From face-to-face to e-learning: transitioning to new training models to strengthen the health system by supporting primary healthcare workers in low- and middle-income countries

Reliance on purely face-to-face in-service training for primary healthcare workers in low- and middle-income countries is increasingly unsustainable. The COVID-19 pandemic accelerated the transition of the University of Cape Town Knowledge Translation Unit's Practical Approach to Care Kit programme from a facility-based cascade model to online and blended learning formats.This paper analyses the implementation of this transition across 29 courses between 2020 and 2023 in South Africa. Using the Health System Process Goals framework, we reflect on the challenges and enablers of e-learning, shifting the focus from digital training as a standalone technical solution to a systemic enabler of health system strengthening.While e-learning expanded access and standardised content, successful implementation relied on addressing systemic barriers. Key learnings include the necessity of subsidised ('reverse-billed') data to ensure equitable access; the superiority of a 'blended' pedagogical model that combines digital content with peer interaction and in-person technical support and the value of automated reporting for workforce management. The systemic barriers included the lack of protected time for learners, which risks placing an inequitable burden on the workforce and reliance on donor funding, challenging long-term institutionalisation.For e-learning to effectively strengthen the health system, it must be integrated into administrative workflows and budget lines. We provide actionable recommendations for Ministries of Health, funders and implementers, advocating for a transition to government-owned platforms, accredited blended learning models and policy that mandates protected time for capacity development.