Transition to Biometric-Based Digital Systems in Healthcare Facilities: Phenomenological Insights from Lusaka, Zambia (Preprint)

BACKGROUND Background The transition from traditional paper-based systems to biometric digital systems in healthcare represents a significant advancement in the management of patient information. This evolution enhances both the efficiency and accessibility of healthcare services [Okolo et al., 2024]. Traditional paper medical records, while a familiar aspect of healthcare documentation, are fraught with numerous challenges. These records often lead to inefficiencies due to their labour-intensive nature and time-consuming processes. High rates of errors can occur, stemming from legibility issues or manual data entry, which can compromise patient safety. Additionally, these records are vulnerable to being lost or damaged, further complicating patient care. As a result, delays in treatment may arise, and communication breakdowns can occur among healthcare providers, hindering collaboration and the delivery of timely and effective care [Overton, 2019]. Additionally, the physical nature of these records poses challenges for information sharing across departments, further complicating patient care [Reegu et al., 2023]. In response to the myriad challenges faced by healthcare systems globally, there has been a noteworthy shift toward the integration of advanced digital technologies. Innovations such as Electronic Health Records [EHRs], Health Information Systems [HIS], and telemedicine platforms are being increasingly adopted. These systems enable the electronic storage, retrieval, and seamless sharing of patient data, which has proven to be instrumental in enhancing the efficiency and accessibility of healthcare delivery. The COVID-19 pandemic has particularly highlighted the critical need for robust digital infrastructures within healthcare facilities, as they are essential for enabling effective remote care and efficient patient management. This urgent demand has catalysed an accelerated adoption of these transformative technologies, as evidenced by recent studies [Maraj et al., 2024; Shao et al., 2023]. The shift not only promises to improve patient care but also facilitates better healthcare outcomes through timely interventions and data-driven decision-making. Biometric technologies, including fingerprint scanning, facial recognition, iris scanning, and voice recognition, have emerged as crucial tools in healthcare to enhance security and streamline patient identification [Ahmed and Asghar, 2023]. By ensuring accurate data linkage, these technologies reduce the risk of medical errors and fraud. Countries like Estonia [Tammpuu and Masso, 2019], and Denmark [Dahler, 2020] have set examples by successfully implementing biometric systems, such as AI-based facial recognition in Estonia and biometric age assessments in Denmark. These advancements have resulted in improved patient outcomes, more efficient healthcare processes, and enhanced security measures. Despite the global trend towards digitalisation, healthcare systems in sub-Saharan Africa, particularly Zambia, face unique challenges in adopting digital and biometric technologies [Hamapa et al., 2024; Musoni et al., 2023]. Zambia’s public healthcare system is predominantly government-funded and faces a high disease burden, constrained resources, and significant human resource shortages, particularly in rural and peri-urban areas. These systemic limitations present challenges for the seamless adoption of digital solutions, including frequent power outages, poor internet connectivity, and limited availability of digital infrastructure. In response, Zambia’s Ministry of Health has prioritised digital health innovation within its 8th National Development Plan [2022–2026], aiming to integrate digital services to improve healthcare delivery and align with global health standards [Milukutu and Siachisa, 2023; Muyunda and Mpundu, 2023; Organisation, 2024]. Complementing this is the National eHealth Strategy [2017–2021], which articulates Zambia’s vision for secure and accessible health information through an integrated eHealth system. The strategy promotes interoperability, patient-centred data systems, and the establishment of national standards. It is further supported by collaborations with international bodies, including WHO’s Digital Adaptation Kits [DAKs], which provide structured guidance on digitising health systems [Chilunjika et al., 2024; Ko et al., 2024; Mamuye et al., 2022; Muyunda et al., 2023]. Zambia has also made strides in piloting digital health tools such as SmartCare, a national electronic patient record system. However, integration with biometric systems remains limited, fragmented, and under-evaluated. Some pilot projects have introduced biometric tools in patient enrolment or ART [antiretroviral therapy] management, but evidence on their effectiveness, scalability, and ethical implications is scarce. However, significant gaps remain in understanding how biometric systems are specifically implemented in healthcare settings and the potential privacy implications for patients [Newaz et al., 2021]. Privacy by design principles are essential to ensure