Governance and implementation of solar-powered digital health systems in low- and middle-income countries: a mixed-methods study from Kenya and Ethiopia.

Background: Digital health systems are increasingly recognised as critical components of health system strengthening in low- and middle-income countries (LMICs). However, their effectiveness is often constrained by unreliable energy infrastructure, weak governance, and fragmented implementation approaches. Solar-powered digital health systems offer a promising solution, but their scalability depends on integrated governance and sustainable implementation models. Objective: This study aimed to develop a governance and implementation framework for scaling solar-powered digital health systems in LMICs, using empirical evidence from Kenya and Ethiopia. Methods: A mixed-methods study was conducted across selected rural and peri-urban health facilities in Kenya and Ethiopia. Data sources included facility-level infrastructure assessments, key informant interviews with health system stakeholders, and a multi-sectoral validation workshop. Quantitative data were analysed descriptively, while qualitative data were analysed using thematic analysis to indicate governance, coordination, and implementation dimensions. Findings were synthesised into a policy-oriented framework. Results: The study emerged from a hybrid governance model combining national-level policy oversight with decentralised implementation as critical for scalability. Cross-sector coordination, facilitated through a Joint Technical Steering Committee, emerged as essential for aligning health, energy, and information and communication technology (ICT) actors. A phased implementation pathway was developed, incorporating facility readiness assessment, system deployment, interoperability, and lifecycle-oriented maintenance supported by public-private partnerships and blended financing mechanisms. The findings highlight the importance of integrating energy infrastructure into digital health governance to ensure system functionality and sustainability. Conclusions: Solar-powered digital health systems can strengthen health service delivery in resource-constrained settings, but require coordinated governance, sustainable financing, and structured implementation strategies. The proposed framework advances an integrated energy-digital health governance nexus, offering a practical and conceptual pathway for scaling resilient digital health infrastructure in LMICs. Policymakers should prioritise cross-sector collaboration and system-level integration to move beyond pilot-driven approaches and achieve sustainable impact.