Transitioning to digital transactional data capture in primary health care facilities: a case report from Ghana’s Savannah Region

Introduction

Ghana’s health information system changed significantly over the past few decades. Structural changes in the 1990s and 2000s facilitated data collection from health facilities nationwide, increasing the availability of information for decision-making (1). In 2012, the Ghana Health Service (GHS) and its partners adapted District Health Information System 2 (DHIS2), an open-source health management data platform, to collect, manage, and use facility-based health data (2). The adapted system, called District Health Information Management System 2 (DHIMS2), improved data collection, analysis, and use at facilities and government management offices by enabling universal access to a centralized data repository (3).

Although DHIMS2 significantly improved data availability and use, it only supports aggregate health services data (3). The growing demand for patient-level data led to the introduction of DHIS2 tracker (4), a mobile application (app) built on the DHIS2 platform that supports offline and online case-based data collection, monitoring, and follow-up.

GHS piloted DHIS2 tracker in 2015 to collect maternal and child health (MCH) service delivery data in the Awutu-Senya District of Ghana’s Central Region. By the end of 2016, this tracker (known widely as e-Tracker) was scaled up to three additional districts in the same region. The successful rollout of the MCH e-Tracker module marked an important step in leveraging digital technology to improve transactional data collection and use in Ghana (4-6).

In 2023, GHS deployed MCH e-Tracker modules in two additional northern regions: Savannah and North East. Through this deployment, 241 health providers in Savannah electronically captured and managed transactional data at various service delivery points, especially in health centers and community-based health planning and services (CHPS) compounds (7).

Despite these deployment efforts, no health facility in Ghana has transitioned fully to electronic transactional data capture. The literature suggests this is due to factors like inadequate technical capacity of subnational staff, poor staff attitude toward change, work overload resulting from using both paper and electronic systems, and internet connectivity issues (5-9).

This case report describes the implementation of e-Tracker in the Savannah Region of Ghana, including enablers and barriers to uptake. The authors provided technical and logistical support throughout this effort. We present this case in accordance with the CARE reporting checklist (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-42/rc) (10).

Case presentation

GHS, with support from CHISU adopted an implementation science approach for e-Tracker rollout in Savannah with three main components: training health providers and health managers on e-Tracker use, providing post-training follow-up and supportive supervision, and holding periodic implementation review meetings to obtain feedback. This approach aims to help implementers understand and address factors influencing e-Tracker acceptance and compliance to promote implementation effectiveness. Before implementation began, the team collaborated with GHS leadership and subnational health service managers to discuss the implementation plan, clarify roles and responsibilities, and ensure government leadership buy-in (Figure 1).

Figure 1 Timeline of DHIS2 tracker capture (MCH e-Tracker) deployment. DHIS2, District Health Information System 2; MCH, maternal and child health; PPMED, Policy, Planning, Monitoring and Evaluation Division.

Training health providers and health managers

Our team conducted two types of training. The first was a three-day residential training in May 2023 that focused on empowering subnational health service managers to lead, monitor, and supervise e-Tracker rollout. We trained four district health officers from each of the seven target districts and 11 health officers from the Regional Health Directorate (in total, 31 men and 8 women), purposefully selected based on their subject matter expertise in MCH and health information systems. Training focused on applying the GHS mobile handheld device policy to safeguard tablets, using e-Tracker, and resolving technical challenges using basic troubleshooting skills.

The second facility-level training, organized in May and June 2023, targeted all 556 health facility staff (314 men and 242 women) who provide MCH services (Table 1) in the 241 health facilities in the seven districts (Figure 2). A three-member team from GHS facilitated these training sessions, supported by staff from the Regional Health Directorate and CHISU.

Figure 2 Beneficiary districts in the Savannah Region.

During these trainings, GHS distributed 477 tablets. Health centers and polyclinics received three tablets each, CHPS facilities without midwives received two tablets each, and CHPS facilities with midwives received three tablets each. The number of tablets distributed was based on the average client load.

Ghana’s primary healthcare system operates on a three-tiered structure organized at the district level by offering health services through facilities at the district, subdistrict, and community levels (11). The e-Tracker app was mainly deployed at the community and subdistrict level to digitized service delivery data previously solely captured using paper registers to improve accessibility and data quality.

Post-training follow-up and supportive supervision

In October 2023, the team conducted a post-training technical monitoring and support visits to 21 health facilities to observe e-Tracker use, obtain feedback, assess data quality, and resolve challenges. Selected facilities represented a range of e-Tracker use—including high, moderate, and no use—so the team could identify enablers and barriers.

User compliance

Of the 241 health facilities enrolled onto MCH e-Tracker, 80.1% (n=193) were CHPS, 16.6% (n=40) health centers, 2.1% (n=5) maternity homes, and 1.2% (n=3) polyclinics. Facilities began using e-Tracker in June 2023.

