Abstract
Background: The global shift towards digital health care presents significant challenges for municipal health systems striving for digital transformation. In Gauteng, South Africa, municipal clinics face multiple barriers including limited infrastructure and low digital competence among patients and healthcare workers, exacerbated by socio-economic disparities. This study aims to identify key obstacles to successful digital transformation in these settings.
Aim: The study explores barriers such as inadequate infrastructure, financial constraints, healthcare workers’ resistance to adopting technology, and patients’ concerns about data security.
Methods: A qualitative research design was employed using semi-structured interviews with healthcare staff across Gauteng clinics to gather rich, context-specific data on digital transformation challenges.
Results: Findings indicate that barriers are deeply interlinked. Inadequate funding underpins many challenges, including insufficient infrastructure, poor digital skills among staff, weak data protection systems, and general resistance to technological change.
Conclusion: Overcoming these obstacles requires a multifaceted strategy that includes infrastructure development, digital literacy training, change management frameworks, robust information security, and increased financial investment.
Contribution: This study enhances understanding of the structural and socio-economic barriers to healthcare digitalisation. It offers practical insights for policymakers and healthcare managers aiming to implement equitable digital transformation in municipal healthcare services. Additionally, the study contributes empirical evidence to the field of electronic health records (EHRs), informing strategies to improve healthcare delivery and equity in similar developing-country contexts.
Keywords: digital transformation; municipal health care; digital health barriers; health care infrastructure; health care funding.
Introduction
The fourth industrial revolution (4IR) represents a global shift driven by rapid advancements in digital technology, fundamentally altering how industries operate. This revolution is especially significant in health care, where the integration of information technology (IT) and automation has shown potential to enhance service delivery, improve patient outcomes and optimise operational efficiency. Through digital transformation, health care systems worldwide are reconfiguring how they provide services, manage patient records and interact with stakeholders, thereby redefining the health care landscape (Øvretveit 2019; Pinto et al. 2020). Countries with established digital infrastructures, such as Estonia, Denmark and Canada, are leading this transformation by implementing electronic health records (EHRs), telemedicine and patient management systems, which streamline workflows and improve access to care. These advancements showcase the capacity of digital transformation to meet health care demands and improve patient care, underscoring the potential benefits for other regions striving to digitise their health care systems (Cuevas et al. 2017; Signé 2021; Tikkanen et al. 2020).
In Africa, however, the digital transformation of health care faces unique obstacles, primarily because of socio-economic disparities, infrastructural limitations and low levels of digital literacy (Acharya et al. 2023; Ahmed et al. 2024). Despite these challenges, some African countries have made significant strides by leveraging digital tools to enhance health care accessibility. Rwanda, for example, uses drones to deliver medical supplies to remote areas, and Namibia introduced telemedicine to ensure continuity of care during the coronavirus disease 2019 (COVID-19) lockdowns (Mbunge et al. 2022). These initiatives illustrate the adaptability of digital solutions to address infrastructural and logistical constraints, offering a model for other African nations, including South Africa, to explore similar innovations in health care.
South Africa, being one of the more economically developed nations in Africa, has made considerable investments in digital infrastructure and has undertaken several digital initiatives to modernise its public services, including health care. However, the pace of digital transformation within its health care sector remains inconsistent, particularly at the municipal level (Ahmed et al. 2024; Brandt 2025). Gauteng province, as one of South Africa’s most populous and economically significant regions, symbolises this challenge. Gauteng is home to over 14 million people and has a diverse population with varying health care needs, but its health care system is hindered by an uneven digital transformation process, particularly in municipal clinics serving rural and underprivileged urban communities (Hartley & Morrow 2021). Municipal clinics, which play a crucial role in delivering primary health care, encounter numerous obstacles in their efforts to implement digital systems, limiting their capacity to deliver timely, efficient and patient-centred care.
One of the primary challenges faced by municipal clinics in Gauteng is the digital divide, a socio-economic disparity in access to digital technologies that affects both urban and rural communities (KuikaWatat & Jonathan 2020; Steyn & Slabbert 2023). Although urban areas in Gauteng may have better access to digital resources, the socio-economic gaps within the province still pose significant hurdles to achieving a cohesive digital health care system. Rural areas are particularly disadvantaged, as they often lack the necessary infrastructure, such as high-speed internet, to support digital health services (De Leo et al. 2024). This lack of infrastructure, compounded by limited digital literacy and low-income levels, prevents patients and health care providers from fully utilising digital tools, creating barriers to accessing real-time information, medical records and efficient communication channels (Pal et al. 2022; Peek, Sujan & Scott 2020; Odone et al. 2019).
The socio-economic challenges in Gauteng are further compounded by structural and organisational issues within the health care system. Many municipal clinics operate on limited budgets, making it difficult to invest in advanced digital solutions, while health care staff often lack the training needed to manage digital systems effectively (Acharya et al. 2023; Aruleba & Jere 2022). This environment restricts the adoption of digital tools, impacting everything from patient record management to the implementation of telemedicine services. Additionally, the administrative burden placed on health care workers is often exacerbated by outdated manual processes, limiting their capacity to engage with new digital systems that could streamline workflows and improve patient outcomes (Seegan & McGuire 2024).
In the light of these challenges, this study seeks to understand the specific factors preventing effective digital transformation within Gauteng’s municipal health care services. By investigating these barriers, this research aims to contribute to developing a targeted, systems-based framework for digitalisation that addresses Gauteng’s unique socio-economic and infrastructural landscape. This focus aligns with the broader goals of improving health care accessibility, enhancing service delivery and fostering patient-centred care, which are critical for achieving equitable health outcomes across Gauteng’s diverse population.
