INTRODUCTION:
EMR systems have a key role in enhancing health service delivery, particularly in resource poor settings. With the eventual withdrawal of the donor, their sustainability is uncertain. This study investigated factors associated with sustainability of EMR systems in Malawi's decentralized health governance context.

METHODS:
A qualitative case study design was adopted. Twelve key informants were purposively sampled, including district health leaders, EMR users, council staff, digital health partners, and Ministry of Health representatives. Data collection involved semi-structured interviews; the data was thematically analyzed using NVivo. The Program Sustainability Assessment Tool (PSAT) guided the analysis across eight sustainability domains.

RESULTS:
Results indicated both facilitators of and barriers to the sustainability of EMRs. Potential local champions include HMIS and M&E Officers; however, limited financial autonomy weakens their capacity to support EMR systems. Funding instability was highlighted as a significant threat due to its reliance on delayed central government transfers. Strong partnerships with EGPAF and PIH provided requisite technical and financial support; however, long term continuity is not secured. Other challenges identified were fragmented information systems, inadequate technical personnel, and the lack of a written sustainability plan. Councils demonstrated ability to assess and adapt; however, communication strategies are poorly developed and long-term planning approaches are lacking.

CONCLUSIONS:
Sustainability of EMR in decentralised settings necessitates enhanced organisational capacity, diversified funding mechanisms, increased partnerships, and explicit sustainability planning. Without such systemic investments, EMR systems are at a great risk of decline once the donors pull out their support. Insights from this study can inform digital health policy and implementation in similar low-resource settings.