Lesotho faces numerous health and development challenges. These both contribute to, and in part stem from, the HIV and AIDS epidemic, income inequalities, and poor access to information and services on sexual and reproductive health and rights. Both child and maternal mortality rates follow a similar trend of increasing from 1991/2 until 2004/5 then steadily decreasing until the most recent measurements in 2015/16.
Unsafe abortion is a factor in the high maternal mortality rate. Abortions are available only if there is a risk to the mother’s mental or physical health. Rates of HIV and AIDS have climbed from 1.3% in 1990 to 25% in 2015. This positions Lesotho amongst countries with the highest of HIV rates in the world, though the rate of new infections has been reducing since 2000. Key populations in Lesotho are battling with stigma, discrimination and a range of human rights abuses, in some cases because criminal law creates barriers to their access to HIV prevention, treatment and care services
World Databank (2017) Maternal mortality ratio (modelled estimate, per 100,000 live births) https://data.worldbank.org/indicator/SH.STA.MMRT Accessed 01.03.2018
World Databank (2017) Mortality rate, under-5 (per 1,000 live births) https://data.worldbank.org/indicator/SH.DYN.MORT Accessed 01.03.2018
World Databank (2017) Prevalence of HIV, total (% of population ages 15-49) https://data.worldbank.org/indicator/SH.DYN.AIDS.ZS Accessed 01.03.2018
Lesotho’s health system has very limited capacity, with adverse sexual and reproductive health and HIV indicators, a dissolved and reconstituted National AIDS Commission, fragmented and outdated health legislation, and severe shortage of health personnel. Government expenditure on health as percentage of total government expenditure peaked at 14.5% in 2011, and has remained around 13% up until the latest figures of 2014 – just shy of the 15% pledged in the 2001 Abuja Declaration.
There are ten health districts in Lesotho, but most health care facilities are concentrated in the urban areas, especially Maseru. Differences in terrain and socio-economic conditions have given rise to large inequities in access to health care with the effect that disease patterns vary geographically. There is a lack of adequate human resources for health. Some initiatives since 2010 have aimed to improve primary health care services and make these services more accessible to the population. Health services have been decentralised to some extent to the Ministry of Local Government and Chieftainship Affairs.
World Databank (2015) Health expenditure, public (% of government expenditure) https://data.worldbank.org/indicator/SH.XPD.PUBL.GX.ZS Accessed 01.03.2018
Young people face barriers both in accessing sexual and reproductive health services and commodities, and having opportunities to discuss and learn about their sexuality and how to practice safer sex. To improve the situation, Youth Friendly Centres at government hospitals are available but are, reportedly, ineffective due to understaffing, underfunding, and the services being located too close to other services (which, combined with stigma, results in young people feeling exposed and reluctant to use them).
Lesotho has made progress in reducing rates of maternal mortality since 2005 when it exceeded the average rates for sub-Saharan Africa, but it remains high. Drivers of maternal mortality in Lesotho include limited access to quality maternal care, unsafe abortion, high adolescent pregnancy, unmet need for contraceptives, low proportions of skilled health worker during delivery, and alarmingly high rates of gender based and intimate partner violence despite a number of large, donor-funded, programmes to address this.
There is a high unmet need for contraceptives and access varies across poverty quintiles with the poorest having the highest unmet need. A gender disparity in condom use amongst young people with multiple partners is also reported. Low contraceptive and condom prevalence combine with a lack of comprehensive knowledge of HIV/AIDS and undertaking HIV testing to exacerbate the HIV prevalence and high numbers of children orphaned due to AIDS.
Rates of intimate partner violence are high and legal recourse is limited with conflicting customary and civil laws. Legal recourse is further hindered by social acceptance of intimate partner violence amongst women and men, and women misrepresenting injuries from beatings when they are hospitalised as a result. Shelters for survivors of intimate partner violence are provided by the civil society sector.
Overall Lesotho has a number of laws, policies and strategic frameworks that prohibit discrimination against women and of people living with HIV and protect some elements of women’s sexual and reproductive rights. However, the legal environment fails to protect marginalised populations such as men who have sex with men and sex workers.
Criminal Procedure and Evidence Act of 1981 criminalises sodomy as an offence for which arrests may be made without a warrant
The Sexual Offences Act (2003) is progressive in that it strengthens protection against sexual violence; prohibits various forms of sexual assault
The Legal Capacity of Married Persons Act 9 (2006) has strengthened women’s equality rights within marriage. However, due to both legal contradictions between customary and civil laws, and socio-cultural norms, this law is not adequately implemented.
The National Adolescent Health Policy (2006) aims to protect the health, development and rights of adolescents and a National Reproductive Health Policy (2008) commits to achieving the integration of HIV/AIDS and SRH.
Penal Code (2010) criminalises sex workers, but also criminalises marital rape in specific circumstances, including where the accused spouse is suspected to have a sexually transmitted infection.
The Lesotho Children’s Protection and Welfare Act (2011) has strengthened protection of the rights of children, including the right of children to non-discrimination on various grounds, protection from sexual violence, and specific protection of children living with HIV.
The National Health Sector Policy 2011 places HIV and AIDS as a top priority for treatment and prevention
The Country Cooperation Strategy WHO 2014–2019 focuses on strengthening the prevention and control of TB, HIV & AIDS and other communicable diseases; strengthening maternal and child health services; prevention and control of non-communicable diseases; health systems strengthening and; addressing the sociocultural and environmental determinants of health.
PEPFAR Lesotho Strategic Framework 2015-2020 aims to accelerate the number of eligible people receiving antiretroviral therapy amongst other HIV-oriented objectives.
National Guidelines on the Use of Antiretroviral Therapy for HIV Prevention and Treatment (2014) made Lesotho the first country in sub-Saharan Africa to adopt and launch the ‘Treat-All Strategy’
The Zero Draft Domestic Violence Bill aims to provide protection of women and adolescents in the domestic sphere has been under progress for a number of years but the dual legal system would limit its application. For instance, customary and civil laws contradict on cases relating to issues of sexual violence.
African Charter on Human and Peoples’ Rights (also known as the Banjul Charter)
United Nations Convention on the Rights of the Child (commonly abbreviated as the CRC, CROC, or UNCRC)
Convention on the Elimination of All Forms of Discrimination against Women
Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa
African Charter on Democracy, Elections and Governance