Problem statement and research gap
Although South Africa has invested in digitalising public services, municipal health care services in Gauteng struggle to implement digital transformation effectively. The province’s clinics face numerous challenges, including infrastructural limitations, low digital literacy and a digital divide that disproportionately affects rural and underprivileged communities (Ahmed et al. 2024; Tikkanen et al. 2020; Van der Hoogen, Scholtz & Calitz 2021). This lack of digital adoption leads to delays in patient care, inefficiencies in service delivery and an inability to provide tailored care, particularly in rural areas where internet access and technological resources are limited (Brandt 2025; De Leo et al. 2024). The gap between Gauteng’s health care digitalisation needs and current capabilities highlights the necessity of a targeted framework to address these obstacles, enabling a more integrated, effective health care system that meets the demands of its population.
Despite the growing body of literature on digital transformation in health care, limited research specifically addresses the unique challenges faced by municipal clinics in Gauteng province. While studies such as Joshua, Bhattacharyya and Rao (2022), Anakwe et al. (2021) and Van der Hoogen et al. (2021) discuss governmental digitalisation initiatives in South Africa, they often overlook the particular socio-economic, infrastructural and organisational factors impacting Gauteng’s municipal clinics (Acharya et al. 2023; Burnett et al. 2024). Current research lacks a comprehensive analysis of the barriers specific to Gauteng, such as the digital divide, limited digital literacy and health care worker resistance, which prevent effective digital adoption in its health care facilities (Ahmed et al. 2024; Paige & McGuire 2024). This study aims to fill this gap by examining these factors in detail and proposing a framework tailored to the needs of Gauteng’s health care system. Specifically, this study explores the barriers to digital transformation in municipal health care services in Gauteng clinics, with the goal of informing policy and implementation strategies that enhance digital health care accessibility and efficiency.
South Africa’s health care system
South Africa operates a dual health care system comprising public and private sectors. The publicly funded system serves over 84% of the population and is financed mainly through government subsidies, whereas the private sector functions on a profit basis and is accessible primarily to those with private health insurance (Borgen Project 2022; Lavers 2020; Malakoane et al. 2020). Despite health care receiving about 10% of the national Gross Domestic Product (GDP), public facilities remain under-resourced, resulting in disparities in infrastructure, service quality and care accessibility (Willie & Nkomo 2019). In this context, digital transformation in municipal clinics offers a potential solution for improving service delivery and efficiency. However, its implementation is hindered by infrastructural and socio-economic barriers, especially in underserved areas such as Gauteng’s rural communities (Borgen Project 2022; Monzon 2023; Pita-Barros et al. 2019).
Legislative Framework for Digital Health Care Transformation
The digital transformation of health care in South Africa operates within a structured legislative framework designed to balance technological innovation with patient rights, data security and equitable access. Several key policies and laws govern digital health initiatives, shaping their implementation across the country, including in Gauteng’s municipal clinics.
The National Health Act (No. 61 of 2003) serves as the foundational legislation for health care delivery in South Africa, emphasising equitable access to services. Although it does not explicitly address digital health, its provisions on health information systems under Chapter 5 mandate the standardisation of patient records, indirectly supporting the adoption of EHRs. However, the Act’s lack of specificity regarding digital tools has contributed to inconsistent implementation, particularly in provinces like Gauteng where resource disparities are pronounced.
The Protection of Personal Information Act (POPIA, No. 4 of 2013) plays a critical role in regulating the processing of personal data, including sensitive health information. POPIA establishes stringent requirements for data privacy, consent management and cybersecurity, which are essential for digital health initiatives such as EHRs and telemedicine. Despite its importance, compliance remains a challenge for under-resourced municipal clinics, where limited technical capacity and funding hinder adherence to these regulations.
South Africa’s National eHealth Strategy (2012–2016 and Beyond) was developed to guide the integration of information and communication technologies (ICT) into health care, with a focus on EHRs, telehealth and mobile health (mHealth) solutions. However, the strategy’s implementation has been slow, hampered by underfunding, infrastructural deficiencies and fragmented governance structures. These challenges are evident in Gauteng, where municipal clinics have struggled to meet the strategy’s targets, particularly in the rollout of interoperable EHR systems.
The updated National Digital Health Strategy (2023–2028) seeks to address the shortcomings of its predecessor by prioritising interoperability of health information systems, universal broadband access to bridge the urban–rural digital divide and workforce training to enhance digital literacy among health care providers. While this strategy represents a progressive step forward, its success hinges on adequate budgetary allocations and provincial-level commitment, both of which have been inconsistent in Gauteng.
The Electronic Communications Act (No. 36 of 2005) governs telecommunications infrastructure, which is vital for the deployment of telehealth and remote consultation services. Despite its relevance, rural clinics in Gauteng often lack the high-speed internet connectivity required to leverage these digital solutions, exacerbating existing health care disparities between urban and rural areas.
Despite these legislative efforts, significant gaps remain in South Africa’s digital health policy landscape. There is no dedicated legislation for telemedicine, leading to fragmented and ad hoc adoption across provinces. In addition, insufficient funding for digital infrastructure in municipal budgets and weak enforcement of data-protection laws in public clinics further impede progress.
