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Institutionalizing Information Systems for Universal Health Coverage in Primary Health Care and the Need for New Forms of Institutional Work


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Achieving that all people can use health services of sufficient quality without being exposed to financial hardship, i.e. Universal Health Coverage, is an urgent priority of global health, and to measure progress towards this, countries need to build robust supporting Health Information Systems. Because Universal Health Coverage must be rooted in Primary Health Care, Universal Health Coverage Health Information Systems also need to be sensitively anchored within the existing routine Health Information Systems. This represents a non-trivial challenge, which we study through an empirical analysis of an Indian state's effort to implement a Universal Health Coverage Health Information System within primary care. Using a theoretical lens informed by institutional theory, we seek to answer the question of “what kind of change is required to develop institutions that support the use of new technologies and associated work processes entailed by Universal Health Coverage?” We identify the contradictions that emerge when the new system clashes with what traditionally exists, and we formulate implications in terms of design of systems, work processes and institutions to support implementation. Our paper contributes by building an understanding of inherent complexities in Universal Health Coverage Health Information System design and implementation, and by providing system design guidelines.
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Institutionalizing Information Systems for Universal
Health Coverage in Primary Health Care and the Need
for New Forms of Institutional Work
Sundeep Sahay
Department of Informatics
University of Oslo
Today, many countries around the world focus on ensuring that all people can access health services of sufficient quality
without experiencing financial hardship (i.e., universal health coverage). To measure progress towards this goal,
countries need to build robust health information systems. Because countries need to root universal health coverage in
primary health care, they also needs to sensitively anchor health information systems that support universal health
coverage in existing routine health information systems. However, doing so involves significant challenges, which we
study via empirically analyzing an Indian state's effort to implement a universal health coverage health information
system in primary care. Using a theoretical lens informed by institutional theory, we seek to answer the question: “What
type of change do institutions need to undergo to use the new technologies and associated work processes that
universal health coverage entails?”. We identify the contradictions that emerge when new systems clash with existing
ones, and we discuss what implications such contradictions have in terms of system design, work processes, and
institutions. We contribute to the literature by explaining inherent complexities in universal health coverage health
information system design and implementation and providing system design guidelines.
Keywords: Universal Health Coverage, Health Information Systems, Primary Health Care, Institutional Work.
[Department statements, if appropriate, will be added by the editors. Teaching cases and panel reports will have a
statement, which is also added by the editors.]
[Note: this page has no footnotes.]
This manuscript underwent editorial review. It was received 06/26/2017 and was with the authors for 8 months for 5 revisions. The
Associate Editor chose to remain anonymous.
1 Institutionalizing UHC Health Information Systems within Primary
Health Care
According to the World Health Organization (n.d.):
Universal health coverage (UHC) means that all people and communities can use the promotive,
preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to
be effective, while also ensuring that the use of these services does not expose the user to
financial hardship.
This definition entails three related objectives: equity, sufficient quality of service, and protection against
financial hardship. Achieving universal health coverage (UHC) represents an urgent global priority, and low-
and middle-income countries need to engage in measuring progress towards achieving it. Further, as Chan
(2007, p. 5), notes: data forms a key ingredient in measuring this progress:
Without these fundamental health data, we are working in the dark. We may also be shooting in
the dark. Without these data, we have no reliable way of knowing whether interventions are
working, and whether development aid is producing the desired health outcomes.
In the Global Health 2035 report, the Lancet Commission on Investing in Health put forth an ambitious
investment framework for transforming global health through UHC, which included building pathways to
provide access to services and financially protecting the poor. While various reports have documented
sound technical advice about achieving these goals, such as about designing health service packages and
financing systems (Bump et al., 2016), guidance on designing and implementing supporting health
information systems (HIS) has arguably attracted less focus.
The Institute for Health Metrics and Evaluation has published a composite indicator-based model to
measure progress towards the United Nation’s Sustainable Development Goals (SDG) and since turned its
attention to measure UHC progress (Maurice, 2016). Boerma, Eozenou, Evans, Kieny, and Wagstaff (2014,
p. 2) describe the UHC measurement challenge as follows:
The UHC monitoring framework focuses on simultaneous monitoring of coverage of population
with essential health services and with financial protection against catastrophic out-of-pocket
health payments, stratified by wealth quintile, place of residence and sex.
