The Lesotho Ministry of Health and Social works (MOHSW) technical assistance project is a five year cooperative agreement awarded by HSS/CDC from September 30, 2009 with a potential value of $3,975,000. The MOHSW will build capacity in laboratory services, strategic information, TB/HIV and coordinate HIV/AIDS prevention, care and treatment programs.

Lesotho has the third highest prevalence rate of HIV infection and the fourth highest estimated TB incidence in the world. The Government of Lesotho is committed to the fight against HIV/AIDS and endorsed a decentralization framework with the strategic objective of attaining universal coverage of essential health care services. The MOHSW is facilitating the establishment of a system that will deliver quality health care efficiently and equitably. The Directorate of Laboratory Services, MOHSW, is responsible for overseeing the implementation and the monitoring of laboratory performances throughout the country and providing continuous guidance and support for laboratory services. There are more than 200 health facilities that include 1 Central Laboratory, 1 National Blood Transfusion Service, 21 hospitals and 184 health centers that provide a range of clinical, laboratory diagnostic and monitoring tests.

Because of co-morbidity of TB and HIV/AIDS epidemics and ART scale up, there is an associated increase in patient load and a demand in laboratory services. To address the shortcomings and improve quality of laboratory diagnostic and monitoring services, the MOHSW has developed a laboratory policy and a five year national strategic plan. The Directorate of Laboratory Services also coordinates the implementation of national laboratory and strategic plan, policy, and guidelines. As part of laboratory quality improvement, Laboratory External Quality Assessment (EQA) schemes have begun in HIV rapid testing, CD4, chemistry and hematology to many of the district hospital laboratories. In collaboration with the PEPFAR implementing partners, the central Laboratory supports the early infant diagnosis of HIV. DBS samples are collected from district hospitals and then transported to the Central Laboratory. These programs have enabled the initiation and scale up of pediatric care and treatment as part of improving the clinical laboratory services at different levels.

The policy and guidelines will also be implemented to support non laboratory professionals to do HIV testing services and ensure national coverage. To strengthen human resources, support will be provided to improve the quality of pre-service education including curriculum revision, provision of training aids, and mentorship. A significant portion of these activities are supported by PEPFAR, which are in line with health system strengthening.

Although sustainable progress is made through the support by PEFPAR, there are still major gaps in the laboratory services. The absence of a National Public Health Reference Laboratory and the limited capacity of the central laboratory to support reference services, especially TB culture and drug susceptibility testing and early infant diagnosis is a concern. The logistic and supply management to support procurement, distribution and inventory management is still weak. The implementation of a quality assurance program is limited and not yet comprehensive. Additionally, infrastructure and human capacity needs to strengthen to support the growing demand of diagnostic and monitoring support at multiple levels.

As part of capacity development and improving the quality of laboratory services for supporting HIV/AIDS, STI, TB and OI prevention, care and treatment program , the MOHSW has been awarded a five year cooperative agreement to build its capacity, strengthen the healthcare system and coordinate HIV/AIDS prevention, care and treatment programs. The implementation through a cooperative agreement came into effect as of October 2009. The primary goals and objectives of include the following: 1) strengthen the technical and management capacity of the MOHSW to effectively manage laboratory , TB/HIV and M&E activities in the country, 2) To strengthen the national laboratory quality program and accredit laboratory services, 3) To develop an effective an efficient inventory management system to ensure laboratory medical supplies are procured, stocked, and distributed in a timely manner; 4) To strengthen the national M&E system that will enable to analyze data for planning and evidence based decision making process.

Through the cooperative agreement, the MOHSW will strengthen an integrated, harmonized and decentralized HMIS, laboratory infrastructure and TB program with technical capacity to produce appropriate and timely quality information that is accessible to all stakeholders for evidence based action. To guide the process, the first sector HMIS Policy and Strategic Plan are being updated. MOHSW is in the process of establishing and strengthening district M&E systems. .

The MOHSW will implement the activities through direct support to central, district and health center laboratories. The planned activities will cover all health facilities (public, nongovernmental and private sectors) that provide testing services. In order to ensure the programs are cost effective and sustainable, the MOHSW will also provide budgetary support and leverage resources with Global Fund, other non- governmental partners, and international and local development partners.

The implementation plan will further enable the MOHSW to meet the most critical health system demands and will ensure reliability, equity, and sustainability for services. Furthermore, strengthening the laboratory services will significantly contribute to achieving the PEPFAR targets, outlined in the Partnership Framework Implementation Plan, by enrolling TB and HIV patients in care and treatment programs in Lesotho.

MOHWS will strengthen the capacity of HMIS, Surveillance and M&E units to collect and use surveillance data and manage HIV/STI/TB surveillance programs and strengthening laboratory support for surveillance, diagnosis, treatment, disease monitoring and HIV screening for blood safety. This will enable the utilization of essential information from sentinel surveillance, national health surveys, clinical and laboratory information systems, and targeted evaluations to improve quality of care.

The MOHSW is building integrated, harmonized and decentralized Health Management information System (HMIS), with increased capacity to produce appropriate and timely quality information that is accessible to all stakeholders for evidence-based action. To guide the process, the first sector HMIS Policy and Strategic Plan were developed and are currently being updated. PEPFAR, in conjunction with other Development Partners such as the Global Fund, the World Bank, Millennium Challenge Cooperation, is supporting through the Partnership Framework with Government of Lesotho (GOL), the MOHSW in establishing and strengthening district M&E systems.

District Health Teams (DHTs) core members (Head of District Health Management Team (DHMT), Public Health Nurse, District Health Information Officer, District Medical Officer and matron) are increasingly responsible for coordination of data collection, processing, analysis, dissemination and use at the district/ local level.

