Healthcare system on its knees: Why Lesotho is losing the war on TB
BILLY NTAOTE
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When ex-miner Motseki Sebota breathes, it sounds like gravel shifting in a tin can. He spent nearly four decades working underground in South African Gold mines as a rock driller, first in the gold mines of Welkom, then later in the platinum shafts of Sasol II, Mpumalanga.
“Where I worked, I was a Rock Driller Operator,” Sebota recalls.
“After drilling holes, we would push in explosives, then go back inside right after the blast, right into the smog and dust. When we breathed without any masks, air would sting the lungs. That dust was silica, it sticks to your lungs, and doctors later told me they were rotten,” Sebota says.
By 2012, mine doctors found that Sebota’s lungs were “torn with holes,” forcing him out of underground work.
“They moved me to the laundry, to wash other men’s clothes,” he says quietly. “That’s when I knew my body was finished. I had to go under TB treatment, and my breathing is no longer easy.”
Today, Sebota is among thousands of ex-miners battling tuberculosis (TB) and silicosis, the occupational diseases that continue to define Lesotho’s public health landscape decades after the mining boom took its men as cheap labour.
Sebota’s story captures the human cost of a health system buckling under historical and structural neglect.
In a country where tuberculosis and silicosis remain the leading occupational and public health crises, the system charged with saving lives is itself gasping for air.
According to Dr. Llang Maama, Head of the Tuberculosis and Leprosy Department in the Ministry of Health, Lesotho remains one of the world’s highest TB burden countries, with an incidence rate of 664 per 100 000 people.
That translates to roughly 15 000 new cases annually, yet only 42 percent are detected and treated. “This means we are missing 58 percent of projected TB cases,” she says. “Those people remain untreated and continue transmitting the infection.”
The result is a cycle of preventable illness and death. Even though TB is curable, Lesotho’s mortality rate remains above 12 percent, triple the global acceptable standard. “We have improved treatment success to around 80 percent,” Dr Maama notes, “but the target is 90 percent. Every death reflects the weaknesses of our system.”
Minister of Health, Selibe Mochoboroane, acknowledges these weaknesses, pointing to fragile health infrastructure and dependence on donor aid.
“Lesotho is landlocked and poor,” he says. “Historically, our fathers went to South Africa to work in the mines, and that is how TB and silicosis became part of our national story.”
Fighting TB on an empty stomach: The harsh reality for Lesotho’s sick and poor
Malnutrition and poverty now sit at the heart of Lesotho’s TB crisis.
“Sometimes it’s not even nutrition per se, but just pure hunger,” says Dr Maama. “When patients take medication on an empty stomach, they fail to respond to treatment.”
Minister Mochoboroane echoes the concern: “Studies show that TB patients must get proper meals so that they can recover. We have lost people to TB because they had no food to accompany the medication.”
Lesotho’s Ministry of Health has established limited feeding programs at regional hospitals such as Queen ‘Mamohato Memorial Hospital for central region, northen region’s Motebang Hospital and Mafeteng Hospital for the southern region.
These feeding programs are places where destitute TB patients, while hospitalized, are provided meals through Global Fund support.
“Those who cannot afford are given food and care,” Mochoboroane explains. He adds: “We are certain they can recover under those conditions.”
However, food support is only guaranteed for patients with multi-drug resistant TB, not the wider cohort of drug-susceptible cases.
“We realized this larger group also needs food,” Dr Maama says. “But it is costly. If you give food, you must secure enough for the household too, otherwise the patient’s ration gets eaten. It makes the program very expensive.”
To ease the burden, government now coordinates with the Disaster Management Authority for occasional food parcels to malnourished patients. But these are inconsistent and insufficient.
“Hunger drives non-adherence. Without nutrition, TB control remains impossible,” says Dr Maama.
The TB challenge is compounded by a shortage of skilled medical professionals, particularly in rural clinics. Member of Parliament for Mokhethoaneng constituency, Mokhothu Makhalanyane, who chairs Parliament’s Social Cluster portfolio committee overseeing health and social services, says the shortage undermines primary healthcare delivery.
“You go to clinics where there’s only a nurse assistant, no doctor, not even a registered nurse,” he says. “The ratio of doctors to patients is dangerously low. Without family medicine specialists in our rural facilities, we miss TB diagnoses at the community level.”
Makhalanyane says the situation worsened after Lesotho lost 1.4 billion maloti in health system strengthening funds under the United States of America’s funded Millennium Challenge Account (MCA).
“That was 25 percent of the health budget allocation. It was meant for primary healthcare, where these poor people live, where TB is supposed to be caught early. We lost it when the US changed its aid priorities,” Makhalanyane explained.
The Trump effect: How US policies made TB treatment even harder to access
When President Donald Trump took office in early 2025, his administration moved swiftly to realign US foreign assistance priorities. Through a series of executive orders, the White House froze or redirected much of America’s global health funding, pending a comprehensive review of what it termed “inefficient legacy aid programmes.”
The impact on Lesotho was immediate. The country, which relies heavily on donor support to sustain its HIV and TB programmes, saw several projects stall as implementing partners awaited new policy guidance. The US contributes roughly 18 percent of the Global Fund to Fight Aids, Tuberculosis and Malaria, the main vehicle financing Lesotho’s TB response.
Minister Selibe Mochoboroane recalls the shock of the first months.
“We had to revisit our budgets and cut some planned activities,” he said. “Some programmes we hoped to cover, we could no longer afford. It created fear among staff and communities because they depend on those services.”
The funding freeze disrupted laboratory testing, data management, and community screening programmes supported by USAID and Global Fund financed partners.
