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Matthysetal. BMC Primary Care (2025) 26:113
https://doi.org/10.1186/s12875-025-02818-w
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BMC Primary Care
Development andimplementation
ofadigital clinical decision support system
toincrease thequality ofprimary healthcare
delivery inarefugee setting inChad
B. Matthys1,5*, N. Monnier1,5, M. Ngaradoumadji2, Y. Toubangue2, P. Delcroix1,5, M. Pereira1,5, T. Schmitz1,5,
J. Armour-Marshall3, M. Zahorka1,5, K. Sugimoto4, M. Léchenne1,5, D. Revault1,5, K. Wyss1,5 and A. Montolnan1,5
Abstract
Background Digital clinical decision support systems (CDSS) enhance the quality of primary healthcare service
delivery for vulnerable populations in resource-limited settings. This improvement occurs by strengthening health-
care providers’ clinical skills and enabling them to operate more independently while adhering to standard treatment
guidelines. From January 2019 to June 2023, we developed and implemented a digital, tablet-based CDSS for children
aged 2–59 months. The phases of development, validation, and implementation, as well as lessons learnt and bottle-
necks requiring attention, are analysed.
Methods The project was carried out in three primary healthcare facilities within a health district in southern Chad,
covering a population of 48,000, which includes a significant number of refugees from the Central African Republic.
The intended end users were nurses, nurse assistants, and midwives, with supervision provided by health district
teams.
Results The CDSS, based on the WHO’s Integrated Management of Childhood Illness (IMCI) and national guidelines,
was tailored to the context of available resources and epidemiological patterns. From the outset, the active involve-
ment of a diverse group of local, national, and international technical stakeholders (clinicians, information and com-
munication technology (ICT) specialists, health workers, and district health authorities) facilitated mutual knowledge
sharing and product co-creation processes. The CDSS was adapted to the local context, which enhanced local owner-
ship. However, its complexity requires significant effort from clinicians and ICT specialists for development and valida-
tion. Additionally, health centres must rely on a technical infrastructure (electricity, internet connection, and server
solutions).
Conclusions From the outset, a participatory approach involving key stakeholders from the local to the national
level of the health system significantly contributed to the successful development and implementation of the CDSS.
The sustainability of such an intervention necessitates ongoing long-term commitment. This includes establishing
and maintaining the infrastructure, ensuring continuous human resources and technical expertise for implementation
and quality assurance, and updating content to reflect advancements in clinical medicine.
*Correspondence:
B. Matthys
barbara.matthys@swisstph.ch
Full list of author information is available at the end of the article
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Matthysetal. BMC Primary Care (2025) 26:113
Keywords Clinical decision support system (CDSS), Integrated management of childhood illnesses (IMCI), Resource-
constrained settings, Refugees, Primary healthcare, Chad
Background
Healthcare inresource‑constrained settings
withahumanitarian context
e quality of healthcare and service delivery in
resource-constrained settings is challenging due to a pau-
city of skilled health workers coupled with poor medical
infrastructure and limited essential equipment, diagnos-
tic capacity, and supply issues [1]. Conflicts marked by
an influx of refugees and insufficient functionality of
primary healthcare (PHC) services pose additional con-
straints requiring innovative and agile solutions to sup-
port healthcare delivery and ensure equity between the
refugee and host area populations [2]. Despite a common
vision of providing access to quality healthcare services
to all populations in need, intervention principles differ
between national health systems and humanitarian care
providers in terms of policies, implementation modali-
ties, and duration [2, 3]. Standard healthcare services and
programs for the control and elimination of diseases (e.g.,
vaccination and deworming) in areas of conflict may be
disrupted or inaccessible for refugee populations, which
negatively affects access and ultimately health outcomes.
e provision of quality healthcare delivery to large num-
bers of people in need calls for integrated approaches and
strategies supporting and strengthening healthcare work-
ers’ capacity to detect, manage, and prevent health issues
in primary healthcare [4].
Clinical decision‑making
A series of WHO guidelines on the integrated manage-
ment of childhood illness (IMCI) [5], maternal and new-
born care [6, 7], and children and adolescents in health
facilities [8] were produced to improve the quality of care
at the PHC level. However, adherence to IMCI guidelines
by health workers may be rather poor in practice [9–12].
Clinical decision support systems (CDSS) are “digit-
ised job aids that combine an individual’s health infor-
mation with the health worker’s knowledge and clinical
protocols to assist health workers in making diagnosis
and treatment decisions” [13]. CDSS offer promising
agile solutions that play an increasingly significant role
in improving the quality and comprehensiveness of pri-
mary healthcare service delivery and health outcomes for
underserved populations [14]. e “Practical Approach
to Care Kit (PACK)” is an example of a simplified and
streamlined paper-based clinical decision support tool
to support PHC providers. e tool was developed,
implemented, and evaluated in South Africa and scaled
up to various other countries. It is tailored to end users
with different levels of training (clinicians, nurses, and
nurse assistants) and is updated annually [15]. When
provided on a hand-held mobile device, the CDSS can
increase health workers’ adherence to clinical guidelines
[16]. Moreover, they hold potential for healthcare pro-
viders’ capacity strengthening by building upon clinical
skills, increasing knowledge, and raising awareness of
lesser-known conditions. is empowers them to work
more independently, which is key for maintaining basic
quality services in resource-limited settings [17–19].