Today, few countries have a UHC monitoring framework, and data for measurement typically comes from
infrequent household and facility surveys that use standardized questions or rely on potentially unsound
estimates (Boerma, Victoria, & Abouzahr, 2018). The lack of data severely hinders financial measurement.
Thus, countries need to invest in strengthening routine facility HIS and regular health examination surveys,
which they can achieve only by institutionalizing UHC-HIS in primary healthcare, which, in turn, requires a
larger architectural, operational, and institutional integration. As Stigler, Macinko, Pettigrew, Kumar, and
van Weel (2016, p. 1811) argue, primary healthcare forms a necessary foundation for UHC:
Health systems development requires more than financing and human resource considerations.
Although essential, these components must be integrated into an overall framework for organizing
and delivering care…. Primary health care provides such a framework…. [It builds the backbone
of an effective health care system.
However, one cannot easily materialize the above design since UHC involve new and different work
practices compared to traditional primary healthcare with significant implications on the HIS. Sahay,
Sundararaman, and Mukherjee (2014) elaborate on these differences in noting that UHC needs:
1) An expanded basket of services (including non-communicable diseases (NCDs)), not just
primarily maternal and child health as with traditional HIS.
2) .
3) To ensure continuity of care, whereas traditional HIS provided care more incidentally and
4) To monitor the cost of care.
5) To allocate resources based on facility needs, not on uniform allocation models.
Such changes will entail collecting other types of information from different sources as the service coverage
expands. As such, [what/who?] will need to organize the way they manage information directly to support
continuous and episodic care and to reshape the demand-driven way they provide service to a planning-
driven mode.
In this paper, we focus on understanding how countries can ensure that these new practices take root in
the health system. We believe that we need to understand change as more than a reconfiguration of work
practices that one can achieve via installing new systems and training staff. On the contrary, we argue that
this entails more profound institutional changes and that, in making such changes, one needs to ask whether
the required supporting institutional structures for a UHC-HIS exist. For example, the HIS in the primary
healthcare settings in most low- and middle-income countries has historically relied on aggregated data
(e.g., on counts of “number of children born last month”). Technologies designed to enable upward reporting
rather than local action support these reporting needs. In contrast, UHC requires data about patients and
their individual encounters with the health system (e.g., date, time, and place they attend hospital). This
requires a radically different HIS that new institutions and technology support. For example, a new technical
solution could use biometrics to enable personal identification, which requires supporting institutions such
as personal and unique identification numbers and data-protection regulations. Based on this, we
investigate the following research question (RQ):
RQ: What type of change do institutions need to undergo to use the new technologies and
associated work processes that universal health coverage entails?
This paper proceeds as follows: in Section 2, we elaborate on our theoretical perspective that we use to
address this question. In Section 3, we present our research approach and, in Section 4, the empirical study.
The study describes an Indian state’s effort to implement a UHC-HIS in the primary healthcare sector, and
we analyze the challenges of this undertaking as indicating institutional tensions. Based on the analysis, in
Section 5, we suggest strategies for systems design and implementation that help [who] successfully
instutionalize a UHC-HIS in the primary healthcare sector.
2 A Theoretical Perspective to Understand Changing Institutions
We focus on understanding how new work practices will emerge and take root [where]. We chose an
institutional lens to better focus on the institutionalized and embedded practices at our case organization.
As a result, we obtain a frame to discuss whether one may need to dismantle or deinstitutionalize existing
institutions and how one could create (or re-institutionalize) new ones that could support the new practices
that UHC and UHC-HIS entail. Through an institutional analysis, we hope to uncover what it takes to
successfully implement UHC-HIS.
We build on existing research on the impact of information technology on institutions (Gawer & Phillips,
2013; Rajão & Hayes, 2009) and argue that we can attend to what users can do and what they actually do
with available technology to understand how information technology can contribute to dismantling
institutionalized practices. Information technology artefacts potentially afford or constrain different
possibilities of users’ actions, which depend on their goals (Majchrzak & Markus, 2013; Markus & Silver,
2008). In traditional HIS in the primary healthcare sector in low- and middle-income countries, the dominant
institutional norms concern data reporting from the local to the national levels and serve primarily
bureaucratic needs. These norms may conflict with the norms that the UHC-HIS inscribe and that need to
focus more on patients (not on bureaucracy) to improve their health and wellbeing. Such tensions between
the old and new norms can lead to different forms of user resistance (Currie, 2012) and, consequently, to
suboptimal data use. Understanding the possibilities of action that the UHC-HIS provides to its users can
help one to more insightfully analyze how the systems may contribute to deinstitutionalizing historically
embedded work and technical practices.
