Digitisation of the Collection of Community Health Data at the Village Level in Lesotho

Village Health Workers in Lesotho with their tablet computers

Village Health Workers attending a training at the St. Matthew facility proudly show their ministry-issued tablets.

UNDP has introduced a digital system that allows better reporting of public health data in rural communities in Lesotho. It consists of tablets and software designed to fit the needs of Village Health Workers, the Ministry of Health unit that collects the data, whose staff has low digital literacy. The initiative led to increased reporting frequencies (essential for monitoring fast-moving epidemics) and reduced costs; as a side effect, it increased the rates of digital literacy of the personnel.

Innovation Summary

Innovation Overview

In Lesotho, disease monitoring and control in communities is the responsibility of Village Health Workers (VHWs). This is a unit within the Ministry of Health. It is staffed not with civil servants, but with about 9,300 volunteers, community residents who provide support to some primary health care activities. They tend to be rural (80%) and middle aged (average age 56), with low digital literacy. After COVID-19 spread in Lesotho, VHWs were identified as frontline personnel. This implied higher-frequency reporting and put the VHWs manual system, designed in 1978, under strain.

Before COVID, VHWs used paper forms for data gathering and analysis. They sent monthly reports to the ministry. This frequency was too low for effective control of the COVID pandemic. As VHWs scrambled to switch to weekly reporting, the legacy system became prone to frequent deadlocks. This resulted in delays, reporting errors, and lost data.
Against this backdrop, the UNDP Lesotho Accelerator Lab launched an experiment to streamline the collection and reporting of health data through digital means. Its intention was not, however, only to contribute to mitigating the COVID crisis. The crisis offered an opportunity to improve the legacy system on several dimensions: (1) digitize community health; (2) integrate hitherto siloed reporting of health data by different development organizations, (3) generally overhaul the VHW programme, and in specific (4) make a case for turning VHWs from volunteers to professionals.

The Lab prototyped a new system, based on tablet computers and a specially developed reporting application and backend database. The application, called Bophelo-Ka-Mosebeletsi (BKM), was carefully designed in collaboration with the National University of Lesotho to be simple and intuitive to VHWs. The tablets mount SIMs provided by a private sector partner, Econet Telecom Lesotho. The Lab tested this prototype in 2020 with 682 VHWs from 11 healthcare facilities in two pilot districts. The quantitative and qualitative analysis of the prototype revealed an uptick in the frequency and quality of health reporting. Cost savings depend on how far each VHW had to travel to submit paper reports in the legacy system, but were found to be considerable.

This improvement benefits VHWs themselves first, as it makes their reporting tasks lighter. Second, it provides the Ministry of Health with better, faster information at a lower cost. Third, such better information improves the health care system and benefits all Basotho.

After the prototype, scaling is happening in two dimensions. One is geographic: the Lab, with the support of UNICEF, extended coverage from 2 to 5 districts in 2023. Plans for nationwide rollout are under way in partnership with the World Bank. The other is functional: BKM has a modular architecture, so the Lab has expanded its functionality by adding 10 more modules on top of the one for COVID-19.

Innovation Description

What Makes Your Project Innovative?

This project used human-centered design and a carefully monitored prototype to hit several birds with the same stone.
1. Human-centered design made the digitization of health data collection into help, not a burden, for Village Health Workers.
2. Careful monitoring generated the evidence to turn a low-cost prototype into a rock-solid case for a nationwide reform.
3. Qualitative evidence allowed to identify secondary benefits and bake them into the project. These benefits include integration of donor-funded community health activities, often siloed and uncoordinated; far better management of VHWs as a result of improved monitoring; the creation of a scaling-ready partnership with of UN agencies, academia and private sector; and the enhanced digital literacy and digital financial inclusion of VHWs.
4. Engagement with this project introduced a learning approach to policy making into the ministry. The latter ended up including community health into its e-health agenda.

What is the current status of your innovation?

The Ministry of Health evaluated the initiative after six months of deployment. All stakeholders and beneficiaries recommended to extend the use of BKM to all VHWs activities and to roll it out to all districts.
Taking this on board, the ministry took steps to integrate BKM into its own digital infrastructure, District Health Information Software 2. With this move, the ministry creates an integrated space for health data that includes rural communities. It also designated BKM as the unified digital tool for data collection, analysis and reporting on community health, to get rid of siloed implementation and duplication of effort.
In collaboration with UNICEF and the World Bank, the Lab added ten more functional modules to BKM and prepares its nationwide rollout. In 2023, 74 VHWs coordinators tested the new personnel management module. At the time of writing, 800 more VHWs are undergoing training. Partners will then train VHWs in the remaining five district, achieving 100% coverage.