Studies from Tanzania using electronic IMCI algorithms
demonstrated improved clinical assessment and man-
agement, resulting in improved health outcomes and
quality of care [20] and reduced antibiotic treatment
[21–24]. e processes of translating clinical guidelines
into a digital decision support system follow a standard-
ised nomenclature that builds on a five-level conversion
system for the digitisation of SMART guidelines devel-
oped by the WHO [25]. Level 1 refers to available clinical
guidelines in a narrative format (disease-specific or other
written guidelines). Level 2 includes the semi-structured
stage, which refers to the transformation of Level 1
guidelines to a decision tree format that is still human-
readable. Level 3 presents the machine readability stage
(with code, terminology and interoperability standards,
and software-neutral specifications). Level 4 concerns
the reference software used to execute the algorithms
and interoperable digital components in a local execution
environment. Level 5 encompasses trained and optimised
dynamic executable clinical algorithms for prioritised
outcomes.
The Chadian context
e Chadian health system is notoriously underfunded.
e coverage and quality of healthcare services are poor
because of a lack of qualified health staff and equipment,
poor infrastructure (absence of electricity and clean
water), and an unreliable supply of medicines and con-
sumables [26–29]. Domestic governmental health expen-
ditures as a percentage of government expenditures were
5.2% in Chad in 2019 [30], whereas the Abuja declaration
of the African Head of State recommended a benchmark
of 15% [31]. e density of medical doctors per 10,000
people was 0.6, and that of nursing and midwives was
2.0. Chad had one of the highest infant and maternal
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Matthysetal. BMC Primary Care (2025) 26:113
mortality rates worldwide, with a value of 1,140 per
100,000 live births in 2017 [32]. Access to PHC services
is low, the ‘continuum of care’ is dysfunctional (poor con-
nection from the PHC level to a higher level of care for
severe cases), and health management information sys-
tems in place are insufficient to produce quality data [33].
e humanitarian crises leading to the influx of refu-
gees from neighbouring countries are overburdening the
under-resourced national healthcare system, even if basic
health services are partially covered by the humanitar-
ian community [34]. Domestic insecurity results in more
than 1 million internally displaced persons and returnees
[35]. Refugees from the neighbouring countries of Sudan,
the Central African Republic, Nigeria, and Cameroon
numbered over 1.15 million in early 2024 [36]. More than
1.8 million children under 5years of age are estimated to
be acutely malnourished [37] as a result of food insecu-
rity, childhood illnesses, displacement, limited access to
healthcare, and poor sanitary conditions [35].
In acknowledging the challenges described above,
we developed and implemented a digital CDSS in
collaboration with the National Ministry of Health
(MoH) and the UNHCR to improve the quality of PHC
services for refugees in Southern Chad. e CDSS
was based on IMCI guidelines and targeted children
aged 2–59 months, and [38] end users at the PHC level
included nurses, nurse assistants, and midwives. We first
describe the phases and processes of developing, validat-
ing, and implementing the tablet-based CDSS tool, as
well as the lessons learnt from development and testing.
Second, we discuss encountered issues and bottlenecks
within the project warranting attention by future similar
initiatives.
Methods
Project zone
e health district of Goré in the Logone Oriental prov-
ince in southern Chad was chosen based on a highly
dynamic influx of refugees from the Central African
Republic since 2003 and a high population density com-
pared with other regions (Fig.1). e project was con-
ducted from January 2019 until June 2023 and covered 3
Fig. 1 Project zone including the health centres and refugee population in the district of Goré, Chad
Page 4 of 15
Matthysetal. BMC Primary Care (2025) 26:113
PHC facilities serving a host population of approximately
48,000 in 2019 [39]. e villages of the host area and the
refugee camps were physically separated. PHC services
were accessible to all in the catchment area but were free
of charge only for the refugees. e health facilities and
services were supported by the UNHCR in terms of the
health workforce, drug supply, and consumables. e
facilities have no internet connection, but antennas were
installed by the UNHCR in the refugee camps in 2019.
Framework fortheCDSS development
andimplementation processes
e project encompassed the three phases of “situational
analysis, organisation and infrastructure set up” from
January-June 2019, “CDSS development and validation”
from July 2019 to June 2021, and “CDSS implementation
and evaluation” from July 2021 to June 2023. e phases
and the CDSS product are illustrated in Fig.2 and sum-
marised below.
Situational analysis
e idea of a CDSS for better quality healthcare provi-
sion to refugees was introduced by the project team to
national and local health authorities and other relevant
stakeholders (the UNHCR and nongovernmental organi-
sations) in Chad. e project team then conducted a
situational analysis of the local context by assessing the
infrastructure, workforce, capacity and skills, and local
population health needs inspired by the WHO Service
Availability and Readiness (SARA) tool [40, 41]. Within
the health system, clinical priorities and resource gaps
that affect the project’s design, scale, and content of the
CDSS were identified. ese findings guided the selec-
tion of health centres, the identification of end users, and
priority medical conditions along with requirements for
technical and medical equipment.
Set upofpartners, project team, andinfrastructure
Cooperation agreements were signed with the key part-
ners, i.e., the MoH, the UNHCR, and the national non-
governmental organisation “Centre de Support en Santé
Fig. 2 Approach of CDSS development and implementation processes and product
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Matthysetal. BMC Primary Care (2025) 26:113
Internationale” (CSSI). With support from the CSSI, we
recruited a local project team, the local office infrastruc-
ture was set up, and solar panels and indoor lighting were
installed in the selected health centres.