2.1 Institutions, Institutional Change, and the Role of Technology
Institutions involve assumptions, values, and norms that regulate human behavior (Berger & Luckmann,
1991), which influence how users implement and use information systems (Srivastava & Shainesh, 2015;
Srivastava, Teo, & Devaraj, 2016). [What] understands institutions has its foundations in conceptualizations
of human agency. North (1990, p. 97), for example, describes institutions as:
Humanly devised constraints that structure political, economic and social interaction. They consist
of both informal constraints (sanctions, taboos, customs, traditions, and codes of conduct) and
formal rules (constitutions, laws and property rights).
Jepperson’s (1991, pp. 143-145) describes institutions as the product (intentional or otherwise) of purposive
action, as “an organized, established procedure” that reflects a set of “standardized interaction sequences”.
Researchers have used this lens to develop institutional accounts to understand how existing institutions
influence work practices and vice versa and how these work practices affect whether or not [who/what]
uptakes information technologies or not (Orlikowski, 2000).
Creating new institutions necessarily involves replacing or breaking down existing ones, a process called
deinstitutionalization (Oliver, 1992). With a particular focus on cultural and political factors, Nicholson and
Sahay (2009) draw on this notion in a policy-based analysis in Costa Rica to analyze how introducing new
practices that contradict or cannot coexist with existing practices can help to deinstitutionalize those existing
practices and build the grounds to reinstitutionalize new ones. Accounts of deinstitutionalization have
typically not highlighted the key role that technology plays, something we emphasize in this paper. Different
users may see the same technology as providing them with varying possibilities of action, as shaping their
practices, and as influencing change in different ways. For example, community health workers may see an
organization’s introducing mobile phone work practices as allowing them to send their reports through SMS
and to give their work more visibility. (Mukherjee, 2017). In this way,.
Technology can impact institutionalization processes in other ways as well. The complexity and
interconnectedness of sector-wide health information infrastructure in itself generates a resistance to
change due to its pre-existing arrangements: “an installed base riddled with social (e.g., legal rights and
ownership) and technical (e.g., legacy systems and technical standards) interdependencies” (Sanner,
Manda, & Nielsen, 2014, p. 221). One can change existing institutions, social practices, and technology only
Various studies of HIS in low- and middle-income countries have adopted an institutional lens to highlight
the relation between HIS, users’ practices, and institutions and how may affect information use (Chilundo &
Aanestad, 2004; Kimaro & Sahay, 2007; Noir & Walsham, 2007). We build on this stream of work and further
contribute to it . This approach resembles the one that Braa, Hanseth, Heywood, Mohammed, and Shaw
(2007) followed in showing how a new “flexible standards” model could break down an existing institution
that involved reporting all locally collected data to the national government. Only a new flexible and user
friendly technology could enable this new institution: it allowed actors the freedom to include or exclude
different data elements for stakeholders at different levels. In this way,.
2.2 Strategies for Changing Institutions: Institutional Work
While much research has focused on studying how institutions influence practices, it has insufficiently
studied the reverse relation. Researchers have examined the role of actors and practices in affecting
institutional change either through focusing on the “institutional entrepreneur” (DiMaggio, 1988; Eisenstadt,
1980) or on deinstitutionalization process. Lawrence and Suddaby (2006) brought these various research
streams together with their notion of institutional work: the work that actors purposefully perform to create,
maintain, or disrupt institutions. This practice-oriented lens views institutional work as “intelligent, situated
institutional action” that actors who “may or may not achieve…[their] desired ends” and who “interact with
existing social and technological structures in unintended and unexpected ways” (p. #) perform. Lawrence
and Suddaby identify nine ways to build institutions: 1) advocacy (the mobilization of support), 2) defining
(create identity, rules, boundaries etc.), 3) vesting (allocation of property rights, confer rights), 4)
constructing identities, 5) changing normative associations (redefining the moral and cultural foundations
for practices), 6) constructing normative networks (inter-organizational sanctioning of practice), 7) mimicry
(leverage existing practices, rules, structures), 8) theorizing (naming new concepts and practices), and 9)
educating (providing skills and knowledge). Further, they identify six ways to maintain and reproduce
institutions: 1) enabling work (create rules that facilitate and support the institution), 2) policing (ensuring
compliance), 3) deterrence (establish barriers to change), 4) valorizing and demonizing (evaluations of
moral status), 5) mythologizing (emphasize normative underpinnings), and 6) embedding and routinizing
(inscribing into practices). Further still, they identify three ways to disrupt institutions: 1) disconnecting
sanctions and rewards (from certain practices, such as through legal changes), 2) disassociating moral
foundations (redefining appropriateness), and 3) undermining assumptions and beliefs. While the authors
do not claim to exhaustively list all possible types of institutional work, their framework shows that an actor
can perform many activities to create, maintain, or change institutions. In Table 1 below, we briefly
summarize these three different categories of institutional work.