Our team used the number of clients enrolled in each facility for clinical services as a proxy indicator to assess user rates and compliance. Client enrollment is essential for using MCH e-Tracker for service delivery and it is the easiest task a user can complete to demonstrate application usage. In January 2024, our team downloaded data representing seven months (June to December 2023) and analyzed it in Microsoft Excel 2016.

Overall, about two thirds (64.7%, n=156) of enrolled health facilities used e-Tracker to capture at least one month of data, and 16.6% (n=40) used e-Tracker for all 7 months assessed (Table 2). For month-by-month use, health facility user compliance decreased from 58.1% (n=140) in June 2023 to 22.8% (n=55) in December 2023, with a marginal increase in October 2023 (42.3%) (Table 3). This increase may be due to a supportive visit that month to select facilities (Figure 3). In contrast, an average of 64.3% of enrolled health facilities consistently reported to DHIMS2 aggregate using data collated from paper-based registers for the 7 months assessed (Table 4 and Figure 3).

Figure 3 Health facilities’ MCH e-Tracker use vs. DHIMS2 aggregate use. DHIMS2, District Health Information Management System 2; MCH, maternal and child health.

By district, compliance for collecting one month of data ranged from 80.6% (29 of the 36 enrolled facilities in Bole District) to 48.9% (22 of 45 enrolled facilities in Sawla-Tuna-Kalba District) (Table 2). When comparing district performance, the percentage of facilities using e-Tracker for 1 to 7 months dropped from 80.6% (29 out of 36) to 22.2% (8 out of 36) in Bole District, and from 60.0% (15 out of 25) to 4.0% (1 out of 25) in the North Gonja District (Table 2).

Post-implementation review meetings

Post-implementation review meetings with health facility managers and e-Tracker users provided a platform to obtain feedback for process improvement and adaptive management. First, our team conducted a virtual meeting in July 2023. Users reported increased workload due to duplicative data entry using both e-Tracker and paper-based registers (a directive from the government of Ghana), difficulties synchronizing data due to internet connectivity issues, difficulties accessing system-generated unique codes, and inability to access aggregate data needed to compile mandatory monthly reports because the team responsible for system configuration had not completed the report modules. Our team responded by conducting a technical support visit to resolve these early challenges.

Our team subsequently held a nationwide in-person review meeting with all stakeholders to obtain further feedback and identify solutions. The meeting provided an opportunity to obtain relevant feedback, with the aim of more effective deployment. A total of 63 participants (9 women and 54 men—reflecting the existing gender inequalities within Ghana’s healthcare workforce) drawn from the national and subnational levels of Ghana’s health system (including the implementing partner community) (Table 5) attended the two-day review meeting in January 2024.

Insightful presentations highlighted achievements, challenges, and recommendations, emphasizing the crucial role of leadership commitment, user motivation, and continuous improvement. The project team led four focus groups using a structured questionnaire to glean insights about e-Tracker implementation, including capacity building, leadership and governance, funding and sustainability planning, and technical challenges. There was consensus on Ghana’s need to decentralize technical support structures to address issues effectively. This would involve establishing robust regional and district-level teams to provide support and address day-to-day technical challenges promptly. A user highlighted in her presentation that “e-Tracker is a game changer—very easy to use. We only need prompt technical support when the need arises.” She added that the system improved data quality in her health center by reducing manual tallying and counting errors.

The system also enables users to easily identify MCH service defaulters by flagging their cases for follow-up. A GHS senior manager underscored the need to strengthen core managerial functions such as onsite and remote supportive supervision, monthly data verification, quality checks, and quarterly validation and feedback on e-Tracker use by staff. Meeting participants emphasized the need for a gradual transition from paper-based to electronic systems. This involves showing staff the value of the tool and providing the necessary support for a smooth transition.

Enablers and barriers to user compliance

The Savannah Regional Health Directorate organized a review meeting in February 2024 to identify implementation enablers and barriers in the region and to develop local strategies to address challenges. Feedback from these meetings indicated that high user compliance and successful adoption of MCH e-Tracker in a few facilities was due to a combination of end user commitment, understanding of the system requirements, regular review and training, and strong leadership support (12). Ongoing training and refreshers—both for new staff and for existing users—was crucial for increasing the user base and improving data quality. Support from district leaders and facility managers who prioritize the mobile system’s implementation through activities like monthly supervision created an environment conducive to compliance. Implementation challenges identified were frequent e-Tracker app version updates, the parallel use of both paper-based and electronic systems, and internet connectivity—which is outside of user control (13).

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Publication of this case report and accompanying images was waived from patient consent according to the Ghana Health Service.