“We lost human resources that had been recruited under US funding,” said Dr Llang Maama, Head of the TB Department.
“There were delays in testing, and many TB patients were never followed up. It set us back in tracing the so-called ‘missing patients’,” Dr Maama says.
MP Makhalanyane, who chairs Parliament’s Social Cluster overseeing health, described the situation as a “policy storm” that struck when Lesotho could least afford it.
“It coincided with our poorest moment, poverty, unemployment, and rising costs of care. The cuts hit rural areas hardest, where community-based programmes are the only form of health access,” Makhalanyane added.
To keep essential services alive, the Ministry of Health resorted to service integration, merging TB, HIV, and maternal health programs to stretch the limited funds that remained.
“Through integration, we continued offering services despite reduced budgets,” said Mochoboroane.
He explained further “We brought in partners like Solidar med and Partners In Health to manage specific districts.”
But by mid-2025, signs of a strategic pivot from Washington began to emerge. The Trump administration, under pressure from global health advocates and domestic pharmaceutical interests, adopted a results focused and innovation driven model of engagement.
Instead of a broad budget support, the US began investing in measurable, high-impact programmes emphasizing scientific breakthroughs and accountability.
These new policy saw the US bring Lenacapavir, a drug hailed as a revolution in HIV prevention, and renewed funding through FHI 360’s EpiC programme, signaling a cautious but significant renewal of US health assistance to countries like Lesotho.
Still, the early disruptions left scars.
“The initial uncertainty weakened confidence. Some partners paused procurement, and for months, we had testing machines without cartridges. We survived that phase, but it exposed how fragile our system is when aid shifts suddenly,” says Dr Maama.
The unfinished fight against TB and Silicosis
Lesotho’s TB epidemic cannot be separated from its mining legacy. Thousands of ex-miners and their families remain exposed and prone to silicosis and TB, both in the mines and in their home communities.
“Health workers and social care workers in crowded environments are also at risk. Ex-miners and their household contacts show high TB rates,” Dr Maama adds.
The Ministry of Health operates only two occupational health centres in Maseru and Mafeteng districts connected and working in collaboration with the South African government’s Medical Bureau of Occupational Diseases to serve the entire country’s ex-miner population.
“We can manage only 20 clients per day. That causes delays in screening, claim processing, and treatment,” says Dr Maama.
Lesotho’s small but overburdened health workforce continues to fight TB and silicosis amid resource scarcity, administrative bottlenecks, and regional inequities.
Makhalanyane calls for structural reform: “We must strengthen family medicine, invest in rural doctors, and ensure that our people are not left in the hands of community volunteers alone.”
Minister Mochoboroane remains cautiously optimistic.
“We have begun to see an increase in TB notifications,” he says. “That means more people are being found and treated. If we can sustain this effort and restore our partnerships, we will turn the corner.”
But the numbers tell a harsher truth: Lesotho is still losing the war on TB and silicosis, trapped between donor politics, hunger, and a health system that cannot stand on its own.
A New Chapter: US recommits to Lesotho’s fight against TB and HIV
On September 15, 2025, a new tone emerged in US–Lesotho health relations. Chargé d’Affaires, Thomas Hines, met with health minister, Mochoboroane, and announced that Lesotho had been selected to receive Lenacapavir, a groundbreaking and long acting HIV prevention drug.
That same week, the US Embassy Maseru joined FHI 360 and partners to launch the resumption of TB and HIV programmes in districts of Maseru, Mohale’s Hoek, Mafeteng and Thaba-Tseka under the Meeting Targets and Maintaining Epidemic Control (EpiC) programme.
The US government committed $6 million (about 105 million maloti) to the effort, signaling renewed confidence in Lesotho’s health system.
“Together, we are advancing the fight against TB and HIV for healthier, stronger communities,” said CDA Hines at the launch, reaffirming America’s partnership with Lesotho.
In a follow-up interview, Chris Dettweiler, the US Embassy’s Global Health Security and Diplomacy Advisor, explained to MNN Centre for Invetsigative Journalism (MNN) that this new initiative represents a scientific and diplomatic turning point.
“FHI 360’s EPIC project will assume some of the work that was done under USAID,” he said. “It supports life-saving HIV and TB care and prevention services across a big portion of the country. We’re very excited, it picks up the great work that PEPFAR has done here for nearly 20 years.”
Dettweiler described Lenacapavir as a “total game-changer.”
“It’s an anti-retroviral injection given every six months, shown to prevent over 99 percent of HIV infections,” he said.
“It’s coming to Lesotho at the same time as to Europe and North America. For a country like this, with high mobility, mineworkers, truck drivers, this is the right medication at the right time.”
The drug, produced by Gilead Life Sciences, will be delivered to Basotho for free through Global Fund and PEPFAR co-financing, ensuring access for vulnerable and mobile populations.
“Lesotho has made impressive gains,” Dettweiler acknowledged.
He added that “most people living with HIV know their status and are on treatment. What has held back total control are gaps among young people and mobile populations. Lenacapavir will close that gap.”
For Lesotho, this renewed support signals not just the return of US funding, but the reintroduction of science driven innovation.
“This is the biggest breakthrough since the modern ARV regimens,” Dettweiler said. “It gives countries like Lesotho the tools to truly end the HIV epidemic, and by extension, to weaken TB.”
Minister Mochoboroane welcomed the move as “a new dawn.”
“The resumption of support under FHI 360 and the new prevention drug come at a time when our health system needs rebuilding. We see this as a renewal of partnership, not just funding,” says Minister Mochoboroane.
MNN Centre for Investigative Journalism (MNN) produced this story. All views are ours. See https://lescij.org/ for our stories.
