Presentation (CTI)

OBJECTIVES: Informal, self-initiated mobile phone use by frontline health workers is widespread across low- and middle-income countries but remains largely invisible to digital-health policy and health-system planning. This study generated real-world evidence on how informal mobile communication shapes service-delivery processes, coordination, and workforce burden within disease-control programmes in Enugu State, Nigeria.
METHODS: Convergent mixed methods were applied across five disease programmes in 13 facilities, combining surveys of 128 health workers, logistic regression, interviews, FGDs, and process-tracing of 200+ mobile-enabled workflow episodes to identify causal mechanisms.
RESULTS: Informal mobile-phone use was ubiquitous and routinised across programmes, functioning as the primary coordination channel for patient tracing, referrals, laboratory communication, emergency escalation, and reporting. Process tracing demonstrated consistent mechanisms whereby phone calls, SMS, and WhatsApp messaging compressed referral intervals, expedited laboratory decision-making, and reduced missed appointments. It restored continuity of care—often achieving in minutes what formal systems required days to deliver. Regression analysis identified performance expectancy and facilitating conditions as significant predictors of high-intensity informal use, confirming that workers adopt personal phones when they directly improve task performance and compensate for infrastructural gaps. However, informal mobile use imposed substantial burdens: average monthly out-of-pocket expenditure on airtime, data, and device maintenance ranged from ₦3,950 to ₦5,000, with a pro-poor concentration index (-0.051) indicating disproportionate financial burden on lower-cadre workers. Temporal and workflow burdens included after-hours communication, task interruptions, and cognitive strain.
CONCLUSIONS: Informal mobile-phone use functions as a de-facto digital infrastructure sustaining disease-control service delivery in real-world settings. While it enhances timeliness and coordination, it shifts financial and workload costs onto frontline workers. Digital-health and service-delivery policies must formally recognise, integrate, and finance frontline mobile practices to improve efficiency, equity, and system sustainability.