Setup ofthenational expert group
An initial workshop served to identify and endorse a
national expert panel consisting of clinical specialists
from the primary to the tertiary and central level of the
MoH, national vertical programmes (IMCI, vaccina-
tion, nutrition, and malaria), international humanitarian
organisations (UNHCR), NGOs and public health insti-
tutions (WHO), and the future end users of the CDSS.
We also engaged with national specialists in paediatrics,
internal medicine, tropical medicine, infectious diseases,
and obstetrics and gynaecology to review and validate
the content of the clinical algorithms for a PHC setting.
Mapping, selection, andapproval ofclinical guidelines
bynational experts
We collected and reviewed available clinical guidelines
and protocols used at the local, national, and regional
levels. ese included, for example, recommendations
and treatment guidelines from national programmes for
malaria, immunisation, and neglected tropical diseases.
e algorithm design was based on the main source
documents of the IMCI guidelines and the national
standard guideline “ordinogram”, which uses a symptom-
based approach. e intended end users were expected
to use the “ordinogram” and, thus be familiar with the
design. Adaptations were made to reflect the local epide-
miology and account for identified priority conditions. If
relevant guidelines were absent or outdated, we sourced
complementary topic-specific publications and recom-
mendations from international public health and human-
itarian organisations. For example, the WHO guidelines
for skin-related diseases, as well as neglected tropical
diseases and Médecins sans Frontiers (MSF) guidelines,
were included, because they address a variety of options
for clinical management under limited resources and
logistical challenges [42, 43]. e national expert panel
reviewed and formally approved the scope of medical
conditions, including their diagnosis and management.
Design, external review, andapproval ofdraft algorithms
e clinical algorithms were designed with open-source
diagram software [44]. In the frame of an external review
process of the draft algorithms, the national expert panel
members were expected to provide feedback on lan-
guage, local terms and content, and discrepancies and
gaps in the L2 flow diagrams. is included critically
reviewing diagnoses, management, treatment, and lan-
guage before consensus and formal approval.
Digitisation ofalgorithms andprototype piloting
e designed clinical algorithms [44] were mapped on an
open-source format (XLSForm/xlm) by the ICT special-
ists. Early versions of the approved clinical algorithms
were manually digitised. e mapping process was later
accelerated by introducing a “tool for rapid implementa-
tion of clinical content” (TRICC) that automatically con-
verts the drawings into the XLSForm/xlm. TRICC was
developed in-house and facilitates automatic updates of
the digitised clinical algorithms. e XLSForm is then
uploaded to an application of choice and presented on
the electronic device as a questionnaire. To evaluate the
CDSS’s functionality, the project team, together with the
health workers, tested an early prototype in the project
health centres.
Testing andvalidation
e approval of the digitised clinical algorithms was
preceded by an extensive iterative process, including
repeated testing, reviewing, and refining by clinicians
and ICT specialists. IT testing consisted of defining and
executing an IT-related system and integration tests to
validate the IT logic (order, structure, content, and form
of questions and instructions, such as “observe”, “deter-
mine”, and “ask”). e consistency between each decision
tree and the questions in the app was verified.
Owing to the complexity of the algorithms, it was not
possible to manually verify each pathway. Hence, for the
clinical content testing and validation, we used a prior-
ity matrix for key health conditions based on defined
criteria concerning occurrence, severity, and needs for
knowledge and management. Diagnoses with an over-
all score above a threshold were systematically tested.
National clinicians with experience in primary health-
care developed clinical vignettes and tested the CDSS
with these for a hypothetical consultation. We defined a
clinical vignette as a test case to simulate a real-life sce-
nario, which consisted of a variety of clinical symptoms
and signs, followed by steps in clinical assessment leading
to a specific diagnosis based on medical standards. e
clinicians and ICT specialists discussed and resolved all
apparent clinical and technical issues. A report was cre-
ated for each test executed and later used for the valida-
tion of the clinical algorithm.
End‑user training
We employed a 3-day training of trainers approach
involving national clinicians at the central and district
levels. e training material was prepared mainly by
local project clinicians and ICT specialists. e content
was tailored to clinical skills for diagnoses covered by
the CDSS and included additional topics, such as patient
management, pre-referral, referral, medical triage,
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Matthysetal. BMC Primary Care (2025) 26:113
principles of consultation and communication, antibiotic
stewardship, and technical skills to manipulate the elec-
tronic device. e participants’ skills were assessed dur-
ing each training session through pre- and post-tests via
a questionnaire containing multiple-choice questions.
Quality assurance
Quality assurance measures were employed throughout
all project phases. e national expert panel reviewed
and approved the source documents and clinical algo-
rithm design. e content and terminology were adapted
to the local setting to minimise misunderstanding and
misinterpretation. Testing and validation of the CDSS
involved external national clinicians. e project team,
together with central, provincial, and district health
authorities and other partners, provided formative
supervision and repeated refresher training to end users,
including topics suggested by them, to strengthen their
clinical and patient management skills.
