Implementation of digital tuberculosis information systems: perspectives from 10 high TB burden countries

Tuberculosis (TB) remains a major global health crisis, with 10.8 million people diagnosed annually and 2.7 million cases going undetected in 2023. While TB digital health information systems offer promising solutions for detection and management in low- and middle-income countries, implementation effectiveness varies significantly across health system contexts. However, no studies have systematically examined implementation experiences across multiple high-burden countries using implementation science frameworks, leaving National TB Program (NTP) managers without evidence-based guidance for context-appropriate system selection and deployment strategies. We conducted semi-structured interviews with 15 TB progam partners across 10 high TB burden countries to evaluate digital health system implementation in national TB programs. Semi-structured interviews were used. The data was analyzed using the Consolidated Framework for Implementation Research (CFIR). Systems were assessed for advantages, disadvantages, and implementation challenges, with findings organized across all five CFIR domains to identify policy-relevant implementation success factors. Across the countries, 29 distinct TB information systems were documented with varying implementation success. Key advantages included real-time data availability, patient-level tracking, and care cascade monitoring. Primary disadvantages included internet dependency, limited interoperability, and parallel paper-based requirements. Implementation success was determined by five policy-relevant factors: innovation adaptability, external policy drivers, organizational readiness (health system infrastructure availability), individual champions (tech-savvy staff), and implementation processes. For health policymakers and NTP managers, successful digital TB system implementation requires coordination across key implementation areas rather than technological sophistication alone. Countries should establish collaborative governance frameworks, prioritize contextual adaptation with offline capabilities, cultivate technical champions, and adopt user-centered design approaches. The study provides a practical framework for NTP managers to assess implementation readiness and develop context-appropriate digital health strategies that support health systems strengthening in low- and middle-income countries. Digital tuberculosis (TB) information systems are increasingly being adopted in countries with a high TB burden; however, their successful implementation relies more on the readiness of health systems and alignment with local contexts than on the complexity of the technology itself. Evidence from ten high-burden TB countries indicates that effective implementation hinges on five interrelated factors: adaptability of innovations, supportive policy frameworks, organizational preparedness, usercompetency, and well-structured implementation strategies. Countries that exhibit robust governance, coordinated partnerships, and ongoing domestic funding tend to deliver more reliable data quality andadoption, while those that depend heavily on donor funding or fragmented systems face challenges in scalability. For policymakers and managers of National TB Programs (NTPs), prioritizing assessments of implementation readiness, ensuring offline capabilities, focusing on user-centered design, enhancing capacity, and establishing sustainable financing models are crucial steps to ensure that digital TB systems bolster health infrastructures and aid in achieving TB elimination objectives.