For Gauteng’s municipal clinics, the legislative environment presents both opportunities and challenges. On the one hand, POPIA and the Digital Health Strategy provide a clear framework for secure, patient-centred digital care. On the other hand, poor coordination between national and provincial policies, coupled with persistent resource constraints, has slowed the pace of digital transformation.
Thus, while South Africa’s legislative framework for digital health is theoretically robust, its practical implementation remains uneven. To overcome these barriers, targeted policy interventions such as earmarked funding for rural digital infrastructure and standardised EHR protocols are essential. This study will evaluate how existing legislative gaps impact digital transformation at the clinic level, with the aim of informing recommendations for better alignment between policy and practice.
Municipal clinic services and primary health care
South Africa faces significant challenges in digitalising health care because of socio-economic inequalities, limited infrastructure and a pronounced urban–rural digital divide (Blom & Uwizeyimana 2020). While internet use and digital engagement have increased in urban centres, rural regions still lack reliable internet and adequate digital tools (Anakwe et al. 2021). This disparity restricts access to digital health services and perpetuates inequality in health care outcomes (Aruleba & Jere 2022).
In Gauteng, the most populous province, digital transformation presents both challenges and opportunities. Urban areas generally benefit from better infrastructure, while rural clinics experience limited connectivity, staffing shortages and outdated systems (Kunene & Mapulanga 2023). These gaps hinder the implementation of electronic medical records (EMRs), telemedicine and other technologies essential for coordinated and real-time care delivery (Blom & Uwizeyimana 2020).
Despite its economic strength, Gauteng’s health care sector struggles with underfunding and insufficient ICT resources, particularly in rural communities (Kuldosheva 2021). The COVID-19 pandemic highlighted these limitations, as only urban clinics could implement basic telehealth systems. Bridging the digital divide requires targeted investment in infrastructure, digital literacy training and policy support to promote equitable and effective health care delivery across the province.
South African context on digital transformation in municipal health care
South Africa faces unique challenges in digitalising health care services because of socio-economic disparities, infrastructural limitations and the digital divide between urban and rural areas (Blom & Uwizeyimana 2020). Despite advancements, only 22% of the African continent had internet connectivity as of 2017, with the majority of South African ICT users in rural areas having limited access to advanced digital tools (Anakwe et al. 2021). While urban centres in South Africa have seen significant growth in internet use and digital engagement, rural areas remain underserved, lacking access to stable internet and digital literacy. These constraints hinder the development and implementation of digital health solutions in municipal clinics, especially in economically disadvantaged areas (Aruleba & Jere 2022). Consequently, the digital divide restricts rural patients’ access to digital health services, widening the gap in health outcomes.
In Gauteng province, digital transformation in municipal health care services faces unique challenges and opportunities because of the region’s demographic and economic profile. Gauteng is South Africa’s most populous province, housing over 14m people, and it includes significant urban centres such as Johannesburg and Pretoria alongside underserved rural communities (Kunene & Mapulanga 2023). While urban areas in Gauteng generally have better access to digital infrastructure, health care facilities in rural parts of the province lag in connectivity and resource availability, which exacerbates health care access disparities. The digital divide is pronounced here, as rural clinics often lack stable internet access, EMR systems and telehealth capabilities. These limitations hinder the effective digitalisation of municipal health care, preventing health care providers from delivering efficient, coordinated care and reducing the capacity for real-time patient data management and communication with specialists in urban centres (Blom & Uwizeyimana 2020).
Despite Gauteng’s position as an economic powerhouse in South Africa, provincial health care facilities continue to experience underfunding, staff shortages and inadequate ICT resources, which inhibit digital transformation efforts (Kuldosheva 2021). The COVID-19 pandemic highlighted the need for digitalisation, as clinics struggled to adapt to increased patient loads and maintain service continuity. During this period, urban Gauteng clinics managed to implement basic telehealth services; however, the lack of digital infrastructure in rural areas made it challenging for these facilities to adopt similar measures. Gauteng’s health care system requires targeted investments and policy initiatives to bridge these digital gaps, with a focus on expanding internet connectivity, digital literacy training for health care staff and integrating digital tools into everyday clinical workflows. Addressing these digital challenges would enable Gauteng’s municipal health care services to provide more equitable, efficient and quality care across both urban and rural areas, aligning with the broader objectives of South Africa’s health care transformation agenda.
The current state of digitalisation in Gauteng’s municipal health care services
The current state of digitalisation in Gauteng’s municipal health care services is progressing slowly, marked by limited funding and significant challenges in implementation. In the 2022–2023 financial year, a budget of R11m was allocated specifically for developing the e-health system in Tshwane, which is seen as a crucial step towards broader digitalisation across municipal clinics (Aruleba & Jere 2022). This relatively small investment reflects the challenges Gauteng faces in advancing its health care digital transformation. Willie and Nkomo (2019) note that, despite various initiatives, the health care sector in South Africa is lagging behind international standards, with essential tools such as EMRs still not fully integrated into everyday clinic functions. Findings from the Health Professions Council of South Africa (HPCSA) also underscore the fact that many municipal clinics lack the digital infrastructure necessary for effective chronic disease management, diagnostics and patient treatment (Willie & Nkomo 2019).