Discussion

This case report explores factors impacting the adoption and use of e-Tracker for MCH services in Ghana’s Savannah Region. Facilities’ initial acceptance and use of e-Tracker was high after one month, but this waned as time went on due to increased workload resulting from the parallel use of paper and electronic systems. There were significant variations in e-Tracker use among districts due to differences in user acceptance and commitment to use the new system, perceived ease of use, and level of local leadership support, including supervision, feedback, and provision of basic logistics like internet bundles to users. However, the usage rate for the paper-based reporting system was consistently high for the periods observed due to government mandate.

These findings corroborate research conducted by Lee et al. in the Volta and Eastern regions of Ghana (8) which assessed the changes in health workers’ knowledge, attitude, and use of the e-Tracker by comparing the pre- and post-survey results. They observed that 49% of end users initially expressed preferences for the mobile application, but this decreased to 33% after 3–10 months of e-Tracker use (8). Other studies show that stakeholders’ perceived usefulness and ease of use of mobile technology influence its acceptability and sustained use (14-19). In South Africa, a 2022 study explored the barriers and enablers to implementing digital-linked diagnostics models at point-of-care. Of the 18 participants, 13 rated ease of use as the top enabler (88.9%) (15). Similarly, a 2020 study in Ghana’s Western and Western North regions assessed the factors influencing e-Tracker use for antiretroviral therapy across 43 facilities, with 74.4% of respondents (n=32) citing the system’s ability to track clients on treatment as a key motivator (5). In our implementation, perceived usefulness was a challenge, as end users needed to continue using their traditional paper-based data system, resulting in an increased workload.

Several studies have also identified lack of internet connectivity as a primary barrier to the implementation of mobile technology for healthcare delivery in developing countries (5,17-21). Ghana’s internet penetration rate stood at 68% of the total population in 2021 (22), but there is no data about internet penetration in health facilities. Internet connectivity issues impact the synchronization of configuration settings and service data capture in e-Tracker. Synchronization was one of the key challenges identified by Savannah Region end users during post-implementation review meetings. To address this challenge, users periodically had to leave their health facilities to go to internet connectivity zones in their communities to perform data synchronization. Future implementation should consider conducting a robust connectivity analysis and devising a risk mitigation plan before launching a widespread digital data collection effort.

The ability to use a new technology is dependent on the adequacy of training received by end users (5,6). In the Savannah Region, an alternate implementation strategy focused on fostering strong leadership involvement and user-centered design techniques could have improved ultimate user rates. Engaging end users earlier in the design process and ensuring both government and health facility leaders actively drove the transition to the digital system could have resulted in higher adaptation and a smoother transition. Our implementation highlights the need for clear policy direction to eliminate paper-based systems, bolster consistent training, and ensure the provision of sufficient resources, such as internet connectivity and technical support.

Many other factors may threaten the adoption and sustained use of mobile technology, such as financial restraints and the high workload of facility staff (23). The initial rollout of a mobile system may increase workload as users incorporate the tool into their existing workflow. Implementers should consider more supportive supervision, follow-up training, and other check-ins to ensure continued use.

Opportunities for further research

One potential area for further exploration is the integration of digital transactional data capture systems with other electronic medical record (EMR) platforms used in primary care in Ghana. While the transition to digitizing data capture for transactions such as MCH and clinical outpatient services offers tremendous potential benefits, the lack of seamless integration with EMR systems could lead to inefficiencies and data silos. Investigating technical approaches to achieving bi-directional data exchange between these systems, as well as workflow optimizations to facilitate this integration, would allow health facilities to maximize usage of these systems. Additionally, research examining health workers’ perspectives, training needs, and change management strategies would shed light on the socio-technical factors influencing successful EMR-transactional data system interoperability. Such insights could guide evidence-based implementation approaches as digital transformation evolves in resource-limited primary care environments.

Conclusions

Transitioning to digital transactional data capture offers significant potential to improve data quality and availability, ultimately improving service delivery outcomes through effective monitoring and informed decision-making. In Ghana, the practice of maintaining both paper and electronic records created significant inefficiencies, leading to frustration among service providers and lower adherence to the digital system. This challenge stems primarily from a lack of leadership buy-in and support for transitioning to a fully paperless system. For the sustainability of new tools and systems, it is crucial for implementers to address behavioral, technical, and operational challenges. This includes decentralizing technical support to peripheral levels, providing clear policy guidance, and establishing strong local governance structures.

Acknowledgments

This publication was made possible through support provided by the United States Agency for International Development (USAID) Country Health Information Systems and Data Use (CHISU) program.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-42/rc

Peer Review File: Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-42/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-42/coif). E.S. serves as an unpaid editorial board member of mHealth from September 2022 to August 2024. All authors report the grants from USAID. E.A., G.A., L.K., and L.E. receive grants from USAID via employment with the nonprofit organization JSI Research & Training Institute, Inc. (JSI). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Publication of this case report and accompanying images was waived from patient consent according to the Ghana Health Service.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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