Facilitators and barriers to the implementation of digital tools and harmonization of community health worker reporting tools and registers: The Zimbabwean experience

Introduction: The Community Health Information System (CHIS) in Zimbabwe has transitioned from a centralized structure to a decentralized approach using harmonized reporting tools and digitization. Evolution to harmonized and digitized data collection would lead to reduced workload, timely reporting, better data quality, data use and reduced inefficiencies. There was limited documentation on adoption of harmonization and digitization of the CHIS. We assessed use of digital tools and harmonized registers by village health workers (VHW) for reporting and identified barriers and facilitators in four provinces in Zimbabwe Methods: We carried out a mixed methods  study. Two hundred VHWs from 4 provinces; southern region  (Midlands and Matabeleland South) focusing harmonized paper tools and 2 provinces in the northern region (Manicaland and Mashonaland West) focusing digital tools. Data on use of reporting tools, types of tools used for data collection, training, availability of devices, facilitators, and barriers to reporting using harmonized tools and digital devices was collected.  Information on infrastructure, equipment, capacity building, availability of funding, stakeholder collaboration, digitalization, and harmonization of CHIS was collected from key informants. Results: Most 166 (83%) VHWs were female, median age for VHWs was 49 years (IQR 43-55) and median years in service was 10 years (IQR 7-14). Majority (72.5%) of VHWs were using paper-based tools; the remainder used both paper and digital tools. Districts that piloted digital interventions report use of both. The number of registers used varied from 1 to 16. Availability of revised register varied widely across districts. Less than half of VHWs reported use of digital devices for their work. Distance to health facility, lack of training, unavailability of reporting tools, poor network and unavailability of airtime were major barriers to reporting. Timeliness and completeness of reports was highest in Manicaland and lowest in Midlands. Key informants reported gaps in provision of resources necessary for VHWs to collect and report data as guided. Conclusion: Implementation of harmonized and digital VHW reporting tools was affected by suboptimal coordination as well as lack of necessary tools. The time lag between trainings, delivery of registers, the monthly reporting forms and installation of software were identified as barriers to successful implementation of the CHIS. Key enablers of the reporting were the high level of the willingness by the VHWs to report using both paper and digital tools, the supervision provided by the facility in charge and generally high network connectivity in the districts surveyed.