Evaluating user adaptations and perceptions of OpenELIS in sustaining its implementation in Côte d'Ivoire: A Qualitative Study

Abstract

Background: Sustainability remains one of the most persistent challenges facing digital health interventions in low- and middle-income countries (LMICs). OpenELIS (OE), a laboratory information system introduced across Côte d’Ivoire’s public health laboratories with donor support, offers an opportunity to examine how digital health systems evolve in resource-constrained settings and what factors may shape their long-term adoption and institutionalization. Methods:This qualitative study analyzed stakeholder perspectives on the implementation and sustainability of OE across 37 laboratories in Côte d’Ivoire. In-depth interviews were conducted with laboratory personnel, information technology staff, and other stakeholders involved in OE use. A hybrid inductive-deductive thematic analysis was performed using the Consolidated Framework for Implementation Research (CFIR) and the Dynamic Sustainability Framework (DSF) to guide coding and interpretation. Analytic memoing and reflexivity practices, including a positionality statement, were used throughout the process to ensure rigor. Results:Findings were organized into four interconnected themes: (1) system readiness and infrastructure; (2) leadership and workforce capacity; (3) system adaptation and workflow alignment; and (4) perceptions of sustainability and donor dependency. Participants described how inconsistent infrastructure, informal leadership structures, staff turnover, and limited training disrupted OE implementation. However, adaptive transitions—such as the shift from OE Basic to OE Classic—improved usability and trust. Concerns about future sustainability were prevalent, especially in the absence of national transition plans and institutional ownership. These findings map onto CFIR’s Outer and Inner Setting domains and DSF’s emphasis on the dynamic interplay between intervention, setting, and broader ecological factors. Conclusions:The study highlights the complexity of sustaining donor-funded digital health tools in LMICs. Implementation success does not guarantee long-term sustainability without adequate investment in infrastructure, human capacity, and national ownership. Integrating implementation science frameworks such as CFIR and DSF can support more context-responsive digital health strategies that evolve with systems over time. Lessons from the OE experience in Côte d’Ivoire can inform broader efforts to strengthen digital health sustainability in similar settings.