Implementation of a mobile health application used by community health workers in Ekurhuleni Health District

Abstract

Background: The introduction of digital technology into the health sector began globally in the early 2000s, revolutionizing healthcare delivery and management. In 2017, the Ekurhuleni Health District was chosen as a national pilot site for the CommCare mobile health application, intended for Community Health Workers (CHWs) and Outreach Team Leaders (OTLs) within ward-based primary healthcare outreach teams. Despite the promise of digital health interventions, challenges in scaling and sustainability persist globally and nationally. This study assesses the experiences of end-users and key stakeholders in implementing CommCare over a five-year period in Ekurhuleni. Methods: A mixed methods cross-sectional descriptive study was conducted in the Ekurhuleni Health District. Data were collected through semi-structured interviews with seven key informants and an online self-administered questionnaire distributed to 1,197 CHWs and OTLs. Quantitative data were analysed descriptively, while qualitative data underwent thematic analysis using Atlas.ti. Results: Out of 1,197 end-users, 39% (n=464) participated in the study. Most participants (83%) reported that CommCare met their expectations, with 85% expressing overall satisfaction, and 95% recommended its adoption in other districts. However, 35% encountered challenges including connectivity issues, difficulties with data management, and technological problems like app freezing or hardware malfunctions. Key informants identified logistical challenges in training, particularly in sourcing suitable venues. The diverse ages and educational backgrounds of the CHWs created challenges but pairing them helped bridge learning gaps. Asset management was a significant issue, with frequent device losses prompting the enforcement of a provincial policy to hold CHWs accountable. The cascade model of training was successful and highlighted as a best practice. They also emphasized the need for dedicated technical teams, multi-stakeholder engagement, improved ICT infrastructure, long-term planning, and ongoing technical support. Conclusions: The implementation of the CommCare app in Ekurhuleni was generally successful, with high end-user satisfaction. Stakeholder feedback highlighted the importance of robust planning, investment in ICT infrastructure, and multi-stakeholder engagement for future digital health interventions. Evaluating existing programs and understanding the factors that contribute to their success will be essential for guiding the scale-up and sustainability of future digital health initiatives.