This review included studies that applied qualitative, quantitative, and mixed methods to assess barriers and facilitators to the implementation of the IDSR system from the perspective of health workers in Africa. The inclusion criteria were as follows: (1) primary, peer-reviewed, published, or gray literature research evaluating the IDSR system following its alignment with the International Health Regulations (IHR) 2005. Therefore, studies conducted in 2010 onward were included, and the review process was completed on June 30, 2025. (2) The setting is Africa. (3) The intervention of interest was a public health surveillance system guided by the IDSR, as described by the World Health Organization (WHO). The exclusion criteria were as follows: (1) studies that did not report any determinants (barriers or enablers) of IDSR system implementation. (2) Studies not published in English. The review protocol was registered in PROSPERO, with registration number CRD42024571576.

Our review focuses on the perspectives of African health workers.

The primary objective of this systematic review was to identify the barriers associated with the implementation of the IDSR system from the perspective of health workers in Africa. This outcome was based on the findings of studies that evaluated IDSR implementation in African countries that adopted the IDSR guidelines from 2010 or later. The secondary outcomes of this review were facilitators or enablers for the implementation of IDSR systems.

We focused on public health surveillance systems that had been developed based on the IDSR strategy. The IDSR system was launched in Africa as a strategy to strengthen national public health surveillance to effectively detect and respond to health threats (10). Following the revision of the International Health Regulations (IHR) in 2005 by the World Health Assembly, the IDSR guidelines were revised in 2010 to support the implementation of IHR in Africa. Therefore, the core and support functions of the IDSR system, guided by the second (11) and third editions of the IDSR guidelines (12), ensured alignment with the IHR, 2005 (13), which is a legally binding framework aimed at coordinating efforts to prevent, detect, and respond to health threats (14). The key activities of the IDSR system are organized into eight core functions: (1) identification, (2) reporting, (3) analysis and interpretation, (4) investigation and confirmation, (5) preparation, (6) responding, (7) communicating risk, and (8) monitoring, evaluating, supervising, and providing feedback for improvement (12).

Tables 1A–C present a summary of the 37 studies reviewed, categorized by study type, country of implementation, participant groups, research aims, and the frameworks employed. Most of the studies (n = 27) utilized mixed methods approaches, while six employed quantitative methods and five used qualitative methodologies (Table 1A). Geographically, the studies were predominantly conducted in Kenya (n = 6), followed by Uganda, Nigeria (n = 5 each), and Ghana (n = 4). Other countries included the Democratic Republic of Congo (DRC), Ethiopia, Malawi, Liberia, and South Africa, with two studies each, and Sierra Leone, Somalia, South Sudan, Tanzania, Zambia, Zanzibar, and Zimbabwe, with one study each. One study encompassed multiple countries, including the Ivory Coast, Ecuador, Madagascar, Namibia, and the Kingdom of South Arabia, however, our analysis focused on the results reported from African countries, as we focused on the results from Ivory Coast, Madagascar and Namibia (Table 1A).

The participant profiles varied across studies, with surveillance officers being the most frequently involved (n = 24), followed by data clerks and clinicians (n = 15 each), nurses (n = 9), laboratory personnel and community health workers (n = 6 each), in-charge health facilities, and general healthcare workers (n = 5 each). Additional participants included epidemiologists, regional respondents, district management team members, and program focal persons (Table 1A).

In terms of research aims, 18 studies focused on evaluating surveillance systems, whereas 12 aimed to identify barriers and facilitators for the implementation of integrated disease surveillance and response (IDSR) systems. Four studies investigated the existing gaps and challenges, and two assessed the knowledge, perceptions, and practices of surveillance practitioners. Other objectives included evaluating the feasibility of scaling national surveillance systems and comparing the surveillance system performance with laboratory data (Table 1B).