Aruleba and Jere (2022) further explain that while the potential of the 4IR offers technologies such as artificial intelligence, machine learning and data analytics, these are not yet widely applied within South Africa’s health care sector. These digital health technologies could greatly support chronic disease management, a critical need given the rising incidence of lifestyle-related conditions like diabetes in South Africa. However, in practice, most ICT infrastructure is limited to basic uses such as SMS and voice calls, especially in rural and underserved areas. Internet access disparity between urban and rural areas exacerbates the challenge: as of 2018, only about 1.7% of rural households had internet access at home, compared to 17.3% in urban areas, highlighting a notable digital divide (Aruleba & Jere 2022). As a result, the digitalisation of municipal health care services in Gauteng is still in its early stages, constrained by budgetary limitations, infrastructural gaps and the digital literacy needed to effectively utilise these new technologies (Borgen Project 2022; Pita-Barros et al. 2019; Ricciardi et al. 2019).
Barriers to digital transformation of municipal clinic services
Digital transformation is hindered by a range of barriers including high costs, limited internet access, low-quality platforms and information security concerns (Pita-Barros et al. 2019; Ricciardi et al. 2019). User engagement and alignment with patient needs are critical for success, especially in chronic care contexts (O’Connor et al. 2016). Low digital literacy further complicates implementation (Kuldosheva 2021).
Institutional barriers such as unclear governance, weak leadership and resistance to change also obstruct progress (Blom & Uwizeyimana 2020). Legal gaps in data protection and cybersecurity policies exacerbate institutional reluctance. Additionally, cultural resistance and geographic disparities require locally tailored strategies to facilitate widespread adoption and effectiveness (Blom & Uwizeyimana 2020; Siddiquee 2016).
The literature reveals significant barriers to digital transformation in municipal health care services, particularly in resource-limited settings such as Gauteng’s rural clinics. While existing studies highlight infrastructural and socio-economic challenges, only a few focus on the nuanced implementation of EHRs within South Africa’s public health care framework. This study seeks to address that gap by examining how EHR adoption is influenced by digital readiness, resource allocation and institutional frameworks in municipal clinics. In doing so, it contributes valuable empirical evidence to the field of EHRs, with implications for improving health care delivery and equity in similar developing contexts.
Theoretical framework
In examining the barriers to digital transformation in Gauteng’s municipal health care services, the Complex Systems Theory provides a robust theoretical framework. This theory, which focuses on understanding systems with multiple interacting components, is highly relevant to the intricacies of health care digitalisation. In particular, the Complex Systems Theory is useful for understanding how various interacting factors such as technological, institutional, socio-economic and regulatory policies impact the progression of digital transformation efforts within health care services (Bar-Yam 2019).
The origins of the Complex Systems Theory can be traced to disciplines such as physics, biology and systems science, where researchers sought to understand how large-scale behaviours emerge from interactions among smaller components. In recent decades, the theory has been increasingly applied in organisational studies and public health to analyse how decentralised, interdependent elements give rise to unpredictable system behaviours. The Complex Systems Theory suggests that systems composed of interrelated parts, such as municipal health care services, tend to exhibit complex and often unpredictable behaviours because of the interactions between those parts. In a health care context, these components include various stakeholders (e.g. health care providers, patients, government bodies), digital infrastructure, policies and socio-cultural norms that collectively impact the digitalisation process. Bar-Yam (2019) argues that these systems do not function in a linear way; instead, changes in one part of the system can lead to unexpected outcomes in others, which aligns with the unpredictable nature of digital transformation in health care. Understanding these interactions is crucial for identifying barriers and creating effective digitalisation strategies.
Health care delivery, especially at the municipal level, is inherently complex, as it involves multiple stakeholders, each with their own interests, goals and operational procedures. The implementation of digital systems within this context does not simply mean introducing new technologies but requires shifts in organisational behaviour, user adaptation and infrastructural support. Kern et al. (2019) point out that this complexity often results in challenges when introducing quality improvement measures in primary health care settings, as changes need to be adaptive to suit the diverse practices across different sites. Applying the Complex Systems Theory, therefore, allows for an analysis that considers these interdependencies and highlights the barriers resulting from these dynamic interactions.
The Complex Systems Theory is particularly relevant in situations where a multitude of variables affects system functioning. Chandler et al. (2016) suggest that in community-based health care settings, previous interventions have achieved only limited success because of the variation in practices across different sites. This variation can be attributed to the complex interactions within the system, where each component, whether technological, procedural or human all contributes to the outcome in ways that are difficult to predict. When applied to Gauteng’s municipal clinics, the Complex Systems Theory can help evaluate the interaction between various barriers, such as limited digital infrastructure, socio-cultural resistance to digital tools and regulatory challenges, providing insight into how these elements influence one another and the overall digital transformation process.
One of the theory’s major strengths is its emphasis on adaptation and flexibility within complex environments. As highlighted by Chandler et al. (2016), digital transformation in health care requires continual adjustments based on the interactions and feedback within the system. This adaptability is critical in a health care context where technological innovations often demand structural changes in how services are delivered. The applicability of the Complex Systems Theory to this study is significant, as it provides a lens through which to explore the intricate interactions and barriers in the digital transformation of municipal health care services in Gauteng (Freeman, Harrison & Zyglidopoulos 2018; Iyanna et al. 2022; Radebe, Moropeng & Patrick 2024). However, a key limitation of the Complex Systems Theory lies in its inherent abstraction and the difficulty of translating its conceptual insights into concrete policy or operational strategies. In addition, the theory may not always offer clear causal pathways, making it challenging to design linear interventions within complex environments.
