One of the core foundations of effective public health practice lies in providing precise and prompt data regarding health-intervention coverage, quality, and fairness. To accomplish this, community health data comprise one way to improve the standard of public health data overall.^1,2 This is achieved by implementing a community health information system (CHIS), which effectively collects data in the field from community health workers (CHWs) and other providers who directly engage with the community.¹ In the context of Lesotho, CHWs are referred to as village health workers (VHWs).

The CHIS is a health information system that connects various stakeholders and healthcare providers within a specific community.³ It serves as a locally driven and family-focused system for managing and overseeing the efforts of community workers in educating households and providing a comprehensive range of health services, including promotion, prevention, and basic curative care to families.⁴ Additionally, it has enhanced the decision-making process at the community level by offering decision-makers the necessary data and making the process more transparent.⁵

King et al. introduced a community health record framework, a multitiered, multisector model proposed to facilitate the development of a community health record.⁶ It describes an iterative and participatory process for achieving collaboration and information exchange between health care, public health and community organisations. One of the aims is to enable meaningful collaboration, which requires trust and time to develop and begins with focusing on a common purpose. The other aim is to facilitate a shared approach, which requires that stakeholders understand each of the problems and potential solutions from their perspective and the perspective of their collaborators. Furthermore, the framework aims to build workforce and infrastructure capacity by developing, implementing, and sustaining the community health record. This requires that multisector stakeholders develop the necessary epidemiology, informatics, and technical expertise and resources. Lastly, it aims to establish a new way of conducting business that enables the transformation of community health data into information and information into knowledge to aid decision-makers in collectively improving population health. Efficient and timely access to relevant multi-sector community health information depends on interoperability, the ability of different systems and organisations to exchange and use information easily.^6,7

The national human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) strategic plan of Lesotho 2018 places community-level service delivery at the forefront of health service promotion, focusing on strengthening it to support the achievement of the 95-95-95 targets effectively.⁸ Various stakeholders, such as VHWs, community ART groups (CAGs), civil society organisations (CSOs), non-governmental organisations (NGOs), and community councils, play a role in delivering HIV interventions across the prevention, testing, and treatment continuum.⁸ To enhance the VHW programme, the Ministry of Health (MOH) has established a VHW policy and strategy.⁹ Additionally, key performance indicators have been instrumental in informing the development of data-collection tools for VHWs, and the VHW programme is currently working on creating a data-management system specifically for VHW information.⁹ These efforts align with the findings of the Jeremie et al. study, which emphasised the importance of an organised community information management system for health managers to plan and support community healthcare effectively, thereby benefiting primary healthcare.¹⁰

The availability of community data plays a vital role in facilitating the exchange of health information between the community and the healthcare system.¹⁰ Village health workers and health centre committees have led to increased coverage of services, making health services more accessible to the community. These services primarily focus on promotion, prevention and rehabilitation. Braun et al. highlighted the various functions CHWs performed, including conducting home visits, assessing and treating diseases, collecting data, providing education and counselling, and making referrals for further care.¹¹ They also support TB and HIV patients by accompanying them to health facilities, ensuring timely medication pick-up, and promoting adherence. Furthermore, CHWs organise health education gatherings and facilitate immunisation efforts within their communities. This information must be compiled and shared with the MOH and other stakeholders to assess if targets have been met. Jeremie et al. emphasised the significant role of CHWs in gathering information at the community level.¹⁰ USAID states that a well-functioning health information system provides reliable and timely information on health determinants, health system performance, and overall health status.¹² The production, analysis, dissemination, and utilisation of information form a crucial foundation for effective health systems.¹²

The National AIDS Commission (NAC) uses District Health Information System 2 (DHIS2), which is intended to collect non-clinical data from CSOs and community councils. This DHIS2 at NAC is called the Lesotho Output Monitoring System for HIV and AIDS (LOMSHA). Lesotho Output Monitoring System for HIV and AIDS was established to enhance the coordination of non-clinical data from all stakeholders providing HIV and TB services as per the Lesotho Essential Package of HIV Services (ESP).¹³ National AIDS Commission further articulates that organisations will be empowered with efficient accounting and reporting practices to deliver reliable and consistent information about HIV and TB.¹³ This will enable them to improve their capacity to provide accurate and up-to-date information on these diseases. However, there is no indication of information integration between DHIS2 and LOMSHA. Therefore, a lack of information sharing on community-based data from LOMSHA and DHIS2 may affect community-level interventions by MOH, and duplication of efforts may occur.