Results
CDSS
e CDSS was developed as an offline-compatible tablet
application for primary healthcare providers. It included
a structured decision-support system to improve the
diagnosis and management of common paediatric condi-
tions. e CDSS was tailored to local priority health con-
ditions, disease patterns, locally available resources, and
sociocultural factors about the resident and refugee pop-
ulations. e design integrated local terms, language, and
images for appropriate clinical assessment. It was built on
IMCI guidelines, which were adapted from the national
standard guideline “ordinogram” [45], applying a symp-
tom- and syndromic-based approach to facilitate the
detection and management of lesser-known conditions.
Where available, we integrated low-cost point-of-care
diagnostics to support and/or confirm clinical diagno-
sis. We also included clinical algorithms to support the
healthcare provider in the evaluation, case detection,
and management of febrile conditions about emerging or
re-emerging infectious diseases causing recent regional
outbreaks, such as dengue and chikungunya [46, 47]. e
project team developed 33 paediatric clinical algorithms
and tested 40 priority diagnoses via self-developed clini-
cal vignettes. Six workshops with the clinical expert
panel were organised to review and validate the clini-
cal guidelines and algorithms. Advantages of the CDSS
with expected impact in terms of design and clinical and
therapeutic management and advice, as well as issues
encountered, are summarised in Table1.
IT architecture
Figure3outlines the CDSS’ architecture. e CDSS ran
on the initially chosen application CommCare [48] and
was later migrated to the Community Health Toolkit
[49]. e health facilities had no internet; therefore, the
application stored the case recorded by the health worker
offline on the electronic tablet. e data were regularly
synchronised by the health centre manager with an
online data server via a mobile router.
IT governance (data management, protection,
andsecurity)
e patient data were de-identified, and the information
was encrypted and password-protected [50]. A unique
code was assigned to each patient. e code was drawn
from a list of automatically created codes continuously
distributed to the health facilities. It was recorded in
the health booklet at the patient registration service and
then entered into the electronic tablet by the consult-
ing health worker for the first visit of a case and used for
follow-up visits. To secure electronic devices, a liability
contract was signed by the involved parties (the project
coordinator, the district medical officer, and the health
centre manager). e devices, accessories, and their con-
ditions were recorded in a handover book at every shift
change to produce traceability. e devices were tracked
by geolocation and locked in cupboards when not in use.
User access and rights were restricted by creating indi-
vidual user accounts according to the type of utilisation.
New account and access requests were analysed and
approved by the project coordinator. A guideline on the
project’s data governance was developed.
Implementation oftheCDSS
e implementation phase included end-user training,
a CDSS launch, a user satisfaction study, and content
update and adaptation. e CDSS was launched in June
2021. e end users were trained before and received
repeated refresher training in October 2021, April 2022,
and January 2023. ey were also closely accompanied
and supervised jointly by the project and health district
teams. A total of 77,214 consultations eligible for use of
the CDSS were performed, and the CDSS was effectively
used for 25,621 consultations (33.2%) between July 2021
and April 2023. To sustain the intervention, all the pro-
ject equipment was retained by the implementers at the
end of the project. e health district team and a focal
point in each of the health centres were designated by
the MoH to continue providing technical supervision to
the CDSS end users in the health centres. Moreover, they
were supported remotely by the project’s former clinician
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Matthysetal. BMC Primary Care (2025) 26:113
Table 1 Advantages of the CDSS with expected impact
Advantage Description Expected impact Issues encountered
Integrated management of diseases • Main complaint and reason for consultation
as entry point (symptom-based approach)
• Clinical topics were designed in a way to avoid
repetitive questions in the event of an additional
health problem
• Better management of a broad range of health
conditions of refugees within in routine health-
care settings
• Some of the local guidelines were partially out-
dated and showed gaps that had to be comple-
mented with international standard guidelines
Evidence-based decision support • CDSS was built on national and international
standard guidelines
• Integrated prompts with culturally adapted
visuals, e.g. for skin diseases
• Possible diagnoses for comorbidities
• Improved diagnosis, management, awareness
and knowledge of less well known conditions
• Enhanced usability of the CDSS
• Some point-of-care tests (POCTs) included
in the clinical algorithms and supporting decision-
making were frequently out of stock. The lack
of confirmation of clinical diagnosis may have
increased the referrals and generally reduced
the CDSS’ added value of evidence-based support
Harmonised treatment recommendations • Treatment advices were aligned for multiple
diagnoses and adapted to local medications
available (alternative treatments proposed
if the first line treatment was out of stock)
• Drug recommendations were provided
with automated weight-based calculation
of dosages
• Reduced over prescription and over-
or under dosage of medications
• Patient received treatment at health centre
pharmacy
• Consideration of stock outs
• The recommended treatment was based
on the restricted availability of diagnostic tests,
which limited a targeted treatment. Therefore,
a syndromic management was adopted to this
specific setting
Pre-referral management and patient advice • Advices for pre-referral management and treat-
ment, and for patient management at home • Available pre-referral management and treat-
ment advices, which are possibly life-saving
for critical conditions
• Referral was not effective due to a dysfunctional
continuum of care (health centres were better
equipped in terms of infrastructure und skilled
health professionals than the district hospital)
Patient follow-up • Integrated function of call up of previous visits
for follow-up visits • The patient consultation can be interrupted, e.g.
for ordering a rapid test • This function requires a functioning archiving
system of patient files
Reminders and prompts • The clinical algorithm contained reminders
(patient history, examinations, investigations,
diagnostic tools)
• Integrated prompts to respond to each ques-
tion and to confirm key questions (e.g. weight)
• Filters to reduce typing errors
• Predefined processes prevented skipping
• Improved data quality by reducing missing
and erroneous data
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Matthysetal. BMC Primary Care (2025) 26:113
and ICT specialist [51].Figure4 shows a medical consul-
tation of a child in the health district of Goré, Chad.