that personal data is collected, stored, and shared securely and transparently [Saltarella et al., 2023; Semantha et al., 2023]. Addressing privacy concerns, along with the technical challenges of internet connectivity, interoperability, and community engagement, is crucial for the successful adoption of these technologies [Karpakavalli, 2024]. In resource-limited settings like sub-Saharan Africa, including Zambia, the adoption of digital and biometric systems holds the potential to revolutionise healthcare delivery by improving patient identification, reducing errors, and streamlining administrative processes (Anne et al., 2020). Nevertheless, the success of these systems hinges on overcoming the region’s unique challenges, such as limited infrastructure and the need for robust training and community buy-in (George et al., 2016). This study aimed to assess the transition from paper-based to biometric digital systems utilising biometrics in healthcare facilities in Lusaka District, Zambia. This represents a crucial advancement in healthcare delivery, with the potential to improve efficiency, precision, and patient safety. Embracing these technologies will be pivotal in addressing the needs of underserved populations and improving overall health outcomes. OBJECTIVE To assess the transition from paper-based to biometric digital systems utilising biometrics in healthcare facilities in Lusaka District, Zambia METHODS 2 Methodology 2.1 Study design This study employed a phenomenological approach [Williams, 2021] to assess the transition from paper-based to digital systems utilising biometrics in healthcare facilities in Lusaka, Zambia. The study aimed to gain in-depth insights into the experiences and perceptions of Ministry of Health officials, healthcare workers, and patients regarding the implementation and management of biometric systems. Conducted in selected healthcare facilities within Lusaka Province, the research explored the challenges and benefits of shifting from traditional paper-based health records to digital formats. Additionally, it evaluated the levels of adoption and the perceived improvements in operational efficiency as reported by key stakeholders. All research activities adhered to ethical guidelines and regulations to ensure compliance and maintain data integrity. 2.2 The research sites The study was conducted in four healthcare facilities within the District of Lusaka, Zambia: Chilenje, Chawama, Kanyama, 1st Level Hospital and Railways Urban Clinic. These facilities were purposefully selected because they provide fingerprint biometric services under the National Health Insurance Management Authority [NHIMA]. NHIMA, a public entity run by the Zambian government, oversees the implementation of national health insurance services, aiming to improve healthcare accessibility and affordability for Zambians. Biometric systems, such as fingerprint identification, are utilised under NHIMA to ensure accurate patient identification, streamline service delivery, and prevent fraudulent claims. Each facility offers medical services, including primary care, emergency care, maternal and child health services, minor surgical procedures, and inpatient care for common illnesses. They serve diverse populations, with catchment areas ranging from 20,000 to 90,000 people. For example, Chawama 1st Level Hospital piloted an ear biometric identification tool, Railways Clinic tested a fingerprint biometric system, while Chilenje and Kanyama 1st Level Hospital integrated fingerprint biometrics as part of their NHIMA services. Biometric systems are used primarily for patient registration, tracking, and verification to ensure efficient delivery of healthcare services. Data for the study was collected over five months, from August to December 2023, focusing on the experiences and perceptions of healthcare workers, Ministry of Health officials, and patients interacting with these systems. This approach provided insights into the operational dynamics, challenges, and perceived benefits of transitioning to digital systems in these healthcare facilities. 2.3 Sampling strategy and participants This study employed a purposive sampling strategy to recruit participants with direct experience using the biometric systems introduced through the National Health Insurance Management Authority [NHIMA]. This strategy facilitated the inclusion of information-rich cases capable of offering comprehensive insights into the transition from paper-based to biometric digital systems in selected healthcare facilities in Lusaka District. Participants were categorised into three key stakeholder groups: Ministry of Health (MoH) officials, healthcare workers [HCWs], and end-users [patients]. The MoH officials [n = 2] consisted of an Information and Website Management Officer and a Principal ICT Officer, whose roles were pivotal in shaping policy and overseeing the implementation of biometric technologies. Healthcare workers [n = 12] included Senior Medical Superintendents, Facility In-Charges, Matrons, NHIMA Registry Clerks, Information Officers, and frontline clinical staff (nurses and doctors), providing operational perspectives from both administrative and service delivery