Project Information

Objective: The Health Sector Performance Enhancement Project seeks to increase utilization and improve the quality of primary healthcare services in six districts in Lesotho, with a particular focus on maternal and child health, Tuberculosis and HIV.
Status: Active
Date Effective: 02/14/2014 to 07/30/2019
Financing: HRITF $4 million and IDA $12 million
Other Financial Contributions: US$ 4 million (Government)

Photo credit:  UNFPA / Lindsay Barnes


The project focuses on primary health care, particularly MNH given that Lesotho has high maternal and child mortality rates, with 1,024 maternal deaths per 100,000 live births and 85 under-five deaths per 1,000 live births respectively (LDHS, 2014).  Health outcomes are worsening and disparities are widening – for instance, 60 percent of women in the poorest wealth quintile deliver with a skilled health professional, compared to 94 percent in the richest wealth quintile (LDHS, 2014).  This situation is further compounded by system-wide challenges. Service utilization is hampered by poor quality of care, which is exacerbated by a lack of equipment, an inefficient referral system and an inadequate number of healthcare workers. In parallel, given 40 percent of the population lives in remote rural villages, often located several hours away from the nearest health facility, transportation costs and distances feature as the main impediments to service utilization cited by patients.


RBF Payments

The Health Sector Performance Enhancement Project uses supply-side Performance-Based Financing (PBF) to improve health service delivery.  The Ministry of Health (MOH) contracts health centers to deliver a package of primary healthcare services, and signs performance agreements with district hospitals to improve the quality of secondary healthcare services. In parallel, District Health Management Teams (DHMTs) receive performance-based incentives to ensure that supportive supervision, capacity building of healthcare personnel, and oversight of the quality of primary healthcare services are provided.  PBF payments are made quarterly based on the quantity and on the quality of services delivered. To encourage service delivery in remote areas, the facilities in hard-to-reach locations receive a remoteness bonus. Based on a business plan, health centers, district hospitals and DHMTs use PBF payments to reinvest and improve their functioning, and to pay bonuses to health workers. 


The RBF verification is led by a Performance Purchasing Technical Assistance (PPTA) firm, contracted by the Ministry of Health. Specifically, the PPTA verifies the quantity of services delivered by systematically reviewing monthly reports submitted by health facilities. Additionally, PPTA verification officers participate in quarterly DHMT supervision visits to health centers to verify the quality of service delivery, using a quality checklist. For district hospitals, a peer review mechanism is employed to perform quality verification, and provide immediate feedback to the hospital personnel. Peer reviews comprise personnel from other hospitals, and from the MOH Clinical Services Directorate with a representative from the DHMT. Based on performance-related data, the District PBF Steering Committee and the MOH’s PBF Unit review and validate the quarterly amounts to be paid to health centers and district hospitals.

Conversely, the PPTA contracts local community-based organizations or non-governmental organizations to carry out random home visits to ascertain that reported services were indeed delivered, and conduct a client satisfaction survey.   Additionally, health facility quality of care assessments will be carried out to independently verify the health facility quality of care score.


Status and achievements

The project is now fully operational in all six targeted districts in four waves. Following implementation in the two pilot districts since April 2014 in the case of Quthing, and January 2015 in the case of Leribe, the project was scaled up to Mokhotlong and Thaba-Tseka in July 2016, and subsequently to Mafeteng and Mohale’s Hoek in October 2016, encompassing 92 health centres and 8 district hospitals. Health centres and hospitals have signed performance contracts, opened Health Centre Committee administered bank accounts, submitted invoices, and undergone verification and counter verification processes on a quarterly basis. There is a high level of motivation at districts health centres, District Hospitals (DHs) and District Health Management Teams (DHMTs), and the concepts have been well understood.