M & E of the Health Sector reform is an important process that is supported by World Bank and Irish Aid. The MOHSW will conduct district-based Health Sector Reviews in order to promote utilization of data at the point of source in all 10 districts. This will improve the quality of data with respect to completeness, comprehensiveness and timeliness. The MOHSW will strengthen the capacity of the DHTs to conduct biannually quarterly reviews while the central level of MOHSW will conduct the other two reviews including the Annual Joint review.

The M&E Unit, MOHSW, will conduct refresher training with core DHT members of all 10 districts on data collection, analysis and dissemination. This refresher training will be followed by mentoring sessions on how to check for data quality, produce statistical tables, interpret data, and on how to write the District Health Sector Review report. Additionally, FY10 funds will support the printing of the 10 district reports and the actual review seminars in all 10 districts twice a year. MOHSW will work closely with John Snow Inc. (JSI) to train and mentor the DHT in the 2 districts supported by JSI.

In FY1O, the MOHSW will support the following. 1) Strengthening of Human Resource Capacity The MOHSW will strengthen the administrative and technical management structures of the Directorate of Laboratory Services to play a leadership and coordination role. Salary and benefit to existing four full- time employees and recruit TB lab QA manager and equipment maintenance coordinator will be supported. Human resource is one of the major factors for effective coordination and scale up of TB/HIV collaborative activities at the national level and district levels. To strengthen the TB/HIV collaborative program, MOHSW will recruit administrative and technical staff at national and district levels and implemented retention strategies.

2) Training support Support in-service training of laboratorians in HIV diagnosis, monitoring, quality assurance and management using customized and standardized training modules Strengthening the management of MDR TB by training National TB Program (NTP) staff at national and district levels through in-service training, study tours for Queen II Hospital doctors, workshops, and conferences related to TB/HIV care services. The MOHSW will support health training institutions of health care works, such as laboratory technologists, microscopists and others in customizing curricula and integrating HIV/AIDS/TB diagnoses , treatment and preventions programs in the trainings.

3) Leadership and coordination of program The MOHSW will enhance the technical management and program capacity of the respective divisions to coordinate, monitor and evaluate laboratory, TB/HIV, surveillance and related activities at national and district levels. The MOHSW will support implementation of policies, strategic plans guidelines, and operational tools. Policy, guidelines and information-education- communication (IEC) materials will be disseminated. The MOHSW will coordinate and work with all relevant stakeholders and implementing partners for harmonization of Laboratory, TB/HIV activities, M&E, surveillance and other areas. MOHSW will support the joint review meetings with stakeholders and other implementing partners to ensure the implementations are integrated and coordinated at service delivery levels.

FY 10, the MOHSW will implement the following: 1) Expansion and strengthening the national quality assurance program The Quality Assurance (QA) Unit of the Directorate of Laboratory Services will coordinate the implementation of compressive External Quality Assessment (EQA) schemes in all health facilities that provide diagnostic and monitoring tests in the country. These include serology including HIV rapid test, chemistry, hematology, microbiology, parasitology, Tuberculosis (TB) smear microcopy and CD4 monitoring.

The QA Unity will support the preparation and distribution of the HIV proficiency panels and quality control samples to all 201 facilities twice a year. In coordination with the central TB laboratory, TB smear microcopy panels will be prepared and distributed to 18 hospitals.

2) Strengthen Laboratory Support Systems In order to ensure the continuity of testing services and avoid disruption of services, MOHSWS will support procurement of minor equipment and accessories for DNA PCR based early infant diagnosis (EID) and TB culture facilities. In addition, maintenance service contract will be supported for molecular diagnostic equipment and biosafety cabinets and centrifuges in those facilities. For effective quantification and forecasting of supplies required for HIV diagnostic and monitoring tests, the inventory and stock management system will be supported. The referral testing services will be strengthened through logistics support and effective coordination between collection sites and central laboratory. The referral testing services will include dried blood sport (DBS), TB cultures and drug susceptibility testing, CD4 and viral load monitoring. For coordination of implementation plan, regular laboratory review meetings with partners will be held. Office supplies and communication services will be purchased for effective running of the project management office.

3) Strengthen Data Management and lab records Lab register and reporting forms will be standardized and be used for collection, analysis, and reporting. The standardized paper based data management tools (registers, request forms, reporting forms) will be printed and distributed to all clinical laboratory facilities.

4) Renovation and furnishing of district laboratories MOHSW will support the upgrading of the district laboratories by renovating and furnishing with equipment, lab furniture and accessories.

The National Tuberculosis Program (NTP), a unit within the MOHSW, supports the collaborative TB/HIV activities including coordination of activities with National HIV/AIDS Directorate, HIV testing of all TB patients, provision anti TB drugs and ART for all TB patients co-infected with HIV. Along with the Directorate of Laboratory Services, NTP also supports and coordinates the laboratory testing at national and district levels to diagnose and treat active tuberculosis including Multiple Drug Resistance TB (MDR- TB).

The MOHSW will strengthen the capacity of NTP for effective implementation of TB/HIV activities in the country. The FY10 budget will be used to support the following activities:

1) Site assessment and supportive supervision: NTP will conduct site assessment and regular supervisory visits to clinical and laboratory services to monitor and evaluate the TB/HIV programs using one tool.

2) Infection Control measures: Support will be provided for baseline assessment of current infection- control practices, revise national infection-control guidelines and implementation appropriate infection- control measures. Necessary supplies such as out-patient department masks for infection control in hospitals will be procured a stop gap measure. Advocacy and promotion of window opening as part of infection control.

3) Monitoring and Evaluation (M&E): Strengthen the national M&E system of TB/HIV and MDR TB, data collection, analysis and disseminate of information. In FY10, the MOHSW will also support program evaluation with emphasis on TB/HIV activities.