Methodology
This research employed a qualitative, exploratory research design as this aligns with the study’s goal of uncovering the experiences, perspectives and contextual factors influencing digital transformation efforts in Gauteng’s municipal clinics. Exploratory research is particularly suited to areas with limited pre-existing knowledge, as it allows for the flexible and open-ended collection of data. As this study sought to gather detailed information on the complex and context-specific barriers to digital transformation, a qualitative design was ideal, allowing participants to express their thoughts and experiences in their own words (Erath et al. 2021; Hunter McCallum & Howes 2019).
Primary data collection was conducted through semi-structured interviews. This technique allowed for the exploration of pre-determined topics while enabling flexibility for interviewees to introduce new ideas or elaborate on points of interest. The researcher designed open-ended questions focused on areas such as technological challenges, institutional support, training, infrastructure and patient acceptance of digital systems. By utilising interviews, this study captured the perspectives and insights of clinic staff, including nurses and administrative personnel, who are directly impacted by digitalisation efforts in their day-to-day operations (Simister 2019).
The population targeted for this study consisted of health care professionals working in municipal clinics in the Gauteng province, specifically in metropolitan areas such as Johannesburg, Ekurhuleni and Tshwane. Gauteng is the most populated province in South Africa with an estimated population of over 15m people, placing significant demand on its health care infrastructure (Statistics South Africa 2023).
A purposive sampling method was employed to select 15 participants who had relevant experience and knowledge regarding digital transformation initiatives in their clinics. This sample size was chosen based on prior qualitative research that suggests that 15 participants can often provide sufficient depth of insight to achieve data saturation when the participant group is relatively homogeneous (Ahmed 2025). In this study, data saturation was reached when no new themes or insights emerged from the interviews, confirming the adequacy of the sample size. By focusing on professionals who interact daily with clinic management systems and patient records, the study aimed to capture a comprehensive understanding of the challenges associated with digitalisation from an operational perspective. The final sample included nurses, support staff and clinic managers, providing a diverse range of insights into the existing barriers to digitalisation (Changiz, Yousefy & Fakhari 2020; Hodge 2020).
The researcher conducted interviews in a semi-structured format, enabling a conversational approach while ensuring that key topics were covered. Before the interviews, participants were informed about the study’s aims and provided consent. The interviews were conducted at a time and location convenient for the participants, ensuring comfort and privacy, which encouraged open and honest responses. Each interview lasted approximately 30 min – 45 min and was recorded with the permission of the participants to ensure accuracy in data collection. Anonymity and confidentiality were emphasised to protect participants’ privacy and promote candid feedback on institutional challenges and experiences (Siedlecki 2020; Sivaram, Munawar & Ali 2019).
Thematic analysis was used to analyse the data collected from interviews. This method, following Braun and Clarke’s (2006) six-phase framework, is well-suited for identifying and interpreting patterns within qualitative data. Transcripts were reviewed multiple times to ensure familiarity, and initial codes were generated using both inductive and deductive approaches. This allowed the researcher to identify both anticipated and emerging themes.
Codes were organised into broader themes such as technological issues, infrastructural challenges, institutional support and training needs. These were reviewed and refined to ensure clarity and relevance. Each theme was then clearly defined and linked back to the study’s objectives.
This structured and iterative process ensured a rigorous, transparent analysis grounded in participants’ experiences, enhancing the credibility and trustworthiness of the findings (Braun & Clarke 2006; Iacus, King & Porro 2019; Tuffour 2017).
To enhance the study’s validity, member checking was used, where participants reviewed summaries of their interviews to ensure accuracy and relevance. This step helped to validate the findings by ensuring that participants’ views were accurately reflected in the study’s outcome. Reliability was addressed by conducting interviews in a consistent manner, using the same guide and structure across all participants. By cross-referencing findings with previous studies on health care digitalisation challenges, the study sought to ensure that the emerging themes aligned with existing research while reflecting the specific context of Gauteng’s municipal clinics (Opie 2019; Sürücü & Maslakci 2020).
Ethical considerations
Ethical clearance to conduct this study was obtained from the University of Johannesburg, Business School of Research Ethics Committee (JBSREC2023142).
Results and findings
The digital transformation of municipal clinics is vital for enhancing health care delivery and patient experience. However, several barriers impede this process. Interview participants provided insights into these obstacles, which can be categorised into themes such as inadequate infrastructure, financial constraints, resistance to change, data security concerns and staffing issues.
Inadequate infrastructure
One of the main barriers to digital transformation is inadequate infrastructure. DM found that municipal clinics are inconsistently equipped with the necessary facilities to support digital processes. A participant stated:
‘To fully transform a clinic digitally, you require facilities such as electrical generators, computers, digital screens for queue management, etc. These are not readily available at various clinics across municipalities.’ (Respondent 1, Supervisory (Technical Duties - ICT), Between 41–50)
Additionally, a reliable ICT infrastructure, crucial for connectivity and the functioning of digital platforms, is often missing. Respondent 2 added:
‘Reliable ICT infrastructure forms the basis for a digitally transformed municipal service, and this is not available for some of the municipal health facilities.’ (Respondent 2, Political Head, Policy Maker – Health, Above 51)
The lack of this essential infrastructure results in disparities between clinics, where some can offer digitally integrated services while others still operate with outdated systems. This inconsistency not only reduces the health care system’s efficiency but also creates unequal access to quality care across different municipalities. Therefore, addressing these infrastructural gaps is essential for successful digital transformation across municipal health services.