Update andcontent adaptation
e end users were encouraged to provide feedback
on the CDSS during piloting, validation, and imple-
mentation, and their inputs were collected mainly
through supervision visits, analysed, and addressed as
appropriate.
Evaluation ofuse
Five evaluations were carried out by the national MoH
and the "Ministry of Economic Forecasting and Inter-
national Partners". In addition, the Foundation com-
missioned an evaluation given its funding programme’s
future. We conducted a user satisfaction study with end
users of the CDSS and auxiliary personnel who did not
directly use the CDSS but were impacted by changes in
the CDSS implementation in their daily work. e study
is detailed elsewhere [52]. e study design and question-
naire were adapted from a previous study that assessed
key elements of successful CDSS implementation, includ-
ing adaptation, adoption, feasibility, acceptability, and
sustainability [53]. Two-point data collection 6 and 16
months after implementation allowed the assessment of
satisfaction over time. Using a mixed methods approach
combining semi-quantitative and qualitative data allowed
the authors to quantify and compare satisfaction between
the two study time points and find explanations for the
observed changes in satisfaction.
Fig. 3 Architecture of the CDSS
Fig. 4 Medical consultation of a child in the health district of Goré,
Chad, January 2023. Picture credit: Salomon Djekorgee Dainyoo/
Swiss Tropical and Public Health Institute/Stanley Thomas Johnson
Foundation/Fairpicture
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Matthysetal. BMC Primary Care (2025) 26:113
Table 2 Phases and activities, approaches and outcomes of the CDSS development and implementation
Phase, activity Methodological approach Outcome
Situational analysis, organisational and infrastructure setup
Situational analysis • Appraisal of health management and services, infrastructure,
technology, workforces and skills, and guidelines • Better understanding of the local context
Setup of partners, project team and infrastructure • Setup of local office infrastructure, rehabilitation of health centres
• Recruitment of project team
• Collaboration agreements with key project partners
• Operational framework conditions created
• IT architecture tailored to a local low-resource setting
Setup of national expert group • Setup and endorsement by the MoH of a national expert panel
• Creation of a national technical working group (national expert
panel members, national medical specialists)
• Compliance with quality assurance measures throughout project
duration
• Ensure adaptations to local context and setting
Development and validation of the CDSS, content update
Mapping of clinical guides and approval by national clinical
specialists • Selection and approval clinical guidelines and local priority
medical conditions • Medical conditions and reference documents for clinical algo-
rithm development build on local needs and take into account
low-resource setting
Design, external review and approval of draft algorithms • Clinical algorithms build on national and on standard interna-
tional guides and on a symptom- and syndrome-based approach
• Revision and refinement of clinical algorithms based
on repeated reviews by end users and national clinical specialists
• Consideration of the local setting (epidemiological and sociocul-
tural factors, available resources and skills, national policy)
• Adaptation and formal approval of clinical algorithms
Digitisation of algorithms, prototype piloting • Digitisation of clinical algorithms via an automatic transcription
programme
• Pilot test of a CDSS prototype
• Digitised algorithms (interrogatory) are ready for testing
• Functionality of CDSS tested, major issues identified
Testing and validation • Definition and execution of IT-related system and integration
tests on interrogatory
• Priorisation and scoring of clinical algorithms to be tested
based on clinical diagnoses and selected key criteria (likelihood,
clinical severity, epidemiological risk, knowledge)
• Systematic testing of diagnoses with defined high scores
• Development, review, and approval of clinical vignettes
• Testing of clinical vignettes with CDSS interrogatory by clinicians
• Adaptation of drawn and digitised algorithms based on feed-
back, repeated testing until no single issue is detected
• Final review and approval of tested clinical algorithms
by national clinicians
• Validation of IT logic
• Priorisation of health issues for clinical testing
• Clinical validation of digitised algorithms
• Issues on clinical approach, diagnosis and validation of clinical
vignettes identified and addressed
Implementation and evaluation of the CDSS
End user training and CDSS launch • Preparation of training course and material
• Training of national trainers and of end users
• Assessment of participant’s skills via pre- and post-test
• Participants feedback on training (evaluation form)
• Launch of the CDSS
• National clinical, analytical and teaching skills strengthened
• Participant’s evaluation to improve following trainings
Update and content adaptation • Regular feedback on the CDSS by end users
• Technical working group of national clinical and IT specialists
created to regularly update the tool
• Ensuring crucial adaptations
Evaluation of the use • End user satisfaction study conducted • Evaluation of five satisfaction indicators (adaptation, adoption,
acceptability, feasibility and sustainability) of the CDSS 6 and 16
months after implementation
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Matthysetal. BMC Primary Care (2025) 26:113
e phases and related activities, methodological
approaches, and outcomes of the CDSS development and
implementation are summarised in Table2.
Discussion
We developed and implemented a digital CDSS target-
ing children aged 2–59 months. e design and clinical
content were tailored to the end users’ competencies and
resources available to them, thereby taking into account
the context. Key achievements and issues encountered
and limitations identified in the different phases of the
project, are discussed here and structured along ‘impact’,
‘potential’, ‘adoption’, and ‘challenges and weaknesses’.
