**1. Introduction**

The Lesotho Kingdom is a relatively small country, 30,360 km2 divided into 10 administrative districts and further divided into four ecological zones, namely the lowlands, foothills and highlands (mountains) and the Senqu valley [1]. The mountainous terrain makes ground travel very difficult in Lesotho [2]. The mountainous topography and harsh winters make it difficult to access essential services, including healthcare services [1]. The Republic of South Africa surrounds Lesotho, with a population of slightly more than 2 million [1]. About 99% of Lesotho people are ethnic Basotho, with Christianity being the majority religion. The national languages are Sesotho and English [2]. Altitudes in Lesotho range from 4500 to over 13,000 feet, and 33% of Lesotho population resides in the urban areas leaving the majority of the population living in the mountain areas. High mountains cover about two-thirds of the country, and snow is expected in the winter months [3].

Lesotho, classified as a lower-middle-income country with a per capita income of US\$1879, ranks 161 out of 187 countries on the UN Human Development ranking [4]. National poverty figures indicate that 57.1% of the population lives below the national poverty line [4]. Poverty is particularly acute in the mountainous areas, which are hard to reach [5]. Besides, Lesotho's economy is dependent on clothing and textiles; diamond extraction; exports of water to South Africa and workers' remittances from the Southern African Customs Union (SACU) [4]. The agricultural sector, which accounts for only 8.6% of Gross Domestic Product (GDP), is the primary source of income for the majority of the rural population [4].

The World Bank and UNICEF report indicates that the main priority for the Ministry of Health (MoH) should be to strengthen its control systems both for compliance which now appear extremely weak as well as performance at all levels (centre, district, facility level) [6]. The health system looks very fragmented, with several pools of resources from donors and government and different service providers operating according to different priorities and operating mechanisms and without any accountability for results.

The health outcomes for major indicators remain poor despite the increase in funding by the government [6]. Considering the fact that HIV prevalence and incidence are slowly improving, TB incidence, maternal and infant mortality rates remain among the highest in the world [6]. The Government of Lesotho (GoL) should strive to meet the objective of universal health coverage, the quality and cost-effectiveness of health care and increase access to underserved populations within a very tight budget [6]. Therefore, more quantifiable efforts have to be taken towards getting outputs worth the investment made on health system.

To clarify this further, the government of Lesotho has incurred increased expenditure in the District Health Management Teams (DHMTs) (135%) and Christian Health Association of Lesotho (CHAL) (121%). Another increased expenditure was seen in laboratories (126%), planning (163%) and pharmaceuticals (162%) [6]. Perhaps, the increase in DHMT expenditure may be understandable as it is the main implementer of decentralisation of health service delivery at the primary healthcare level [6]. However, looking at the topography of the country, it is believed that the community councils may play a similar role with better cost-effective health outcomes.
