Community health workers (CHWs) are of paramount importance in bringing lifesaving services to those who need such services the most (1–4). One crucial service CHWs provide is frontline implementation of mass health campaigns, including immunization (5). However, countries face challenges of retaining CHWs because of their low pay on the one hand (5, 6) and the challenges they face in receiving their payment, on the other. These challenges include exploitation by some supervisors, long journeys or prolonged waiting times to collect payments, and unreliable payments (7–9). Moreover, when CHWs and those paying them are not in the same place location, it necessitates travelling with large amounts of cash which is risky (7). In addition, cash payment to frontline workers during mass health campaigns presents other significant operational challenges (4, 10, 11).

Digital payment systems are widely used globally but are still in early stages in Africa for paying CHWs. Digital payments facilitate an efficient, secure and transparent payment system. Most African countries are now experimenting digital payments for frontline workers. Digital financial services (DFS), enable financial transactions via mobile phones, the internet, or bank cards, offer a promising solution to these challenges. DFS facilitate efficient, secure and transparent transactions (12). They also have the potential to reduce financial transaction costs (7) and improve access to formal financial services, especially for users and beneficiaries in remote areas (13).

DFS in the health sector are referred to as digital health payments (DHPs). These are electronically facilitated payments made to health workers. DHPs are known to save time and reduce costs by minimizing the need for physical payment by cash. They also help curb theft by directly transferring funds from financial institutions to beneficiaries, bypassing intermediaries who could divert funds (7, 14). Moreover, DHPs have been shown to improve the motivation and satisfaction of CHWs, leading to better outcomes in the health campaigns they carry out. Various digital platforms, such as mobile money, bank transfers, debit cards, and electronic money, are used for DHPs (15).

Due to these benefits, DHPs are increasingly being adopted to pay CHWs and other frontline workers in mass health campaigns, particularly in immunization (13). Successful adoption of DHP in Africa has been reported in Burkina Faso, Democratic Republic of Congo, Gambia, Liberia, Nigeria, Republic of Congo, Sierra Leone, Somalia, and South Sudan (10, 16). In collaboration with WHO, donors, and national governments, and in partnership with local banks and mobile telephone companies, CHWs have been paid successfully (10). In fact, DHP is the only payment method available in politically fragile states such as Somalia where conventional financial systems are unavailable (17, 18).

However, DHPs for CHWs are still designed and implemented in a fragmented way, and large-scale use of DHPs in sub-Saharan Africa remains limited (19, 20). Besides, experiences of governments and national agencies in adopting and scaling up DHPs for CHWs are hardly known. Real-life experiences of CHWs and other beneficiaries using DHP system are scarcely described in literature, leaving gaps in knowledge. Additionally, there is little insight into the nature and levels of readiness and capacity of national stakeholders to adopt DHP systems.

Addressing these gaps is critical for enabling African countries to effectively leverage DHPs, ensuring equitable, timely, and transparent payments for CHWs, and in improving the overall impact of primary health care campaigns (21–23). Increasingly, donors and governments are mandating the use of DHPs as a standard method of paying CHWs (24–27). Consequently, it is crucial to gather in-depth information about how DHP systems function, the challenges encountered, best practices and the readiness and strategies to build sustainable DHP payment systems for CHWs and other frontline workers.

The key research question is: how ready are Benin and Uganda to adopt digital payment of health workers? And what are the implications for adopting DHP? Therefore, the aim of this study was to assess nationwide readiness to adopt digital payment systems for CHWs and other frontline workers. The study objectives were to understand the experiences of CHWs and payers of DHP, to assess readiness to adopt digital payment systems nationwide, and to design a protocol and strategy to adopt digital payment systems for CHWs and other frontline workers.

Digital payment CHWS is a recent development. Not much is known or written on it. Thus, as part of the methodology, we sought to understand DHP in a wider context. Literature review guided us to develop the rest of the methodology. We searched and reviewed both general literature and official documents. We made web searches in PubMed, Scopus, and other social science databases using the keywords:

“Digital Health Payment” AND “Africa South of the Sahara” AND “Immunization”

The study used two key concepts: Readiness and Appreciative Inquiry (AI). “Readiness” is a social science concept that refers to the preparedness of an individual or group to undertake an action or bring about a desired change (30, 31). An individual's readiness is their level of awareness, acceptance, capability, knowledge and level of training to accomplish a task in order to cause change. An organization's readiness is a shared resolve by its members and stakeholders to implement an agreed or desired change (32–34).