The IDSR system faces several implementation challenges related to innovation characteristics, including low adaptability to new information needs, complexity that hinders understanding and task completion, limited scope in disease coverage and case definitions, lack of integration across disease programs, and relative (dis)advantage that IDSR is inferior to systems such as laboratory surveillance systems. These findings are in line with the previous literature that innovation adaptability, complexity, design, and relative advantage influence innovation implementation in the health sector (22, 23). Unlike similar systematic reviews of IDSR that largely emphasized surveillance attributes and descriptive implementation (5, 16), the current study applied CFIR to conceptualize IDSR as an innovation, thereby synthesizing innovation-related characteristics that were previously reported but not analytically foregrounded as implementation barriers. These issues collectively impede the effectiveness of the system in performing the IDSR roles. To enhance IDSR implementation, it is crucial to address these challenges through system redesign, improved training programs, better integration of disease reporting across programs, expansion of the scope of the system, and increased adaptability to evolving health priorities. These improvements would boost the capability of the system to meet the current and future public health surveillance needs.

The outer setting domain significantly impedes surveillance activities in health facilities. Key barriers found in our study include undue donor influence (External Pressure), insufficient funding (financing), negative stakeholder perceptions of the IDSR system (Local Attitudes), the absence of data-sharing frameworks, and non-compliance with international case confirmation standards (Policies & Laws). These findings corroborate previous research (24–27) that highlighted the impact of external pressure, lack of policy or inadequate policy adherence, and lack of financial support on the implementation of health system innovation. However, this study uniquely identified local attitudes as a barrier, possibly because of the use of the updated CFIR (19). This distinction underscores the importance of employing the current analytical framework to comprehensively assess the implementation challenges in healthcare settings.

The lack of available resources for IDSR implementation, such as funding, materials and equipment, transport, and space, was identified as a crucial barrier. This resonates with previous literature, indicating the depth of under-resourcing of health facilities for IDSR-related activities (28, 29). A lack of materials and equipment, space, and transportation may arise from inadequate funding.

Lack of access to knowledge and information for the staff, such as training, feedback, supervision, and IDSR information materials, was identified as another key barrier. This finding confirms those of prior studies, highlighting the need to improve access to knowledge and information for staff (3, 30, 31). A lack of available resources may affect access to knowledge and information, which in turn limits the staff's ability to perform IDSR functions.

Challenges with health facilities' structural characteristics are among the barriers identified in this review. Deficits in Information Technology Infrastructure, including the absence of interoperability of data systems, use of old data systems/software, unstable electronic data systems, and poor network signals, result in inefficient electronic data systems that may lead to reliance on manual and paper-based systems (31–34). Other studies highlighted limitations such as health facilities' work infrastructure resulting from shortage of staff, high staff turnover, industrial action, lack of training, and lack of designated IDSR focal persons, which negatively affect the adoption, fidelity, and sustenance of IDSR as an innovation (16, 30, 35). These challenges may affect the effective implementation of IDSR, resulting in poor surveillance and case detection.

Problems with communication within the health facility were also an important barrier to the implementation of IDSR. The lack of reporting systems, inadequate feedback mechanisms, and lack of communication between surveillance and HMIS officers posed problems with the implementation process. This corroborates previous studies and calls for the need to improve health facility communication, especially among staff, to improve the implementation of IDSR. For instance, in Malawi, one study reported poor timeliness in providing monthly and weekly reports in regards to surveillance (35). Other studies have shown lack of reporting forms, inadequate reporting tools, and internet connectivity as hindrances to effective communication for enhancing implementation of IDR (28, 36).