domains. End-users [n = 16] comprised nine outpatient department [OPD] patients (three males, six females) and seven women who accessed maternal care services through the Mother and Child Health [MCH] Unit. Recruitment was conducted on-site. MoH officials were contacted at their offices, healthcare workers were accessed through facility Matrons and OPD in-charges, and patients were approached during routine visits to OPD or MCH services. Participants were included if they had accessed biometric-supported services for primary or maternal healthcare and were willing to participate in face-to-face interviews. Exclusion criteria included a lack of biometric interaction and unwillingness to consent. Sample size adequacy was established through theoretical saturation, whereby data collection continued until no new themes, variations, or insights emerged, indicating that the breadth and depth of the phenomenon had been sufficiently captured [Saunders et al., 2018]. The final sample size of 30 participants was considered sufficient for thematic saturation across all three groups. Table 1 Summary of Participant Demographics 2.4 Trustworthiness To ensure the study's trustworthiness, several strategies were utilised. Credibility was strengthened by engaging with participants for extended periods and having them review and confirm the accuracy of transcriptions and interpretations. Transferability was addressed by providing detailed descriptions of the research context, participants, and procedures, allowing readers to assess the applicability of the findings to other contexts. Dependability was maintained by documenting all research decisions and changes made during the study. Confirmability was ensured through rigorous reflexivity. Researchers actively engaged in continuous self-assessment throughout the study, critically examining their assumptions, biases, and prior knowledge to mitigate potential influences on data collection and analysis. This reflexive approach involved keeping a research diary where personal reflections, methodological decisions, and challenges encountered were recorded, providing transparency in the decision-making process. Additionally, peer debriefing was employed, where colleagues and external experts reviewed the findings, questioning interpretations to reduce the risk of subjective bias. Furthermore, an audit trail was maintained to document all analytical steps, including coding procedures and thematic development, ensuring that findings were rooted in participant narratives rather than researcher perspectives. Triangulation of data sources by cross-referencing insights from MoH officials, healthcare workers, and end-users enhanced confirmability by providing multiple viewpoints on the implementation and impact of biometric systems. These collective measures reinforced the study’s objectivity, ensuring that findings accurately represented the experiences and perspectives of participants rather than being shaped by researcher predispositions [Kelp and Simion, 2023]. 2.5 Data collection methods and tools The research study employed face-to-face semi-structured interviews [Barriball and While, 1994] with end-users [patients], Ministry of Health officials, and healthcare workers to gather in-depth information. This approach involved using open-ended questions [Husain et al., 2012; Züll, 2016] to explore participants’ perspectives on the implementation and impact of biometric systems in healthcare facilities within Lusaka Province. An interview guide with open-ended questions facilitated a two-way conversation, allowing for a thorough exploration of relevant themes. The in-depth interviews included patients who utilised fingerprint biometrics, accessed either through the Maternal Child Health Unit or the Outpatient Department. Across all interviews, the use of open-ended questions enabled a deeper understanding of the participants' experiences and views. The principal investigator and trained research assistants conducted individual in-depth interviews [IDIs] to explore the transition from paper-based to digital systems involving biometric utilisation in healthcare facilities. Interviews with end-users [patients], Ministry of Health officials and healthcare workers were conducted in English and the local language, Chinyanja, depending on participants' preferences. The principal investigator and two trained research assistants provided language assistance during these interviews. This bilingual approach was designed to capture nuanced insights from Ministry of Health officials, healthcare workers, and end-users [patients] while considering linguistic and cultural factors in the research process. Audio recorders were used to conduct face-to-face interviews, each lasting 35 to 65 minutes. The recorded interviews were transcribed verbatim, coded using NVivo version 12, and analysed through an inductive thematic analysis approach. 