Impact
Even though the project’s approach to outcome and
impact monitoring did not allow to establish evidence
in respect to quality of care changes or other clini-
cal outcomes, the CDSS contributed to strengthening
the end user’s clinical knowledge and skills, and their
awareness of less well-known diseases. e provision of
repeated refresher training and formative supervision
to end users to build and maintain their knowledge and
skills in clinical and patient management and to use the
CDSS was crucial to sustaining such an intervention, as
also mentioned in other sub-Saharan settings [10, 11,
54]. e CDSS is currently replicated in an additional
selected health district within the national health sys-
tem. e involved stakeholders and end users expressed
their strong interest in the continuation and expansion of
CDSS use, which would require the involvement of key
stakeholders at all levels of the MoH.
Potential
An integrated disease management approach beyond
IMCI, including priority and less well-known condi-
tions, may consider integrating adapted algorithms for
syndromic disease management, such as sexually trans-
mitted infections. is approach would allow accounting
for endemic parasitic diseases with confounding clinical
symptoms (e.g. female genital schistosomiasis), to guide
assessment and management in girls as a vulnerable
group. Coupled with a reliable electronic recording and
reporting system, the CDSS has the potential for health
facility-based disease surveillance. CDSS-based real-time
data generated can be fed into dashboards for case detec-
tion, support basic mapping and monitoring of potential
outbreaks, and identify trends of notifiable, epidemic-
prone, and emerging infectious diseases. Health facil-
ity-based electronic integrated disease surveillance and
response (eIDSR) systems are increasingly implemented,
e.g., in Nigeria [55], Sierra Leone [56–58], and Tanza-
nia [59]. Refugee settlements are particularly at risk of
endemic disease outbreaks because of poor sanitary
infrastructure and high population density. Population
and cross-border movements and alterations in local vec-
tor abundance can facilitate the emergence or re-emer-
gence of communicable and vector-borne diseases, such
as dengue, chikungunya, and zika, which can then spread
among formerly disease-naïve populations [60, 61].
Adoption
Partner commitment benefitted from an established
long-term network in Chad through previous projects
and programmes. e MoH’s interest and commit-
ment throughout all project phases were crucial. e
national expert panel established by the MoH’s Depart-
ment of Health Services Organisation and Quality of
Care brought different stakeholders from the ministry,
national vertical programmes, NGOs, and academia
together and substantially contributed to strengthening
the technical capacity of digital health. e organisation
of national workshops on the capitalisation of the project
and digital health contributed to advocating the CDSS at
the national and regional levels. e active involvement
of the national expert panel that also included end users
in the development and validation processes and provi-
sion of feedback on the design of the clinical algorithms
helped to refine and adapt the CDSS and enhanced co-
creation and local ownership of the CDSS. Being aware of
the need to keep exchanges for regular content updates
to sustain the intervention, the national clinicians from
the expert panel formed a technical working group on
their initiative. e content update consists of reviewing
and updating the clinical content of the CDSS based on
novel drugs, diagnostics, clinical guidelines, and chang-
ing patterns of disease epidemiology. Access by health
professionals from resource-constrained settings to
communities of practice is crucial to strengthen the col-
laboration and regional and international networks [62]
and can be a well-accepted resource for clinical decision-
making by peers [63].
e findings from the user satisfaction study indicated
high acceptance of the CDSS by the end users. Adapt-
ing the CDSS to the local context, building a co-creation
and constant feedback process, and providing continuous
technical support to the end users was key to a successful
implementation of the CDSS [52].
From a gender perspective, female health profession-
als at the local and national levels were represented in the
expert panel. e national clinical consultants to develop
locally adapted clinical vignettes were men, as no female
clinical consultants could be engaged in this task.
Page 11 of 15
Matthysetal. BMC Primary Care (2025) 26:113
e situational analysis allowed the identification of
significant pre-existing resource limitations, namely,
poor medico-technical equipment and stock shortages of
medications and rapid diagnostic tests. e project thus
provided health centres with medico technical equip-
ment, and the CDSS was adapted to suggest second and
third-line medications as well as offer decision points
with and without test availability.
e project team and national clinical specialists
involved underwent a mutual learning process during
the development and validation phases, from reaching a
common understanding of the concept and scope of the
CDSS to thorough testing, reconsidering, and adapting
different approaches, which required agile management.
e complexity of the CDSS is an approximate reflection
of clinical decision-making. It is thus essential to what,
how, and in which order information is presented. e
information chosen out of a diagnostic process can be as
important as the information chosen to be included. e
clinical content must be up-to-date and evidence-based,
incorporate and balance national and international
standards and guidelines, and be appropriate and use-
ful to end users. erefore, the development of clinical
content for a decision tool is completely different from
translating a pre-existing guideline into a digital format
and requires a high investment of reflection, focus, and
attention at various levels. e CDSS provides clinical
decision support and is not intended to provide the user
with a diagnosis. e user has the freedom to rely on her
or his judgment and retains ultimate responsibility for
the decision that has been made or the medication that
has been prescribed. e end users come with varying
levels of training, experience, and baseline knowledge,
and the tool might replace individual judgments or assert
a cognitive bias. For accuracy and clinical safety, there-
fore, the tool should, as far as possible, reflect the deci-
sion logic that a majority of clinicians would most likely
make if presented with the same set of parameters and
background information. A comparative analysis of four
IMCI-related CDSS showed that conversion of narra-
tive guidelines in a decision logic requires interpretation,
which calls for CDSS development standards to ensure
health and quality of care outcomes [64].