Deficits in mission alignment, as exemplified by studies highlighting substantial reporting burden, workload, and competing tasks, have been identified as significant barriers. This observation corroborates findings from previous studies that reported that the misalignment of innovation with organizational goals adversely affects the implementation of innovation (37–39). Perceived incompatibility with organizational workflows results in resistance among implementers and a lack of leadership support, ultimately hindering adoption. Another barrier was insufficient tension for change, as staff assigned low priority to disease surveillance activities, perceiving them as redundant. This observation is consistent with the findings of Lewis et al., who noted that primary care staff deprioritized a new care model, believing they were already providing high-quality care (40). Therefore, healthcare personnel may not perceive the necessity of engaging in IDSR functions and view them as duplicative. This perception could result from the existence of multiple reporting systems for disease programs and Health Management Information Systems (HMIS). Culture among health workers in which IDSR functions as a vertical program surfaced as another barrier. Prior research has demonstrated that culture as a barrier limits trust, information sharing, staff involvement in implementation improvement, low participation in decision-making, and resistance to change (41–43). These factors may hinder the successful implementation of IDSR. It was also revealed that limitations in partnerships and connections between district health authorities and private health facilities lead to difficulties in obtaining data from private health facilities. This resonates with studies in Kenya that demonstrated that weak interdepartmental communication and lack of shared platforms can impede coordination and innovation implementation (40, 44, 45). Health authorities must employ strategies aimed at strengthening partnerships and connections with the private sector through improved communication and coordination. This may enhance data sharing for implementation, thereby creating an enabling environment to support the implementation of IDSR. Similarly, inadequate relational connections with other health-relevant sectors were another barrier to the implementation of IDSR. Previous research has also shown that weak relational and professional connections among key stakeholders may affect the implementation of IDSR activities (46–48).

We identify barriers related to innovation deliverers and facilitators. The lack of capability and motivation among the staff posed a significant challenge in the implementation of IDSR. Furthermore, the review highlighted that a lack of knowledge and skills to perform surveillance functions, such as data management and analysis, supervision, feedback, and knowledge about case definitions and guidelines, affected the ability of staff to effectively implement the IDSR system. Similar results were reported in other studies where lack of knowledge among the health workers in using surveillance technologies, data management, surveillance and reporting of notifiable diseases hindered the implementation of surveillance programs (3, 49, 50). Knowledge deficits may result in the poor detection of cases, under-reporting, and poor responses to public health emergencies.

It was also revealed that lack of motivation had an impact on IDSR performance. This has resulted in inconsistent supervision from implementation facilitators, inadequate implementation of training programs for surveillance deliverers, delays in sending data to the next higher level in time, lack of commitment to conduct community-based and active surveillance, carryout response activities, proper management of data, and low acceptance of the IDSR system. Furthermore, lack of motivation contributed to poor adherence to IDSR materials, especially guidelines and case definitions, under-recognition of priority diseases, underutilization of the laboratory for confirmation of cases, and poor data and reporting completeness. Other studies have shown similar findings, where a lack of motivation was observed among supervisors, as they were not motivated to perform supervisory roles (34, 51). This may compromise the frequency of supervision, adherence to guidelines, and implementation of enforcement measures for IDSR activities. Additionally, lack of motivation has been reported in other studies as a contributing factor to poor participation among employees in surveillance programmes (3, 16). It is evident that a lack of motivational strategies for HCWs may hinder the implementation of IDSR, as demotivated staff may not feel attracted to take part in IDSR activities such as data collection, reporting, case detection, and others.

Limitations in engaging implementation deliverers, planning, and teaming were identified as barriers to the implementation of IDSR. It was found that lack of engagement with implementation deliverers, such as those in private health facilities and other one-health-related sectors (animal and environmental health sectors), was a threat to the effective implementation of IDSR. This is in line with previous studies, in which CFIR was used to understand the implementation of health information technologies. These studies found that implementation was facing challenges due to the lack of engagement of stakeholders such as various health care practitioners, in the implementation process, as they were being left out in the initiation process as well as implementation activities (52, 53). Deficits in planning were also reported in previous studies, which highlighted a lack of planning, such as the absence of a strategic plan, lack of need-based planning, and lack of a roadmap for implementation (53, 54). These factors hindered the effective implementation of innovations to support public health interventions. The review also revealed a lack of teaming, such as the absence of technical working groups, as well as rapid response teams in the implementation process, as a barrier to the implementation of IDSR. Previous research highlighted the significance of teaming where various health professionals, leaders, and designated personnel come together to facilitate IDSR implementation (55). Teaming may play a role in ensuring that relevant individuals with skills are incorporated and assigned responsibilities accordingly to enhance timely response, reporting, and case detection through IDSR.