2.6 Data collection procedure Before conducting the interviews, participants were briefed on the study's objectives, and informed consent was obtained. They were made aware that participation was entirely voluntary, with no financial incentives provided. To ensure confidentiality, pseudonyms were used to protect participants' identities. Importantly, there was no prior relationship between the participants and the research assistants, which helped minimise potential biases and influence on participants’ responses. The research assistants approached the participants as independent researchers, fostering an environment where Ministry of Health officials, healthcare workers, and end-users [patients] could freely share their honest and unfiltered perspectives on the implementation and impact of biometric systems in healthcare facilities. Data were securely stored on a password-protected computer, with access restricted to the principal investigator. Both verbal and written consent were obtained from all participants, and their demographic details were collected using standardised forms. 2.7 Data management and analysis The study employed a thematic analysis approach as the foundation for its data analysis process. Thematic analysis systematically identifies recurring themes, patterns, and insights from the collected data [Riger and Sigurvinsdottir, 2016]. The data gathered through interviews and focus group discussions were carefully transcribed and organised. Following transcription, the data were coded, classified, and grouped into themes reflecting the perspectives, concerns, and experiences of healthcare workers and patients. NVivo version 12 software was utilised to facilitate this process. The resulting themes encompassed a variety of factors influencing the utilisation and adoption of biometric systems, including technical considerations, economic aspects, regulatory compliance, ethical concerns, and operational challenges. 2.8 Ethical considerations The study received ethical approval from the Lusaka Apex Medical University Biomedical Research Ethics Committee [LAMUBREC] [Ref No: 00513–22] and the National Health Research Authority [NHRA] [Ref No: NHRA000007/23/02/2023] before the commencement of data collection. Additionally, permission to conduct the research was obtained from the provincial health office, allowing access to the necessary facilities. Gatekeepers at the Ministry of Health and each selected healthcare facilities granted further permission to carry out the research within their premises. Eligible participants were approached and provided with informed consent documents in both English and Chinyanja. Informed consent was obtained from all participants in both verbal and written forms. To maintain anonymity, participants were assigned pseudonyms and were explicitly informed that their participation was voluntary, with the option to withdraw at any time without repercussions. Throughout the study, stringent confidentiality measures were implemented to safeguard participant privacy and sensitive information. RESULTS Introduction In recent years, the integration of digital technologies into healthcare has become vital, especially in low- and middle-income countries where limited resources can hinder the delivery of efficient services. In Zambia, we are observing a significant shift as healthcare moves from traditional paper-based medical records to more advanced biometric digital systems. This is not just about adopting new technology; it is a transformative step that tackles long-standing problems, enhances the accuracy of patient identification, and ensures better continuity of care. As healthcare facilities in Lusaka begin to implement these biometric systems, it’s important to take a closer look at the real-life experiences of both healthcare providers and patients who are navigating this change. Understanding their stories and perspectives can shed light on the practical challenges they face, the operational adjustments necessary for this new approach, and the cultural dynamics at play. This study uses a phenomenological approach to delve into these experiences, offering valuable insights into the impact of biometric integration in urban Zambian healthcare settings. Transformative shift from paper-based to digital systems The transition from traditional paper-based medical records to biometric digital systems at healthcare facilities in Lusaka has truly changed the game. This shift has tackled some serious inefficiencies that were holding back the delivery of healthcare services. Previously, the old system could be really slow, causing frustrating delays for patients seeking care. However, many participants in the study expressed that the introduction of biometric technology has made a real difference, significantly easing these challenges and improving the overall experience for everyone involved. The old system was time-consuming, and patients often faced delays. Biometrics have addressed these inefficiencies….(IDI/Information and Website Management Officer/Ministry of Health) Participants stated that biometric systems have replaced manual record-keeping with secure digital storage, allowing for faster access to patient data and reducing administrative burdens. With biometrics, all patient information is stored digitally, making it easier to access and manage than paper-based records….