Table 1. Different Categories of Institutional Work (Lawrence & Suddaby, 2006)
Creating institutions
Maintaining institutions
Disrupting institutions
Work that focuses on creating new
Forms of institutional work:
advocacy, defining, vesting,
constructing identities, changing
normative associations, constructing
normative networks, mimicry,
theorizing, and educating.
Supporting, repairing, or recreating
the social mechanisms that ensure
actors comply with institutions.
Forms of institutional work:
enabling work, policing, deterring,
valorizing and demonizing,
mythologizing, and embedding and
Attacking or undermining the
mechanisms that lead members to
comply with institutions.
Forms of institutional work:
Disconnection sanctions,
Disassociating moral foundations, and
undermining assumptions and beliefs.
Researchers have used this framework to unpack how the design of HIS relates to underlying changes in
healthcare models (Thorseng & Grisot, 2017; Vikkelsø, 2010). In the context of UHC, we ned to ask which
institutions actors need to maintain, disrupt, or create and how (through which strategy) they can do so. At
the same time, we critically discuss the role of contradictions that emerge from different and potentially
conflicting institutional arrangements (new and old) and the transformational power that lies in them (Seo &
Creed, 2002). In summary, we focus on:
1) Understanding the institutional nature of the existing and new practices around the UHC-HIS,
the institutional work, and the ensuing contradictions and tensions the new practices entail when
they clash with the traditionally existing practices and systems.
2) Analyzing these institutional contradictions as opportunities for change and deriving insights on
how actors can effectively leverage this potential on the ground.
3) Deriving insights on the necessary technological material features (design guidelines) that
support the institutional work that actors need to undertake to redesign institutions to create an
effective UHC-HIS.
3 The Empirical Approach
3.1 Case Study Context
3.1.1 Background on Research Project
We conducted a case study in a state in North India. While UHC represents a national priority in India,
different states have shown unequal progress in pursuing the UHC reform agenda, which includes
revamping their HIS (Patel et al., 2015; Devadasan, Ghosh, Nandraj, & Sundararaman, 2014). However,
the state we examined had initiated at least two alternative models (including the one we report on) for
implementing UHC-HIS. We began our case study by focusing on understanding the experience that health
facilities across various districts in the state had with the pilot UHC-HIS implementation, which had ran for
about nine months and had delivered less than expected results. Specifically, we focused on incorporating
the lessons from the first unsuccessful pilot (reported here) into a new attempt to design and anchor a UHC-
HIS in this setting. This new project, which adopted a UHC framework, focused on designing, developing,
and implementing a patient-centric information system for the healthcare facilities, testing its effectiveness,
and allowing the state to evaluate and scale it up if it found the system useful.
The case study forms part of a larger project (called “Building patient-centric systems for primary healthcare
in resource-constrained setting) that wetwo researchers from a university in Norway and one researcher
from a public health university in Norwayundertook with various other stakeholders from 2016 to 2018.
This project focused on. The other stakeholders included two informatics students (one at each university
in Norway and India) who pursued master’s theses on topics relevant to the project (one studied the
evolution of requirements for such a patient-centric system, and the other studied the role of standards and
how to align system design with national-level standards on nomenclature and formats) and a medical
doctor in India who studied the effectiveness of patient-based systems more generally in India and how the
new system impacted patients’ health. In addition to the two research institutions, a third entity, an Indian
NGO, helped to develop the technical systems. The first author of this paper has worked in the public HIS
context in India since 2000 and, more specifically, in the state we examined since 2008. Thus, he has come
to deeply understand the research context, , the state under study, and HIS problems in India more
generally, such as its deeply embedded existing institutional norms and assumptions.