Innovation Development

Collaborations & Partnerships

• The UNDP Lesotho Accelerator Lab provided leadership, design, prototyping, advocacy for scaling.
• WHO Lesotho provided policy support.
• Lesotho Ministry of Health offered the VHW as testing ground, policy review.
• National University of Lesotho provided software development technical support.
• Econet Telecom Lesotho provided zero-cost connectivity.
• UNICEF and the World Bank Group are supporting the nationwide rollout.

Users, Stakeholders & Beneficiaries

• The citizens of Lesotho gained faster, more granular reporting and improved community health service.
• The Village Health Workers unit gained costs and travel time-savings; enhanced digital and financial inclusion.
• Ministry of Health officials gained better quality, easier-to-access community health data.
• Health sector development partners gained better data for an effective use of resources.
• Academic and private sector partners gained inclusion in the government's health agenda.

Innovation Reflections

Results, Outcomes & Impacts

Before digitization, VHWs had to travel to healthcare facilities to deliver their data in paper form. With digitization this travel disappeared, giving rise to substantial financial savings.
Timeliness, quality and actionability or reporting improved. Once uploaded, reports feed into a dashboard available to ministry officials and local facilities.
The tablets issued to VHWs mount SIMs that support mobile money-based payment and saving services. The evaluation reported that 35% of VHWs had used one or more of these services in the six months after the prototype started. Recall that most VHWs are rural, middle-aged, with low digital literacy.
The ministry adopted for the first time a human-centered approach to policy review.

Challenges and Failures

The landscape of development organizations working on health in Lesotho is quite crowded. Organizations like WHO, UNICEF, the World Bank, USAID, JhPiego, EGPATH, ICAP and so on are all present. This made it quite difficult for the Accelerator Lab to gain the government's trust, especially as UNDP's primary mandate is not health.
The UNDP Lesotho Accelerator Lab had only with a small budget (10,000 USD) for the prototype. It made up for this disadvantage by securing a smooth collaboration with the University and the private sector partner.

Conditions for Success

A balanced collaboration with the academic (National University of Lesotho) and the private sector partner (Econet), formalized via MOUs, was critical to ensure the rollout of the BKM platform and the relative technical support.
Continuous learning and adjustment ensured that the project aligned with needs that emerged during the prototype phase.
BKM was built in-house, by ministry ICT staff, with support and leadership from the National University of Lesotho. This ensured skills transfer and improved ownership, and therefore sustainability.
We believe this approach is general enough to carry through to other domains invested by a digital transformation.

Replication

The BKM project has not yet been replicated, but it is scaling. This has led it to be ported to addressing other problems in the field of community health care.

1. The BKM project has already scaled up from the two districts of the prototype to five, thanks to UNICEF's support. A national rollout supported by the World Bank Group is underway.
2, It has also scaled deep, with the addition to the BKM platform of ten more modules to report on diseases other than COVID-19. The platform is now integrated into the Ministry of Health's digital infrastructure. The ministry designated BKM as the unified digital tool for data collection, analysis and reporting on community health.

Lessons Learned

The BKM project has taught (yet again) the Accelerator Labs to remain open to opportunities that might arise to produce positive externalities outside of a project's administrative silo. So, we designed and deployed it as a health project that also advances digital and financial inclusion, promotes social cohesion, rationalizes policies downstream and builds new partnerships.
The project has also taught us the importance of high-quality, diverse partnership. Without them, sustainable implementation is a difficult challenge.

Anything Else?

The UNDP Lesotho Accelerator Lab is part of the UNDP Accelerator Labs network, the world’s largest and fastest learning network on wicked sustainable development challenges. The network consists of 91 Labs covering 115 countries. It cultivates a stance of sharing knowledge with one another and with the development community at large. The lab in Lesotho, then, could benefit from a rich exchange with other Accelerator Labs working on government innovation. These include the 22 labs incubating government innovation labs, the 27 supporting the adoption of innovation policies, and the 37 training civil servants in innovation methods. Some instructions to replicate their best initiatives are visible here: https://nie.sdg-innovation-commons.org.

🇱🇸