Validity, Digital Responsibility, and the Community Health Workforce in Fragile Contexts: Governance Innovations and Health Service Performance in Somalia

Abstract Objectives This study investigates the association between the deployment of a community-based female health workforce program (Marwo Caafimaad) and the integration of District Health Information Software 2 (DHIS2)-enabled digital accountability mechanisms with maternal and child health (MCH) service utilization, governance responsiveness, and perceived service-level legitimacy within Somalia’s fragile health system. Methods An explanatory sequential mixed-methods case study was conducted across multiple Federal Member States of Somalia. Quantitative analyses utilized routine DHIS2 data (2018–2024) on antenatal care (ANC1), skilled birth attendance (SBA), and third-dose pentavalent vaccination (DPT3), applying difference-in-differences (DiD) models where phased roll-out permitted. Exposure was defined by the documented implementation of the Marwo Caafimaad program and functional district-level DHIS2 community feedback channels. Data quality was assessed through reporting completeness, cleaning protocols, and sensitivity analyses. Qualitative data (2024) were collected via key informant interviews and focus groups, analyzed using a realist evaluation lens to derive mechanism–context–outcome configurations. Findings were triangulated through joint display. Results Districts implementing both interventions demonstrated statistically significant improvements in ANC1, SBA, and DPT3 coverage relative to comparison districts. Qualitative analysis identified three reinforcing mechanisms: (1) culturally aligned female CHWs enhanced trust and acceptability; (2) digital feedback loops facilitated timely responsiveness and problem resolution; and (3) pragmatic legitimacy was strengthened through visible fairness and accountability. These mechanisms contributed to increased service uptake amidst insecurity and variable facility readiness. Conclusions In fragile and conflict-affected settings, the alignment of community health workforce strategies with actionable digital accountability mechanisms is associated with enhanced service performance and service-level legitimacy. Somalia’s experience underscores the amplifying effect of governance “software” (trust, responsiveness, fairness) on technical reforms.