e testing and validation of digitised clinical algo-
rithms are crucial for providing end users with a safe
digital tool and ensuring sufficient adaptation by mini-
mising the risk of providing erroneous advice, which is
more harmful than beneficial. Every conceivable sce-
nario should be considered; therefore, various clinical
tests (clinical vignettes) were developed and carried out.
e approval of the digitised clinical algorithms is thus
preceded by an extensive iterative process of testing,
reviewing, and refining each of the prioritised clinical
diagnoses, involving close interactions between clinicians
and ICT specialists. End users should be actively involved
in this process from the beginning to foster their under-
standing. Early testing focused more on the IT logic and
clinical vignettes covering diagnoses of common child-
hood illnesses, whereas later testing was built on lessons
learnt and included a broad range of additional clinical
vignettes developed by national clinicians. To respond to
new evidence and updated guidelines, a process of regu-
larly refreshing the clinical content (by periodical revisits
of the clinical algorithms and adaptation if required), is
needed to ensure that it remains relevant. To sustain cer-
tain agility of the CDSS over time, processes should be
established to clinically and technically reassess and test
it after each adjustment. is should be addressed at both
the planning stage and during the initial development.
e national expert panel reviewed and approved the
source documents and algorithm design during repeated
validation workshops. However, a critical review of
inputs questioning the content and quality of the algo-
rithm and feedback on discrepancies and gaps was rather
poor for the paediatric algorithms. is lesson was taken
into account during the development of adult clinical
algorithms (which are not further discussed here). We
adapted the review approach by building small work-
ing groups of national clinicians and assigned them
several clinical algorithms for a thorough review and a
later discussion in the plenum. is approach provoked
lively debate among the panel members and encour-
aged critical input. Moreover, the repeated workshops
likely allowed gradual familiarity with the project team,
encouraging the expert panel members to question the
clinical algorithms.
Challenges andweaknesses
e major challenge of the development, validation, and
deployment of a CDSS to a refugee context in south-
ern Chad was its complexity. It required a strong com-
mitment and a substantial effort, particularly from the
clinicians and ICT specialists, during the development
and validation phases, which resulted in an unexpect-
edly high workload. At the beginning, the project team
had to reach a common understanding and consen-
sus of the concept and procedures. e decision on the
algorithm’s design had to be weighted between its com-
plexity and the usability of the end product (CDSS) in a
resource-constrained local context. Some of the algo-
rithms were thus decided to be slightly reduced to keep
the number of items to answer per consultation as short
as possible. We believe that work overload may affect
health professionals’ ability to perform their duties at a
high quality, including consistently using the tools and
tests provided, which may result in inaccurate diagnoses
Page 12 of 15
Matthysetal. BMC Primary Care (2025) 26:113
and inappropriate treatment. ese compromises have
also been reported in other settings of low- and middle-
income countries [65]. Importantly, the development
process is not complete with the launch of a CDSS; its
use needs to be solidly embedded into working routines
and local training curricula.
e local setup and sustainment of a CDSS involves
the continuous maintenance of infrastructure resources,
including technology and equipment, by local clinical
and ICT expertise, which requires solid long-term com-
mitment, including funding, as it has also been pointed
out in comparable settings, such as in Burkina Faso [66],
Cameroon [67], and in Tanzania [68]. e setup of the
current project’s IT infrastructure faced several bottle-
necks. For example, health centres had to be equipped
with solar panels for electricity provision for room light-
ing and charging electronic tablets. Mobile routers had to
be installed for data synchronisation between the online
server and the electronic devices. Regarding data host-
ing, storage, and transfer, the project team made exten-
sive inquiries about a host server solution in Chad. e
governmental infrastructure and technology were insuf-
ficient at that time to host a local server, so the team had
to opt for a cloud server subscription.
A limitation of the project design was the evaluation
framework, which lacked a robust research design to
evaluate the clinical outcome, efficacy, safety, and quality
of care of the intervention. is would however require
substantial financial resources for the conduct of a clini-
cal trial or a pre-post study which was unfortunately not
available. e assessment and analysis of the target popu-
lation’s health priorities should have been based on dif-
ferent sources instead of mainly routine health data. is
would have allowed the project team to gain a deeper
understanding of key issues and gaps and to set a reliable
baseline benchmark of the target population’s health situ-
ation to design project indicators adapted to this specific
local context.
An important health workforce-related barrier to
embedding the CDSS into routine healthcare delivery was
the mobility of health workers. eir observed monthly
patterns influenced the use of the CDSS, explaining the
comparatively low use of the CDSS. Towards the end of
the project, the health staff in the facilities was drasti-
cally reduced due to funding issues. e user satisfaction
survey indicated that nurses organised themselves into
a team of two, whereby one performed the patient con-
sultation, and the other applied the CDSS and recorded
the information in the patient registry. When the patient
consultation was performed by one nurse, the motiva-
tion to use the CDSS decreased because of the addi-
tional workload and increased consultation time [52].