The study found that the staff's perception of the lack of usefulness (Innovation Outcomes) of the IDSR system was a barrier. This perception might have an impact on the staff's motivation to perform the IDSR function with fidelity, thereby affecting its implementation. This resonates with prior research, in which some health workers expressed reservations regarding the flexibility of the system to adapt to new demands and changing conditions, making them feel that the system was less useful for surveillance under various conditions (56).

This study demonstrated that a perceived strong evidence base for the IDSR correlates with enhanced performance in detecting and reporting public health threats, with data analysis identified as a facilitating factor. This finding aligns with previous research that examined the barriers to and facilitators of the implementation of community-based healthcare innovations (57, 58). These studies indicate that the perception of a strong evidence base supporting the efficacy of innovations serves as a facilitator for implementation (57, 58). It has been observed that such a perception motivates staff and leadership, fosters trust, and enhances the adoption of innovation (57, 58).

The occurrence of Critical Incidents, such as COVID-19, posed an opportunity to strengthen the health system and provide a good implementation climate for IDSR implementation. It is evident that the emergence of COVID-19 was a wakeup call to invest and strengthen surveillance programs to prevent future outbreaks and ensure timely detection and response to emerging public health threats. This resonates well with prior studies, which highlighted that COVID-19 made countries recognize their vulnerability to public health emergencies, which forced the authorities to implement surveillance programs, allocate surveillance resources toward surveillance, and implement capacity-building programs (59–61). This suggests that conditions such as COVID-19 were facilitators of implementation, as well as strengthening surveillance programs aimed at preventing future emergencies.

Local Conditions, such as foundations from other initiatives, have emerged as facilitators of the implementation of IDSR. For instance, the existing foundation of the EWARN system was identified as a facilitator to improve the implementation of IDSR, as it facilitated case detection as well as reporting during public emergencies. Similar results were reported in a study conducted in Somalia and Syria, where the existing EWARN system played a role in facilitating COVID-19 reporting, signifying its flexibility to accommodate the integration of reportable diseases (62, 63). This enhanced timeliness, disease, flexibility, alert verification, and responding to emerging outbreaks.

It was further revealed that Partnerships and Connections are essential for enhancing surveillance initiatives. This partnership enhanced collaboration among healthcare facilities with others who provided financial and other forms of support for enhancing surveillance. This was confirmed in other studies that highlighted the significant role played by partners such as the WHO, who were actively involved in supporting surveillance programs through funding support, capacity building, and providing resources in response to public health emergencies (64, 65). The presence of policies and laws was an enabler to the implementation of the IDSR in most countries, as it enhanced the standard procedures as well as the approach to surveillance. For instance, some studies have reported the presence of technical guidelines for supporting IDSR as a tool for enhancing surveillance programs (3, 16). The guidelines provide the standards for case detection, data management, case reporting as well as response to public emergencies, which enhances surveillance (3–5, 34).

Our study found that various issues in the inner setting domain of the CFIR facilitated IDSR implementation. Access to knowledge and information was found to be an enabler for the implementation of IDSR. Some studies have reported the availability of guidelines that are essential sources of knowledge for guiding health workers and other individuals in surveillance programs.

Other studies have highlighted the availability of essential resources as an enabler for the implementation of IDSR. These findings stress that the presence of a supportive infrastructure is essential for strengthening surveillance activities. Resources such as information technology infrastructure, mobile phones, computers, internet connectivity, and data management tools, are enablers of timely data reporting and communication within the surveillance system. Additionally, the availability of IDSR equipment, such as technical guidelines, case definition manuals, and reporting forms, is essential to ensure consistency in case identification and reporting. Another form of resource identified as an enabler for the implementation of IDSR is human resources. These findings corroborate with previous evidence, where it was found that the availability of laboratory infrastructure with diagnostic tools and integration of information and communication technology were facilitators of IDSR implementation (3, 32). Furthermore, mobile phones are available using short-message services (32). These findings are consistent with previous evidence, where it was found that the availability of laboratory infrastructure with diagnostic tools, integration of information and communication technology, availability of mobile phones, and short message services (32).

