An underfinanced health-care system means that Lesotho's HIV/AIDS sufferers often don't get adequate treatment. Now, a lack of international funding may signal the end of a successful 'expert patients' scheme.
The peeling, heart-shaped sticker on the frosted glass door at the entrance to Mamohau hospital carries a stark message: 'AIDS kills.' Nestled some 2200 meters (7500 feet) above sea level in Lesotho's Maloti mountains, the small hospital and clinic serves a community of over 70,000 people. Many of those who travel from across the highlands to the hospital are living with HIV.
Reaching patients in this rugged, inhospitable part of southern Africa is almost impossible – or, at least it was before the 'expert patient' scheme began.
"I have been able to bring many people to the clinic," says Malilamo Mafwa, who, like the rest of Lesotho's 600 expert patients is HIV positive. She counsels neighbours living with HIV on how to take their medication and accompanies patients to the clinic.
Mafwa is one of the lucky ones. Her tiny corrugated iron house is only two hours from the hospital. Other patients have to travel much further, as the many horses tied up in the yard behind the new clinic attests.
Currently, she is paid 700 Maloti (around 60 euros) a month for her work as an expert patient. But now vital funds used to pay for the counsellors are being withdrawn as Lesotho's government struggles to cope with falling donor aid.
Around half of Lesotho's expert patients are funded directly by the Global Fund to Fight Aids, Tuberculosis and Malaria. Now, due to contribution shortfalls from donor countries, support from the Global Fund for the expert patient program is being reduced. In comparison to 2013 levels, spending on the program will drop 30 percent this year, and a further 20 percent in 2015 says Indira Govender, Deputy Medical Co-ordinator for Doctors Without Borders in South Africa and Lesotho.
The development will likely bring further problems for the country's already struggling health-care system. Lesotho has the third highest HIV rate in the world. 23 percent of people between the ages of 15 and 49 are infected, according to the country's Ministry of Health and Social Welfare. Among those aged 30 to 34, the figures rise to 40 percent. Often patients don't get the treatment they need due to a lack of doctors and facilities.
In Mamohau, the hospital is lacking qualified staff to deal with the influx of HIV patients. "We are supposed to have seven doctors but we have only four. We are supposed to have 100 nurses but can only pay for 33," says one of the doctors here, Paul Manka. The hospital itself was built in 1939 but only got electricity in 2005.
This situation is replicated across Lesotho. According to data from Doctors Without Borders, only six out of 171 health centers in Lesotho adhere to minimum staffing requirements. Just 89 doctors and 1123 nurses serve a population of around 2 million people in an area half the size of Ireland.
Expert patients help to fill the gap between the medical professionals and their patients. They often play a key role in getting patients to adhere to their treatment and ensuring that patients maintain a healthy diet, without which their medication is ineffective. They also assist with basic clerical tasks and are expected to provide therapeutic counselling, facilitate support groups and help nurses.
They also act as cultural go-betweens. Most medical staff in Lesotho come from other African states like Angola and the Democratic Republic of Congo, as the country has no medical training college. In a country where most doctors and nurses do not speak the local language, expert patients provide a vital link between health care services and the local community.
"When we go out in the districts in our outreach visits we work with expert patients," explains Lillian Nalwoga, a doctor who hails originally from Uganda. "Most of the time when I go out to health centers, by the time I get there I find that the expert patient has already taken the weight and height of patients, has already counted the pills, documented adherence, and my job is really simplified."
Constant Kasonga, a Congolese doctor working in Lesotho, says that expert patients have helped overcome some of the stigma that is still attached to HIV and AIDS but warns that they cannot save Lesotho's ailing health care system. "Expert patients do not have many skills, and that is where professional counsellors are needed," he says. Kasonga says spending the money on mobile clinics would be a better investment.
Challenges still to come
Back at Mamohau hospital, Maselomi Selomi explains how working as an expert patient has already changed her outlook on life anyway. "I am optimistic about the future now. Because of the counsellors there are no longer hundreds of corpses," she told DW. "People are not dying, I am very proud of this."
But with the new funding cuts this year and next, the future of the expert patient program is in doubt. Indira Govender from Doctors without Borders is worried where the money for the program will come from.
"Lesotho will be expected to provide the finance or they will have to find another plan for these workers," Govender told DW. She says that other non-governmental organizations have also already withdrawn their funding for the program.