Abstract
BACKGROUND: In low- and middle-income countries, maternal, newborn, and child health face significant challenges due to infrastructure limitations, access disparities, and service delivery inefficiencies. The Sehatmandi mobile health (mHealth) app was deployed in 2018 to address these issues across 189 health facilities in Afghanistan's Bamyan and Badakhshan provinces. This app aims to enhance service provision through real-time data monitoring, improved accountability, and performance-based health system strengthening. OBJECTIVE: This study aims to explore the enablers, challenges, and lessons learned for the sustainability of the Sehatmandi mHealth intervention from the perspective of key stakeholders to inform the future scaling of digital health tools in fragile and resource-constrained settings. METHODS: A qualitative study was conducted between June and July 2024 involving 24 in-depth interviews with stakeholders, including health facility managers, administrators, and high-level decision-makers. Participants were selected using stratified purposive sampling to ensure diverse facility representation. Interviews were conducted in person or virtually by using a semistructured guide, recorded, transcribed and translated into English. Thematic content analysis was performed using NVivo version 11 software. Ethics approval was obtained, and informed consent was secured from all the participants. RESULTS: Stakeholders reported that Sehatmandi improved health system responsiveness by enhancing performance monitoring, accountability, timely reporting, and data-driven decision-making. Offline data entry was identified as a critical feature, enabling data collection in remote areas without internet access and ensuring synchronization when connectivity was resumed. However, several barriers affected the long-term sustainability: poor internet connectivity, electricity shortages,inadequate technical support, and high staff turnover, which disrupted functionality and data quality. Training gaps and insufficient supervision further hampered consistent and effective use. Participants emphasized the need for structured capacity building, regular follow-up, and sustainable funding to maintain the intervention. Integration with national health information systems and alignment with broader digital health strategies were also seen as prerequisites for scaling and institutionalization. CONCLUSIONS: The Sehatmandi mHealth intervention demonstrated enhanced performance monitoring and accountability across health care facilities in Afghanistan's conflict-affected settings. However, for digital health interventions to be sustainable and scalable in low- and middle-income countries, foundational investments in digital infrastructure, continuous training and monitoring, system-level integration, and long-term funding are essential. These findings provide actionable insights for governments, implementers, and donors aiming to strengthen health systems through digital innovation in fragile settings.