(IDI/Matron/Chawama 1st Level Hospital) Enhanced accuracy and continuity of care The introduction of biometric systems in healthcare facilities across Lusaka has truly transformed how patients are identified, which is crucial for delivering safe and effective care. Unlike the old paper-based methods that often suffered from human errors, mix-ups, and duplicates, the new biometric identification, especially through fingerprint recognition, creates a unique and reliable connection to each patient's medical history. This change has been particularly beneficial for managing chronic conditions, where keeping accurate track of patient data over time is so important. Healthcare providers have noted that the biometric system has nearly eliminated the chances of having duplicate or lost records, problems that used to lead to disjointed care and unnecessary repeat tests. Now, being able to access a patient's complete medical history across different facilities has not only made clinical decision-making more informed but has also reduced unnecessary testing, ultimately enhancing both the quality and efficiency of care provided. At Chilenje Hospital, the fingerprint system ensures accurate and secure identification, improving continuity of care by reducing errors and maintaining precise patient records....(Senior Medical Superintendent, Chilenje 1st Level Hospital) With biometric systems, I can access a patient’s complete medical history, even if they have visited other facilities. This helps us avoid duplicating tests and ensures accurate treatment...(IDI/Matron/Railways Urban Clinic) The continuity provided by biometric systems plays a crucial role in how we manage patient care. It allows clinicians to keep track of long-term treatment outcomes and make necessary adjustments to care plans using detailed information. This not only helps in delivering better healthcare but also strengthens the bonds between clinicians and patients. This kind of ongoing support is especially important in busy urban areas like Lusaka, where patients frequently shift between different healthcare facilities. Operational efficiency and patient satisfaction. The shift to biometric-based digital systems has truly transformed how healthcare facilities in Lusaka operate, making a noticeable difference in patient satisfaction. By automating the process of identifying patients and retrieving their records, these systems have taken a lot of the hassle out of administrative tasks that used to slow everything down due to manual data entry and handling paper files. As a result, patients are experiencing quicker service, less crowding in waiting areas, and a more effective use of the time spent by healthcare staff. Healthcare workers have shared how much easier their jobs have become with the biometric system in place. Patient check-ins now happen almost instantly, and accessing medical histories is smooth even during the busiest times. This newfound efficiency not only lifts some of the pressure off the healthcare providers but also helps to alleviate the frustration patients often feel when faced with long wait times or having to repeat their information over and over. With the ability to quickly pull up accurate patient data, consultations can be more focused and productive, leading to an overall better experience for everyone involved. The biometric system has significantly accelerated processes at the clinic. Even during busy times, the staff can efficiently attend to more patients without delays or mix-ups…(End-user (patient), Kanyama 1st Level Hospital) Biometric systems securely store all patient information and make it easily accessible at any time, unlike the limitations of paper records….(IDI/Participant/Chawama 1st Level Hospital) Data-driven decision-making and resource optimisation The digitisation of patient records through biometric systems has not only improved clinical workflows but also empowered healthcare administrators with actionable insights derived from real-time data. By aggregating and analysing patient visit patterns, disease prevalence, and service utilisation rates, administrators are now better equipped to make evidence-based decisions that enhance both operational efficiency and patient outcomes. This data-centric approach has enabled more strategic resource allocation, such as deploying staff to high-demand departments, forecasting medication needs, and identifying service gaps. The ability to visualise trends over time supports proactive planning and policy formulation, moving healthcare management from reactive to predictive. This integration allows for informed decision-making at both the clinical and administrative levels, ultimately improving health service delivery....