Appreciative Inquiry (AI) identifies alternative problem-solving approaches, leads to designing effective strategic plans, and elaborates step-wise protocols of implementation. It focuses on what works, rather than trying to fix what does not. AI offers an approach for evaluating and envisioning future initiatives based on existing best practices (31). It has four components known as the 4Ds: discovery (research), dream (vision and strategy), design, and destiny (sustainability and scaling up). It helps to identify inputs, processes and context of experiments, so as to discover factors for successful adoption, scale-up and sustainability of programs (32, 33).

The conceptual framework (Figure 1) consists of three parts. Part one has experiences, challenges, opportunities and gender. The second part of the study consists of readiness of individuals, systems and organizations. And the third part is the construction of the adoption protocol and strategy.

This was a qualitative exploratory case study. The case was the implementation of DHP, with a specific focus on mobile money payment, and immunization and other mass health campaigns. Mobile payments are the most widely adopted form of DHPs in African countries.

The study was conducted in Benin and Uganda, chosen for ongoing DHP initiatives and contrasting contexts in terms of geographic location (West and East Africa, respectively), socio-economic and cultural differences and different stages of nationwide DHP. In Benin, the research was carried out in two health districts and the capital city, where key national institutions are based. In Uganda, the study was done in two health districts, urban and peri-urban, close to the capital city. Easy access, cost and convenience were considered in the selection of sites.

While CHWs provided in-depth information about DHP, other categories of respondents provided information to mitigate against CHWs' possible recall bias. These were supervisors, managers, payers, and GSM/MNO operators. In addition, these categories of participants provided other specialized information which only they could provide. Altogether 49 interviews were held. These 49 participants were selected as follows: at least one CHW from each location, at least one GSM/MNO manager from each country, at least one payer from each of the different organizations or programs, and at least one national supervisor or manager. Table 2 below shows the different categories of participants interviewed.

We selected two organizations or programs per country. These organizations were purposively selected because they were already practicing DHP, and were readily available. The main selection criterion for the study participants was their involvement in DHP process or being a beneficiary of it. In Benin we selected the national agency for primary health care, which is responsible for immunization and malaria. In Uganda, organizations selected were Uganda National Expanded Program on Immunization (UNEPI), Family Health International (FHI 360) and Living Goods. Under them were a range of partner institutions which provided study participants.

As much as possible equal numbers of male and female respondents were selected, to obtain a gender perspective. Through a pre-visit, managers, supervisors, digital service providers, and payers were identified prior to the main study. CHWs who had been paid at least twice using DHP system were selected, balancing CHWs from urban areas with those from rural areas. CHWs who were in active service and those who had left the service were also selected for comparison.

Key informant interviews (KIIs) were conducted with national and district managers, Mobile Network Operators (MNOs), payers and supervisors. Respondents were chosen purposively, based on expertise in DHPs for CHWs. In-depth Interviews (IDIs) were conducted with CHWs. In total, 49 interviews were conducted: 27 IDIs (12 in Benin and 15 in Uganda) and 22 KIIs (13 in Benin and 9 in Uganda).

Interview questions were on DHP process, respondents' awareness of DHP, and their preparedness, willingness, acceptance, knowledge, capability and training related to digital payments. We probed for answers on infrastructure, political will and support, regulation, the digital ecosystem, plans for expansion and sustainability, existing payment policies; and benefits, opportunities, benefits and challenges of DHP.

Recorded interviews were transcribed into Microsoft Word by qualified transcribers. Data was exported and coded. A thematic content analysis approach (35) was used to analyze relevant and important themes. Themes were coded and classified. A gender-lens was also used throughout data analysis to identify gender specificity in users' experiences, challenges and readiness for DHP, and to determine gender-specific actions needed in a DHP system. Readiness was analyzed at three levels: individual, organizational, and national.

Researchers rated readiness as high, medium or low, based on the level of perceived performance, the level of need for improvement, and severity of challenges. High readiness was when a dimension was functioning well, with little to no need for improvement. Medium readiness was when positive aspects were identified, but with room for improvement. Low readiness was when significant challenges were present, requiring substantial improvement. See Table 3. Based on the findings, a framework was made to help plan how to transform current DHP practices into a national, inclusive and sustainable digital payment systems.