3.1.2 Existing Structures, Systems and Work Practices in the Research Setting
The pilot site (i.e., the state) comprised one rural and one semi-urban distinct. In our project, we focused on
one primary healthcare facility in each district and the five or six outreach centers (called subcenters) that
fell under the primary healthcare facility’s jurisdiction. Each subcenter had one or two field nurses (called
auxiliary nurse midwifes (ANMs)) that provided outreach and clinic-based care (primarily related to maternal
and child health) to three to five villages. A primary healthcare facility, which a medical doctor who provides
outpatient services and limited support staff (e.g., a lab technician) operate, represented the first call for
patients to receive medical care.
The healthcare facilities had preexisting HIS in place that staff members used to, for example, report to
national-level organizations and track pregnant mothers and children for immunization (we counted nine
such reporting systems). The ANMs had the responsibility to provide the data for these HIS. Typically, they
recorded data in their field diaries at the point of care and then transferred it to their primary registers
(typically, each subcenter had about 20 registers that related to antenatal care, immunization, TB, Malaria,
and others) where they entered each patient’s name and the date and details of the service encounter. The
ANMs typically entered information about individuals in multiple registers and also multiple times in the same
On a monthly basis, [who] extracted the required data from the respective registers and transferred it to
various reporting forms that [who] sent to the primary healthcare facility. In the facility, staff members entered
the data into a computer. As such, the new system for our project had to engage with (and hopefully replace)
the cumbersome preexisting systems that featured significant redundancy and involved significant manual
processing (in the registers) but also introduce new informational requirements associated with UHC-HIS
(such as population coverage, non-communicable diseases, referral linkages, etc.).
3.2 Data Collection
. While we draw on the data from both projects to inform our analysis, the case we present primarily draws
from the first one.
3.2.1 Third Party Vendor’s UHC-HIS Project
We began collecting data for this project with a state-level review meeting that the state principal secretary
of health convened in April, 2016. At the meeting, the vendor demonstrated the system under development
and discussed the issues it faced in the presence of various state and district level staff. In this meeting, in
addition to seeing the demonstration, [who] held discussions with the principal secretary, the state project
coordinator, and the vendor. Not satisfied with the project’s progress, the secretary requested the first author
(who had worked in the state for many years) to visit the empirical site to assess the issues and give her a
report. Subsequently, the first author first visited the primary healthcare clinic and then two subcenters under
it over two days. At the primary care clinic, the author conducted three interviews: two with the medical
officers and one with the pharmacist who maintained the computer system. Additionally, the author sat in
the doctor’s cabin and observed his interactions with patients and how he used the pilot UHC-HIS to record
the transaction details. Following the visit, we wrote an assessment report and presented it to the principal
3.2.2 Our Own Projects
As we mention above, we began a research project with two universities and various stakeholders in 2016.
Since our research project began, we collected data through two primary modes. First, the first author made
five trips to the research site to attend workshops and have discussions with health staff at the clinics. During
this process, he conducted at least six interviews with the staff of the clinics and many rounds of formal and
informal meetings with other researchers from the Indian health university. Second, we established a
research team at the project site that included a medical doctor, a data-entry operator, and some support
staff. This team.
Importantly, we set up and used a living lab in the clinic site to collect data and enable system design in
context. This lab enabled the research team, in collaboration with the clinical health staff, to jointly discuss
current systems, work practices, information needs and gaps, and other issues to appropriately design the
new UHC-HIS. The research team could also study the registers in use, seek clarifications on why staff
collected certain data, and observe everyday interactions between patients and doctors.
To date, [who] has hosted at least four workshops to discuss larger research issues and to review project
progress. In the first workshop, we invited various national- and state-level stakeholders who presented
varying experiences of similar patient-centric systems in the country. By sharing these experiences, they
helped [who] understand the strengths and weaknesses of existing systems and provided design inputs for
the system we had begun to develop. In the second workshop, we directly interacted with health staff to
understand design considerations. We studied the different registers and input and output formats, and the
health staff described the kind of changes and improvements they wanted in the new system. In the third
workshop in Oslo, four researchers from India in addition to the Norwegian team and other stakeholders
such as the directorate of e-health shed light on how Norway implemented patient-centric systems, which
helped the research team to identify areas of learning, such as the key role that regulation plays in protecting
patients’ privacy. In the fourth workshop held in India in 2018, we presented the systems we had developed
to date and solicited feedback from various participants for further improvements.