A scoping review investigating the use of the CDSS by
health workers and the associated effects on workload
and workflow indicated that using the CDSS did not
necessarily lead to increased or decreased consultation
duration. However, perceived additional time taken for
consultation, increased administrative workload, and dis-
rupted workflow patterns were identified as barriers to
the use of the CDSS and point-of-care diagnostic testing
in daily practice [69–72]. Besides that, incoming health
workers were entitled to use the CDSS only after success-
fully completing a CDSS user training, which may have
influenced the share of consultations using the CDSS as
a support tool. e project team could mitigate the con-
sequences of this dynamic only to a limited extent, for
example, through regular supervision and the design of
the CDSS. Various clinical topics were linked so that the
questionnaire did not need to be restarted in the event of
another health problem.
Conclusions
We described here the development and implementa-
tion of a CDSS in Southern Chad, taking into account
the context, such as high constraints regarding resources
addressing priority needs of vulnerable and mobile refu-
gee population groups. A participatory approach engag-
ing key stakeholders from the local to the national level
of the health system in the process from the beginning
considerably contributed to successful development and
implementation. e sustainment of such an intervention
requires a solid commitment to establish and maintain
the technical and infrastructural setting (electricity, inter-
net connection, and server solutions), continuous human
resources, and technical support (medical professionals
and ICT specialists). e CDSS reflects realities on the
ground and thus requires continuous content updates
to integrate the evolving clinical medicine (refreshed
standard guidelines and new medicines and diagnostics)
and refine for sustainability. A clinical trial or pre-post
study allowing measuring clinical outcome, efficiency,
and safety of the CDSS and quality of care aspects would
contribute to generating evidence of its benefit and the
value of the approach applied for its development and
implementation.
Abbreviations
CDSS Clinical decision support system
CSSI Centre de Support en Santé Internationale
ICT Information, communication and technology
IMCI Integrated management of childhood illnesses
MoH Ministr y of Health
MSF Médecins sans Frontières
PHC Primary healthcare
Acknowledgements
We are grateful to the children and caregivers for their participation in the
project and to healthcare providers from the selected health centres for their
commitment in all project phases, allowing us to improve the CDSS. The local
Page 13 of 15
Matthysetal. BMC Primary Care (2025) 26:113
authorities of the Goré health district and the UNHCR ensured a welcoming
and safe working environment. The MoH, through the MoH’s Department
of Health Services Organisation and Quality of Care (DOSSQS), was actively
involved in all project phases and strongly supported the project. The CSSI
provided administrative and logistical support to the project and staff. We
thank Peter Steinmann, and Talia Salzmann, and the external reviewers for
reviewing the manuscript. We are grateful to the Stanley Thomas Johnson
Foundation for their strong support of the project.
Authors’ contributions
BM drafted the manuscript and led its development process. AM, NM, DN,
YT, PD, MP, TS, JA, MZ, and KS contributed to the content development of the
CDSS. AM, DN, and YT were in charge of the implementation of the tool, and
ML and BM were in charge of its monitoring and evaluation. DR and KW led
the project. All co-authors contributed intellectual content, and reviewed and
approved the final manuscript. The manuscript underwent a language check
and edit suggestions by the AI-supported software “Curie” from AJE (https://
beta. sprin gerna ture. com/ pre- submi ssion/ writi ng- quali ty? utm_ source= Websi
te_ BMC& utm_ medium= Digit al_ Edit& utm_ campa ign= Free+ Digit al+ Edit+
Refer ral+ 2023& utm_ id= Curie 2023).
Funding
Open access funding provided by University of Basel The project was funded
by the Stanley Thomas Johnson Foundation based in Switzerland.
Data availability
Aggregated data and materials are available on request.
Declarations
Ethics approval and consent to participate
The project was approved by the Government of the Republic of Chad (letter
of approval no. 0230/MEPD/SE/DG/0004/DONGAH/2019, project agreement
no. 0668/DSAONGOC/2019). The study protocol for the situational analysis was
approved by the Chadian National Bioethics Committee (authorisation no. 155/
PR/MESRI/SG/CNBT/2019). The research protocol for the user satisfaction study
was approved by the Chad National Bioethics Committee (CNBT) (authorisa-
tion no. 11/PR/MESRSI/SE/DG/CNBT/SG/2021). The North-Western and Central
Switzerland Ethics Commission (Ethikkommission Nordwest- und Zentrals-
chweiz; EKNZ) confirmed that the study met all the requirements of a Swiss
research project (AO_2021 - 00068), implying accordance with the protocol,
the Declaration of Helsinki, the principles of Good Clinical Practice, the Human
Research Act and the Human Research Ordinance. Written informed consent
was obtained from all interviewees who agreed to participate in the studies.
Consent for publication
Consent for publication for Figure 4 from the health care provider and car-
egiver of the child is available.
Competing interests
The authors are members of the project team, contributing to the design and
implementation of the CDSS examined in this study. They hold a financial and
employment relationship with the project under review.
Author details
1 Swiss Tropical and Public Health Institute, Allschwil, Switzerland. 2 Centre de
Support en Santé Internationale, N’Djamena, Chad. 3 Lewisham and Greenwich
NHS Trust, London, UK. 4 Cantonal Hospital Winterthur, Winterthur, Switzerland.
5 University of Basel, Canton of Basel Stadt, Basel, Switzerland.
Received: 31 October 2024 Accepted: 2 April 2025
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