 With regards to the performance of key PBF and results framework (RF) indicators, PBF health centres and district hospitals are experiencing an increase in utilization of priority services and also quality of care. The number of women delivering in health facilities saw an increase of 21.1 percent, and the number of children immunized increased up to 64,979 surpassing the target of 50,000 children. There has been an increase as well in the number of people receiving TB DOTS treatment, pregnant women receiving antenatal care (ANC), and pregnant women living with HIV receiving ARV prophylaxis. Furthermore, the average quality of care scores in the target districts increased from 50.6 percent at baseline to 70.7 percent as of June 2016, following which the quality checklist was revised and made more stringent so as to enable facilities to strive for continued gains in quality of care.  There remains strong ownership for the program, as displayed by the recent PBF consultation workshop organized by the MOH that was well attended by both senior management and participating health facility and DHMT personnel to share good practices and lessons learned. However, governance challenges continue to persist as the National Sexual Reproductive Health Steering Committee (NSRHSC) responsible for providing overall policy oversight has not been meeting regularly. Meanwhile a SRH Technical Working Group (TWG) was delegated to take decisions on operational matters related to the project. However, given the numerous issues to be deliberated by the SRH TWG, it was found that during recent meetings of the TWG, issues pertaining to the HSPE were not discussed due to time constraints and competing issues on the agenda.


The experience from the implementation of the program thus far has yielded significant PBF capacity building and sensitization challenges due to high staff turnovers at the central and district/facility levels. PBF Unit and district level personnel and MOH Senior Management who are trained and capacitated with regards to PBF have moved on, resulting in ownership and sensitization challenges. Furthermore, continuing sensitization of development partners on PBF is also important for the NSRHSC/TWG to effectively function and guide course adjustments, as well as promote the buy-in of PBF indicators by partners. Lastly, as learned during the recent PBF consultation workshop organized by the MOH, exchange of experiences is useful and can motivate and inspire facility managers. 


Following the lessons learned from the PBF program implementation in the two pilot districts, during the recent level one restructuring of the Lesotho Health Sector Performance Enhancement (HSPE) project, the project’s geographic scope was reduced from nine districts to six. As a result, given the loss of statistical power following the project’s reduced geographic scope, a robust randomized control trial is no longer possible. For these reasons, the impact evaluation has been interrupted after completion of the baseline survey.  However, the baseline survey for the Maternal and Newborn Health Performance-Based Financing Project in Lesotho allowed to draw important lessons about the health care delivery in the country.

 The main findings from the report are the following:

  • Almost all women receive at least some antenatal care during pregnancies. However, about a quarter of women have less than the recommended number of four visits and only 36 percent initiated the care during the first trimester of their pregnancy as recommended by international and local guidelines.
  • Seventeen percent of women received antenatal care in hospitals rather than at the health centers providing primary health care.
  • The content of antenatal care is overall good according to the women’s reporting of the components of their antenatal consultations, including being offered HIV testing and iron supplementation. The rate of women receiving two or more tetanus injections is 76 percent and can be improved.
  • Seventy-seven percent of women reported delivering in a formal health facility. The main reasons cited by women for not delivering in a health facility were the long distance to facilities and lack of time to reach the facilities.
  • Seventy-seven percent of women reported receiving postnatal care by a skilled health provider but only 39 percent reported to receive the care within the first two days after delivery.
  • Only 44 percent of children under-5 were measured in the six months before the survey to determine their nutritional status.
  • Thirty-five percent of households reported having had a health-related financial shock in the 12 months preceding the survey. Many of these households had to sell possessions or borrow from others in order to cover the healthcare costs that exceeded what the households could afford with their usual income. In Mokhotlong district, for example, 49 percent of households reported such shocks while in Mafeteng the rate was 28 percent.
  • Almost all health centers offer the services targeted by the PBF program. However, about 18 percent of health centers reported not providing delivery services. All health centers also report operating around the clock.
  • Structural quality is overall good. For example, almost all facilities have access to an improved source of water, all have safety boxes and high share of facilities have functioning toilet facilities and telecommunication abilities.
  • There is room for improvement with regards to the practices of disposal of medical waste and sterilization of medical equipment. In addition, 17 percent of MOH centers did not have soap and water available in all consultation rooms.
  • It is not uncommon for health centers to run out of supplies of very basic drugs and vaccines. For example, 21 percent of MOH centers and 25 percent of CHAL centers reported running out of paracetamol in the 30 days prior to the survey.
  • Responses of health providers to questions using clinical vignettes as well as exit interviews of patients suggest a big variation in actions taken by providers when treating common cases and potential lack of understanding or knowledge of treatment protocols by some providers.