The availability of trained healthcare workers, surveillance officers, and data clerks facilitated the execution of routine surveillance tasks, such as data collection, analysis, reporting, and case detection. For instance, other studies have highlighted the significance of the availability of adequate human resources with expertise as an enabling achievement of the goals of IDSR, as this allows effectiveness in case detection as well as reporting (3, 66).

The review found that individuals' capabilities in performing various roles in IDSR were an influencing factor in its implementation. The capabilities reported include knowledge of case definitions, alert thresholds, and capabilities in using mobile gadgets. These capabilities may allow individuals to effectively detect cases, reports, and analyze data. Similar results were reported in other studies where it was noted that health workers were able to effectively use mobile technologies to report COVID-19 cases and share public health information (67, 68). The current study also found that motivation among individuals involved in IDSR is essential for enhancing its implementation. Similar findings were reported in another study which revealed that community health workers were motivated to take an active role in community health surveillance, as they were motivated through management support, training (54). Motivation among health workers is one of the key drivers that enhances support for public health responses (32, 33, 69). Individual high-level leaders further enhance the implementation of surveillance programmes. The personal commitment of leaders to supervising, monitoring, and managing IDSR programs may result in fruitful results. Previous research highlighted a significant role of high-level leaders, through support in resource planning and allocation, which enhances surveillance during public health emergencies (67, 70).

Tailoring Strategies that involve identifying strategies to overcome barriers to implementation have also emerged as facilitators. Among the tailoring strategies implemented to overcome barriers to the implementation of IDSR include the use of community health volunteers to take part in case detection as well as reporting. Other studies reported similar results, where community case management teams played an important role in community case detection as well as reporting (71, 72). This strategy helps address barriers such as shortage of staff, delayed detection, and notification of cases, as community volunteers take part in community-specific surveillance initiatives. Additionally, teaming and planning were found to enhance the implementation of IDSR. Some studies have shown the collaboration and engagement of various professionals, rapid response team and well-established structure with dedicated staff as an essential strategy for enhancing IDSR implementation (68, 69, 72). This may ensure sustainability of surveillance programs in healthcare facilities.

A distinct Actual Implementation Outcome, adoption of the IDSR, for implementing public health surveillance systems in health facilities, was identified as another facilitator. It was found that a number of facilities adopted and championed the implementation of IDSR, where responsible personnel were identified and some supportive resources were allocated. This corroborates prior research that highlighted that several healthcare facilities adopted IDSR strategy for implementing public health surveillance, where guidelines and protocols were also developed to facilitate surveillance programs (49, 73). This created an environment that would allow effective implementation of surveillance initiatives. Evidence from the review has further shown that the outcomes as well as the impact of the IDSR were enabling factors in its adoption as well as implementation. The significance of the IDSR in improving case detection, enhancing timely response to outbreaks as well as playing a role in strengthening community surveillance, signifies its positive outcomes that may facilitate its adoption and implementation (4, 49, 72).

The interaction between access to knowledge and information and individual capability highlights the importance of sustained capacity-building approaches that extend beyond once-off training. Likewise, the observed interaction between communication and motivation underscores the critical role of feedback mechanisms as a cross-cutting determinant of engagement. Strengthening communication and feedback may therefore represent a high-leverage strategy for reinforcing motivation and improving reporting practices. Interactions between innovation design and work infrastructure further illustrate how system design choices can unintentionally increase workload and undermine usability, particularly in contexts characterized by parallel reporting systems and limited digital infrastructure. Addressing such design-infrastructure misalignments is essential to reduce reporting burden and support sustained adoption.

The CFIR construct Available Resources was identified as a key barrier, manifesting as limited funding, logistics and staffing. According to CFIR–ERIC guidance operationalised through the CFIR-ERIC matching tool (19), this barrier aligns with implementation strategies such as access new funding, develop formal implementation blueprint, and change physical equipment. In practice, these strategies could be operationalised through context-specific actions, thereby addressing the underlying mechanisms limiting implementation.