preventive therapy for TB. Critical vacancies exist in the HIV and TB programs, as well as the Supply Chain Directorate, within the Ministry of Health. This has a direct impact on programmatic activity and implementation of grant activities. In consequence, Global Fund grants have a low absorption rate (68% under NFM 1 and 57% under NFM 2) with key activities not being undertaken. Lack of stability in leadership and ownership for the HIV and TB response in the country, as well as challenges at the Country Coordinating Mechanism were contributing factors. The adequacy and effectiveness of program governance and grant oversight therefore need significant improvement.