One notable strength is the training provided to programme managers, equipping them with the skills to generate various reports using the district health information system (DHIS2). Jeremie et al. further highlighted the training of CHWs to collect accurate data, compile it, and disseminate it is crucial for planning purposes and effective health interventions within the community.¹⁰ Evaluations have also been conducted on the use of mobile health (mHealth) among CHWs, addressing a range of infectious diseases such as tuberculosis (TB) and HIV. Ha et al. assessed the mHealth approach to TB contact tracing in Botswana, which resulted in a reduced median time for completing tracing and improved data collection.¹⁴ The usability and acceptability of the programme were also rated positively. Similarly, an intervention analysis in Nigeria (involving 203 participants) demonstrated modest improvements in health professionals’ behaviour (e.g. increased hand washing and disinfectant use) and knowledge of Ebola.¹⁵

In Kenya, Finocchario-Kessler et al. conducted an observational pilot study that integrated internet and SMS alerts with tracking, leading to improvements in care.¹⁶ These improvements included continued care for mothers, increased uptake of antiretrovirals for newborns testing positive for HIV, and faster delivery of test results. A systematic review by Ambia et al. identified 34 studies, indicating that mobile phone reminders could reduce mother-to-child transmission of HIV and improve early infant HIV diagnosis.¹⁷ A study conducted in Kenya involving 650 mothers demonstrated the potential of mHealth in reducing HIV transmission from mother to child.¹⁸ Another study in Sri Lanka explored mHealth use among 29 public health inspectors addressing dengue fever.¹⁹ They emphasised the need for collaborative and culturally specific programme development approaches.

In Lesotho, the VHW programme suffers from weak coordination and inadequate collaboration among partners, resulting in insufficient support for VHWs and fragmented programmes, activities, support and incentives. There is a shortage of policy guidelines and standardised reporting tools for community-based TB and HIV/AIDS care in districts. Thus, the aim of this study is to review the availability of a CHIS in Lesotho and its integration between the MOH and the NAC.

A CHIS exists in Lesotho. Clinical information from the community is reported to the PHC facility by VHWs, CAGs, expert patients, and local and international CSOs. Clinical information collected from the community by local and international CSOs is reported to MOH through DHIS2. The reports from VHWs and CAGs are not consolidated, may be contradictory, and are not included in the DHIS2. On the other hand, non-clinical community information is reported to NAC by community councils and CSOs. However, no linkages between DHIS2 and LOMSHA indicate that information is not shared between MOH and NAC.

As indicated, clinical information collected from the community by local and international CSOs is reported to MOH through DHIS2, but not information from VHWs and CAGs. The study of Tsoeu has established that DHIS2 is not effectively used.²⁶ The study highlighted that reports from VHWs and CAGs are not consolidated as there are no links between them, and they may be contradictory. One study from Ethiopia indicated that community stakeholders and governments in LMICs lack community-based reporting mechanisms that provide the desired information.¹ This study indicates that clinical information from the community reported by VHWs has no formal reporting tools. The study conducted in Lesotho indicated that in four districts of Lesotho, there are forms to fill out for M&E, HIV, and TB reporting.²⁸ Some studies have found that CHWs are uniquely positioned to provide culturally relevant health-related information to HIS.^3,29 In India, health information from the village level is included in the DHIS2.

On the other hand, non-clinical community information is reported to NAC by community councils and CSOs. However, there are no linkages between DHIS2 and LOMSHA. This is similar to the findings of Pepela and Otieno, which indicate that reported impediments to CHIS data utilisation include data quality, timeliness, and access to minimum data sets.²⁴ Some studies noted that to aid decision-making and prevent unnecessary burdening of data providers, it is essential to identify and prioritise feasible and balanced measures across stakeholder needs, focusing on the minimal set necessary.^6,30 In their study, King et al. added that historically, data-sharing projects have been ad hoc, inconsistent and limited in scope.⁶ However, the community health record framework for achieving collaboration and information exchange between health care, public health, and community organisations is iterative and participatory.⁶ Furthermore, this framework identifies concepts necessary for each aim and proposes an infrastructure to facilitate community health record development.⁶

The study implies that community-based health information is available and needs to be included in the existing health information systems to improve community-based decision-making regarding HIV and TB treatment outcomes. This has positive results for clinical and non-clinical CHIS improvements. Regarding health services, the findings imply that if clinical community health information from VHWs and CAGs is included in the PHC routine report, relevant interventions can be planned and executed locally. As for policy, Lesotho needs to prioritise the inclusion of clinical and non-clinical information, as massive amounts of information are collected at the community level, and if available to decision-makers at all levels, some of the interventions taken at the national level can be implemented at the facility level. Regarding future research, qualitative research should be conducted to reveal the real barriers that delay the inclusion of community health information into the existing health information systems.

It can be concluded that CHISs are available in Lesotho in the form of DHIS2 from MOH and LOMSHA from NAC. However, clinical information from the community reported VHWs and CAGs are not reported on DHIS2, and there are no formal reporting tools. Again, there is no information sharing between MOH and NAC.