Financial constraints
Financial constraints present another significant barrier. Respondents highlighted the effect of limited budgets on digital transformation initiatives. Respondent 3 noticed:
‘Availability of funding for digital initiatives is also a key barrier to digital transformation in general.’ (Respondent 3, Supervisory (Managerial Duties - Strategy), Between 41–50)
Similarly, Respondent 4 mentioned that budgetary limitations affected clinics’ staffing levels and investment in required technologies:
‘Adequately staffing clinics will assist to improve turnaround times for patients and ensure that patients get dedicated individualised attention when consulting.’ (Respondent 4, Supervisory (Managerial Duties – ICT, Between 41–50)
Respondent 5 complimented this and also pointed out that local governments frequently lack the funding necessary to invest in advanced digital health technologies:
‘Financial constraints are a significant challenge, as local governments often lack the necessary funding to invest in advanced digital health technologies.’ (Respondent 5, Supervisory (Managerial Duties - Health), Above 51)
These financial limitations thus form a significant obstacle, as local authorities struggle to allocate resources for adopting advanced digital health solutions.
Resistance to change and lack of digital literacy
Resistance to change and limited digital literacy among health care professionals and patients are also considerable barriers. Respondent 6 highlighted the fact that computer literacy among clinicians and resistance to new systems could hinder digital adoption:
‘Computer literacy by the clinicians is another factor that hinders the adoption of systems that would transform municipal clinics. Resistance to change could also be a barrier if not appropriately managed.’ (Respondent 6, Supervisory (Managerial Duties - Health), Between 41–50)
Respondent 7 agreed with this and said:
‘Healthcare professionals may resist changes due to a lack of understanding of the benefits of digital transformation. Effective change management strategies are necessary to foster acceptance and integration of new technologies.’ (Respondent 7, Technical - Middle Management – ICT, Between 31–40)
Respondent 8 also found that older generations might not be as technologically adept and are often hesitant about change:
‘The older generation is not as tech-savvy and is afraid of the unknown.’ (Respondent 8, Supervisory (Managerial Duties - Health), Above 51)
These responses underscore the need for change management strategies to improve stakeholder acceptance of digital transformation initiatives.
Data security and privacy concerns
Data security and privacy concerns emerged as critical issues in the digital transformation of health care services. AM stressed the importance of protecting patient data as it becomes digitised. Respondent 9 highlighted:
‘As patient data becomes digitised, ensuring data security and privacy is critical. Concerns about information falling into the wrong hands must be addressed with robust security measures.’ (Respondent 9, Technical Work (Clinician, Doctor, Nurse), Between 20–30)
These concerns can foster resistance among stakeholders who worry about the security of digital systems, emphasising the need for stringent data-protection measures to build trust in digital health technologies.
Staffing and human resource issues
Staffing issues, including high vacancy rates and turnover among health care professionals, are also barriers to digital transformation. Respondent 10 observed that staff shortages, with a high vacancy rate, complicated the effective implementation of digital systems:
‘The vacancy rate is currently at around 42%. Adequately staffing clinics will assist to improve turnaround times for patients.’ (Respondent 10, Administrative (Support Staff), Between 31–40)
Respondent 11 opined the impact of high workloads and insufficient support on the turnover of health care professionals, which further hampers the adoption of new technologies:
‘The resignation of healthcare professionals, driven by high workload and inadequate support, further complicates the implementation of new technologies.’ (Respondent 11, Technical Work (Clinician, Doctor, Nurse), Between 41–50)
These responses reveal the fact that human resource challenges hinder both the continuity and efficiency of digital transformation efforts in health care settings.
Digital divide and infrastructure issues
The digital divide, especially in rural areas, was identified as a substantial challenge. Respondent 12 mentioned that access to digital tools and stable internet connectivity is still limited, impacting equitable access to health care services:
‘Access to digital tools and stable internet connectivity remains a challenge, particularly in rural areas.’ (Respondent 12, Technical Work, ICT related, Between 20–30)
Addressing this divide is crucial to ensure that all communities benefit equally from digital health services. However, the barriers to digital transformation in Gauteng municipal clinics are multifaceted, encompassing issues such as inadequate infrastructure, financial constraints, resistance to change, data security and staffing challenges. Tackling these barriers requires a holistic approach that includes investments in infrastructure, securing adequate funding, implementing change management strategies, ensuring data security and improving staffing levels. Overcoming these challenges is crucial for fully realising the potential of digital transformation to enhance health care delivery and patient experience in municipal clinics.
Discussion
The results of this study highlight significant challenges to the digital transformation of municipal health care services in Gauteng, aligning with broader literature on digital health adoption in low-resource settings. Key barriers include inadequate infrastructure, financial constraints, resistance to technological change, data security concerns, staffing shortages and the digital divide.
Inadequate infrastructure and operational challenges
The study identified infrastructure gaps as a fundamental obstacle to digital transformation. Respondents emphasised the absence of a reliable ICT infrastructure, backup power solutions and essential digital tools such as queue management systems. These shortcomings impair routine operations, limit data management capacity and disrupt continuity of care. These findings align with the work of Malakoane et al. (2020) and Fischer, Boone and Neumann (2020), who argue that poor infrastructure exacerbates inefficiencies in health care delivery. The absence of stable internet connections and power supply particularly affects rural clinics, worsening disparities in health care access. Consequently, infrastructure deficiencies not only slow digital transformation but also perpetuate inequities between urban and rural health care facilities. Such infrastructural deficiencies not only delay the digitisation process but also reflect underlying structural inequalities, necessitating targeted infrastructural reform.