Table 4 presents a synthesis of key findings and references from literature. DHP was mentioned under five themes: primary health care (PHC), CHWs, health financing, digital economy, gender and digital payments, readiness for DHP and DHP systems.

Here are the key points in literature. Digital payments are reported as increasing transparency and provider satisfaction. This is reflected by 78% of CHWs who are satisfied with DHP. DHP is enabled mainly by technology and by the willingness of people: leaders, payers and payees. CHW performance in their work depends on the reliable payment systems. Successful CHW programs also depend on a strong PHC system. Currently a good number of CHWs are volunteers in PHC, but they cannot always be relied on. Yet, International Labor Organization (ILO) has made it imperative for all CHWs to be paid regularly, in compliance with international labor law. Payment and non-payment of CHWs is dependent on available financing, governed by public policy. The new approach to revitalized PHC proposes a people centered health financing. This type of financing has 4 attributes: public funding, pooling of funds, equity and based on people's needs.

Currently, there is a momentum of a global push for cashless economies. The key pillars of a digital or cashless economy include e-governance, e-education and e-commerce. In digital payments, women are often hindered by limited access to phones, to salaried work, and by low economic status. The common challenges in digital payments include unreliable internet and electricity, delay in payment, high charges, variations in payee details, lack of feedback, and fragmented legal framework. However, there are opportunities for establishing and improving DHPs. These include high political will, a variety of banking services, and increasing digital economy.

Peer learning is imperative in a rapidly changing technological world. Synergy, synchrony and interoperability of technologies are critical. There is need for dispute resolution systems in digital payments. Network coverage and reliability are critical. To adopt DHP the following generic steps have been proposed: planning, making contracts with key players, elaborating the payment system, establishing accounts management procedures, registration of payees, testing the system on the staff, testing the system on beneficiaries, and then scaling up.

Experiences generated from CHWs were collaborated by network operators, program managers/supervisors, and payers. Themes generated from qualitative data analysis were as follows:

Convenience of digital payment

In most cases, beneficiaries received full payment. In some cases, CHWs did not receive the full amount they were expecting. There were also perplexing and unexplained variations in payments, after having done the same amount of work. In other cases, beneficiaries did not often receive their payment at all. Some CHWs would get unexplained payments. Sometimes CHWs don't tell the truth about receiving money. Here are some of the responses:

The inadequate or absent infrastructure, systems and policy was captured from a Benin government official as follows:

While CHWs provided in-depth information about DHP, other categories of respondents provided information to mitigate against CHWs possible recall bias. These were supervisors, managers, payers, GSM/MNO operators.

Table 6 and Figure 2 summarize and compare DHP readiness of the two countries.

Table 7 presents a synthesis of key findings from literature and its interpretation in relation to DHPs. DHP was mentioned under five themes: primary health care (PHC), CHWs, health financing, digital economy, gender and digital payments, readiness for DHP and DHP systems/protocols.

In designing a protocol for DHP adoption and implementation, we considered inputs from DHP readiness assessment, which are: infrastructure, institutions, training and systems. We also considered DHP establishment and operational processes of the payment system. Finally, we considered DHP outputs of immediate results from process activities, and outcomes as the desired results. The outcomes considered included security and safety of payment, CHW satisfaction and retention, health care coverage and improvement. Cross-cutting elements of the prototype include gender, leadership, policy and public awareness. See Table 8.

Based on Appreciative Inquiry's 4Ds (Discovery, Dream, Design and Destiny) an equivalent framework (consisting of Vision, Mission, Goals, and Strategies in the planning terminology) was imputed. A DHP adoption strategy is in Table 9. There is evidence that DHP is desirable and a trending phenomenon. The mission is to improve CHW financing and motivation to revitalize PHC towards universal health coverage. The goal is to set up a system that is digitized, integrated, gender-sensitive and sustainable. The strategies are to digitalize PHC, set up common financing units for CHWs, ensure interoperable technologies across board, and improve CHW pay level and payment system.

One strength of this study is that it enabled us to understand the DHP experiences of CHWs. The value of the study the estimation of the current levels of readiness and in developing frameworks for a protocol and strategy for DHP adoption. The study has provided leads to what needs to be further researched and improved. The limitation of this study is that it was a qualitative study of only two countries. Thus, future studies on CHWs' mobile payment experiences could include direct and measurable observations of the payment process. There is need to corroborate study findings with actual payment records to identify payment failures and successes.