(IDI/Healthcare Administrator/ Chawama 1st Level Hospital) The shift to digital has really transformed our healthcare spaces for the better. By moving away from bulky paper records, we've been able to free up valuable physical space, making our clinical and administrative areas more efficient and user-friendly. Plus, cutting down on paper has saved us money on printing, storage, and retrieving documents. That’s money we can now put back into enhancing patient care and upgrading our systems. Financial relief and cost-efficiency Participants in the study shared that the introduction of biometric systems in healthcare facilities in Lusaka has made a real difference in how services are delivered and has brought notable economic advantages for both patients and healthcare institutions. Traditionally, many patients had to deal with the ongoing hassle and expense of losing or damaging their medical record books, which often hit low-income individuals the hardest. But with the new biometric systems in place, patient information is securely stored and can be accessed using fingerprint identification. This means no more physical documents to worry about, along with the costs that came with them. The biometric system is nice because even if you lose your medical records card, you won’t lose any important details, and you won’t have to spend money on buying a new book or file....(Participant, Kanyama 1st Level Hospital) From the perspective of institutions, switching to digital records has resulted in significant savings in areas like printing, paper purchases, and physical storage space. These savings give healthcare facilities the opportunity to invest more in vital services, like acquiring medical supplies, providing staff training, and upgrading facilities. Additionally, the smoother administrative processes mean there’s less reliance on clerical support, which helps ensure that operations remain sustainable in the long run. The savings from using biometric systems allow patients to use their money for other needs, like purchasing supplements or other medical items....(IDI/Woman/Kanyama 1st Level Hospital) When we look at the bigger picture, these financial efficiencies really help create a fairer healthcare system for everyone. By cutting out hidden costs and streamlining administrative tasks, biometric systems ensure that the resources we have are better spent on actually improving patient care instead of keeping old systems running. This means that more people can access the care they need, making a real difference in their lives. Building trust through security and equity One of the most significant changes we've seen with the introduction of biometric technology in Lusaka's healthcare system is the renewed trust among patients. People now feel more confident that their personal information is secure, and they believe that everyone has a fair chance to access healthcare services. In the past, many worried about issues like unauthorised access to their medical records and the potential for data loss or fraud, which often left them feeling uneasy about the system, especially in areas with limited resources. However, the rollout of biometric systems has tackled these concerns head-on. By using unique biometric identifiers, patient information is now safely encrypted, ensuring that it can only be accessed by the right people. This has made a real difference in how individuals perceive their healthcare and the integrity of the system. Using biometrics is beneficial as it helps maintain data integrity and prevents fraud and data loss....(IDI/Senior Medical Superintendent/Chilenje 1st Level Hospital) Enhanced security measures have really made a difference, giving patients and healthcare providers peace of mind that their sensitive health information is safe. This creates a culture where accountability and transparency are prioritised, helping everyone feel more confident in the system. With the reliability of these safeguards, there are fewer administrative disputes and mistakes, which in turn boosts the credibility of healthcare institutions. Additionally, biometric systems are playing a key role in ensuring fairness in access to care. Unlike traditional systems that might unintentionally favour individuals with better literacy or more social advantages, biometric identification is fair by nature. Decisions about access to care are based solely on a person's unique biometric data, like a fingerprint. This means that barriers like lost documents, language differences, or the challenges of navigating bureaucracy are less of an issue, making healthcare more accessible for everyone. This system treats everyone equally; your fingerprint is your access, regardless of your background or literacy level....(IDI/Clinician/Railways Urban Clinic) This democratisation of access has been particularly empowering for marginalised populations, including the elderly, women, and individuals with limited formal education. By levelling the playing field, biometric systems contribute to a more inclusive and just healthcare environment, where every patient is recognised and served with dignity. CONCLUSIONS Conclusion In conclusion, the transition from paper-based to biometric digital systems in Lusaka’s primary healthcare facilities has resulted in notable improvements in patient identification, operational efficiency, and healthcare access. While there are still challenges, particularly in rural areas and in overcoming community resistance, the study underscores the potential of biometric systems to revolutionise Zambia’s healthcare sector. To ensure that these systems are sustainable and beneficial in the long term, addressing infrastructure barriers, building community trust through transparency, and ensuring responsible data governance will be essential. CLINICALTRIAL