Financial constraints and budgetary limitations
Limited financial resources emerged as a major impediment to digital transformation, restricting investment in new technologies, system maintenance and staff training. Respondents found that existing budgetary limitations prevent the procurement of essential digital health tools. This finding aligns with Loonam et al. (2018) and Blom and Uwizeyimana (2020), who argue that sustainable funding models are critical for the successful implementation of digital health care systems. The lack of flexible and forward-looking budgeting strategies compounds this problem, contributing to fragmented implementation. Moreover, inadequate financial planning affects the long-term sustainability of digital initiatives, leading to incomplete or abandoned projects. Without sufficient funding, municipal clinics struggle to adopt and maintain digital systems, undermining operational efficiency and patient care outcomes.
Resistance to change and limited digital literacy
A key barrier to digital transformation is resistance to change among health care staff, particularly older professionals with limited exposure to digital health solutions. Respondents noticed a lack of awareness regarding the benefits of digital transformation, contributing to scepticism and reluctance in adopting new technologies. Aruleba and Jere (2022) identified similar challenges in other developing nations, where digital literacy gaps hinder adoption. This resistance is not merely cultural but often stems from fear of job displacement, uncertainty about technological competence and insufficient leadership communication. To mitigate this resistance, targeted training programmes and change management strategies are needed. Structured digital literacy initiatives should focus on equipping staff with practical skills and demonstrating how digital solutions enhance efficiency and patient outcomes. Importantly, cultivating a culture of continuous learning and open dialogue is essential to transforming attitudes and building trust in digital solutions.
Data security and privacy concerns
The digitisation of health care records raises concerns regarding data security and patient privacy. Respondents highlighted fears of data breaches and unauthorised access, which impact trust in digital health systems. This aligns with findings by Pastorino et al. (2019) and Anakwe et al. (2021), who emphasise the importance of strong cybersecurity measures in digital health care environments. Concerns about regulatory compliance, identity theft and inadequate safeguards highlight gaps in institutional preparedness and risk management. Without adequate protections, resistance from both health care workers and patients could hinder digital transformation efforts. The implementation of encryption, secure authentication protocols and regulatory compliance measures is essential to build trust and ensure the safe handling of patient information. Clear policies, user training and accountability frameworks must accompany technological solutions to foster a culture of digital trust and responsibility.
Staffing shortages and high turnover rates
Human resource challenges emerged as a significant limitation to digital transformation. Respondents reported high vacancy rates and frequent staff turnover, which hinder effective digital adoption. Studies by Blom and Uwizeyimana (2020) and Asah et al. (2020) similarly found that overburdened health care staff often lack the time and resources to engage with new digital systems. High workloads and understaffing not only reduce efficiency but also limit the ability of health care workers to participate in digital training programmes. Furthermore, constant workforce disruptions prevent the continuity needed to embed digital practices into daily workflows. Addressing workforce shortages through targeted recruitment, retention strategies and incentives for digital health training is essential for successful transformation. Developing a resilient, digitally literate workforce is not only critical for implementation but also for innovation and sustainability of digital health care delivery.
The digital divide and health care inequities
The study also highlights the impact of the digital divide, particularly in rural areas with limited access to stable internet connections and digital health tools. Respondents from rural clinics noted that unreliable connectivity and lack of access to basic ICT infrastructure prevent them from implementing digital solutions effectively. This finding aligns with research by Asah et al. (2020), Botti and Monda (2020) and James (2022), who emphasise that disparities in digital access reinforce health care inequities. The urban–rural divide in digital capacity reflects broader social and economic inequalities that must be addressed through inclusive policymaking and infrastructure development. Bridging this divide requires targeted investments in rural health care infrastructure, ensuring that digital transformation benefits all communities equally. Inclusive digital strategies must prioritise equity to avoid deepening existing disparities in access to quality health care.
Study’s limitations and suggestions for future studies
While this study offers valuable insights into the barriers to digital transformation in municipal clinics within Gauteng province, several limitations should be acknowledged.
Firstly, the study employed a qualitative design with a relatively small sample size of 15 participants selected through purposive sampling. While this approach facilitated rich, in-depth exploration of participants’ experiences, it may limit the generalisability of findings to other regions or health systems beyond the selected metropolitan areas. Future research could adopt a mixed-methods approach to include quantitative data from a larger, more representative sample across multiple provinces to enhance generalisability and statistical rigour.
Secondly, data were collected at a single point in time, capturing perceptions during a specific phase of digital transformation. This cross-sectional nature of the research limits the ability to track how challenges evolve over time. Longitudinal studies are recommended to assess changes in attitudes, capacity and system performance as digital transformation efforts progress.
Thirdly, while semi-structured interviews offered flexibility and depth, the subjectivity of participants’ responses and the researcher’s interpretations may introduce bias. Triangulating interview data with observational data or institutional records in future studies could strengthen the reliability of findings.
Lastly, the study focused primarily on internal operational perspectives that is, those of clinic staff and administrators without integrating the patient perspective, which is vital in assessing the user-friendliness and accessibility of digital health care systems. Future research should include patient voices to ensure that digital health initiatives are responsive to community needs and expectations.
By addressing these limitations, future studies can contribute to a more holistic and dynamic understanding of digital transformation processes within public health care systems, both in South Africa and comparable low- and middle-income settings.
Recommendations
To effectively drive digital transformation within Gauteng’s municipal health care services, the following recommendations are proposed for consideration:
Infrastructure Development: Investment in stable internet connectivity, reliable power supply and essential digital tools such as EHRs and digital queue management systems is necessary to support seamless health care operations. This addresses the infrastructural challenges highlighted by clinic staff, who reported frequent system downtimes and inadequate digital tools. Provincial health departments, in collaboration with municipal IT units and private telecom providers, should lead the planning and implementation of such infrastructure upgrades. Sustainable Funding and Resource Allocation: Municipal and provincial governments should increase budgetary allocations for digital health care initiatives. Establishing public–private partnerships and seeking external funding sources can provide the financial support needed to maintain and expand digital transformation efforts. This recommendation responds to the finding that limited financial resources hinder the rollout and maintenance of digital systems. Health administrators and treasury officials should develop long-term financial plans tied to measurable digital health objectives. Digital Literacy and Change Management: Training programmes should be implemented to equip health care professionals with the necessary digital skills. Change management strategies should be developed to address resistance to technology adoption and ensure smooth transitions. Based on participants’ concerns about staff unpreparedness and reluctance to adopt new systems, clinic managers and HR departments should design targeted, practical training modules and incentives for digital adoption. Enhanced Data Security and Privacy Protection: Strong cybersecurity measures, including encryption, access controls and compliance with national and international data-protection regulations, must be enforced to build stakeholder confidence and protect sensitive patient information. Given participants’ fears about patient data breaches, provincial e-health directorates must collaborate with cybersecurity consultants to audit existing systems and develop standardised protocols. Workforce Development and Retention: Strategies to recruit, retain and upskill health care workers, particularly in rural areas, should be prioritised. Competitive incentives, continuous training and improved working conditions can help sustain a skilled workforce capable of supporting digital health care systems. Participants cited staff shortages and burnout as barriers to implementation; hence, municipal HR departments must include digital roles in workforce planning and retention strategies. Bridging the Digital Divide: Focused interventions, including the expansion of digital infrastructure to underserved areas, should be pursued to ensure equitable access to digital health care solutions across urban and rural clinics. This reflects the geographical disparities highlighted in the interviews. Stakeholders such as provincial ICT agencies, telecom partners and local leaders should coordinate efforts to extend connectivity and digital tools to marginalised locations. Stakeholder Engagement and Collaboration: Active involvement of all stakeholders—including health care providers, government agencies, technology experts and community members is essential for the successful design and implementation of digital transformation initiatives. Policymakers should engage in continuous dialogue with health care workers to ensure that digital solutions are practical, user-friendly, and aligned with patient needs. Interviewees emphasised the need for inclusive planning. Policymakers should engage in continuous dialogue with frontline staff and end-users through regular feedback forums, pilot programmes and participatory design workshops to ensure digital solutions are practical and acceptable. Monitoring and Evaluation Framework: A structured evaluation system should be established to track the progress of digital transformation efforts. Key performance indicators (KPIs) should be used to assess the effectiveness of digital tools, measure improvements in service delivery and identify areas for further refinement. Given concerns over accountability and sustainability, the provincial Department of Health should institute a digital transformation performance dashboard, regularly reviewed by a multi-stakeholder advisory committee.
By implementing these recommendations, municipal health care system can overcome existing challenges and move towards an integrated, efficient and digitally-enabled health care framework that improves patient care and overall health system performance.
Conclusion
This study highlights the significant potential of digital transformation to enhance municipal health care services in Gauteng, yet its implementation is hindered by a range of systemic and structural challenges. Key obstacles include inadequate infrastructure, financial constraints, resistance to digital adoption, data security concerns, staffing shortages and disparities in digital access between urban and rural clinics. These barriers not only slow the adoption of digital health care solutions but also contribute to inefficiencies and inequitable service delivery.
The findings indicate that successful digital transformation requires a strategic, well-coordinated approach that integrates technological, financial and human resource considerations. Addressing these challenges will necessitate significant investment in ICT infrastructure, sustainable funding mechanisms, training programmes to improve digital literacy, robust data security measures and workforce strategies that ensure sufficient staffing and support for digital adoption. A well-structured and integrated digital framework will be critical in bridging the existing gaps and facilitating the seamless implementation of digital health care solutions.
Ultimately, by overcoming these challenges, municipal clinics in Gauteng can improve the quality, accessibility and efficiency of health care services. Digital transformation presents a viable path towards achieving better patient outcomes, reducing operational inefficiencies and enhancing overall health care system resilience.
Acknowledgements
This article includes content that overlaps with research originally conducted as part of Musawakhe Khumalo’s doctoral thesis titled ‘A digital transformation framework for enhancing access and quality of municipal clinic services’, submitted to the Johannesburg Business School, University of Johannesburg in 2025. The thesis was supervised by Prof. Tankiso Steven Moloi. Portions of the data, analysis and/or discussion have been revised, updated and adapted for journal publication. The original thesis is publicly available at the university library. The author affirms that this submission complies with ethical standards for secondary publication, and appropriate acknowledgement has been made to the original work.
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Authors’ contributions
M.H.K. contributed to the conceptualisation of the study as well as writing. T.S.M. provided supervision. The study is part of the PhD submission at the University of Johannesburg. All authors contributed to the article, discussed the results and approved the final version for submission and publication.
Funding information
This research received no specific grant from any funding agency in the pubic, commercial or not-for-profit sectors.
Data availability
The data that support the findings of this study are available from the corresponding author, M.H.K., upon reasonable request.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.
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