As we state above, two Norwegian masters students in informatics also worked on this project. The first
student diligently recorded the evolution of requirements that resulted from emerging discussions we had
with health staff and the NGO responsible for building the system. Sometimes, particular design choices did
not work, and, through discussions, we identified new requirements, which led to changes in the master
requirements document. The other student, who worked on standards (especially about nomenclature and
formats), produced a wealth of data for his thesis work that became a common shared data resource for
analysis. Further, one PhD student from the Indian side worked on the project and studied the impacts of
the ICT intervention.
In addition to these direct data-collection activities, the research project also included designing, developing,
and implementing the UHC-HIS and training healthcare staff. In the process of building different versions of
the system prototypes and training, we received much feedback that became important sources of data for
the project. These different activities helped generate insights into the institutional challenges of reforming
the old HIS and introducing a new UHC-HIS.
All stakeholders documented the data in the form of interview notes, minutes for meetings, project review
reports, and PowerPoint presentations. Additionally, we compiled informal messages over phone and email
where relevant and often shared and discussed them through face-to-face meetings. We made this data
available to the research team using Google drive, which became the data repository for the project. Table
2 summarizes the different data we collected.
Table 2. Summary of Data Sources
Means of data collection
At project site of third party vendor
At research project site
Five interviews: two with medical officers
and three with field nurses. All conducted
in respective clinics.
Six formal interviews including two with
medical officers and four with field nurses
and clinic staff.
One at the office of state principal
secretary health.
Multiple meetings with research team
during the course of the workshops held.
Four workshops: three in India and one in
Research activities
Developed assessment report.
Two masters students and one PhD
System demos
One at principal secretary health office and
one at primary health care clinic.
At least three formal system demos
Carried out in the primary healthcare clinic
and subcenter of work practices and how
[who] used registers and reports.
We extensively observed HIS-related
activities and interactions between health
staff and patients.
3.3 Data Analysis
To analyze the overall case, we draw on the learning and insights we developed as we designed and
developed the UHC-HIS as we conducted the research project. As a first-level analysis, we compiled data
into various progress reports at different stages of the project and shared it with others. For example, in the
third workshop in Norway, participants intensively discussed a report compiled on the “landscape of patient-
centric systems in India” based on data we collected during the first workshop in India. We prepared and
discussed a preparation based on this report along with other presentations from the Norwegian
participants. We made all various policy documents (such as privacy regulations) available in the common
As a second-level analysis, based on studying different documents and reports, we identified and discussed
themes to help link the themes to the theoretical concepts that we drew primarily from institutional theory.
We contextualized these identified themes and concepts in the broader historical understanding of the state
health system, which led to our developing the case study description.
The research themes identified through the conceptual analysis focused on the challenges that the different
healthcare staff we interacted with reported. We grouped these challenges into five categories: 1) increased
work burden for health staff, 2) the new UHC-HIS added little value, 3) an increase in UHC-HIS complexity
due to the need to both combine individual and aggregate data, 4) extreme technical and institutional
contradictions between the old and the new systems, and 5) severe capacity and resource constraints in
effectively working with the new systems. We then used these themes as focal points to develop an
institutional-inspired analysis to identify the contradictions that UHC-HIS encounter. In Table 3, we provide
some examples that show we inductively identified the themes.
Table 3. Inductive Identification of Themes
Sample evidence to generate this theme
Increased work burden for the health
Health staff said that, with the new system, they now needed to spend
nearly 60 percent of their work time on data-management activitiesmuch
more than before.
The new UHC-HIS added little value.
We saw that the system did not strengthen their local care practices, such
as being able to electronically synchronize data from their tablets to the
primary healthcare facility system to build the referral system.
Extreme technical and institutional
contradictions between the old and the
new systems.
Technical contradiction: in the clinic, we saw a nurse trying to log in
unsuccessfully into the internet. The system we designed relied 100 percent
on the Internet.
Institutional contradiction: the ANMs now had to screen all people over 35
years for conditions of hypertension, diabetes, oral cancer, and others,
which represented new tasks as compared to her earlier focus on
reproductive and child healthcare.
An increase in UHC-HIS complexity
due to the need to combine individual
and aggregate data.
We saw that [who] needed to collect a lot of new information from diverse
sources, which heightened the complexity of the HIS.
Severe capacity and resource
The same ANM who was already overburdened with work now had a
significant amount of additional work through the UHC without more
resources to help.
4 The Case: Indian State's Effort to Implement UHC-HIS
From initially reading the relevant literature on UHC and having discussions with researchers and the state’s
administration, we realized that the requirements of the UHC-HIS fundamentally differ from existing HIS for
the primary healthcare sector. Changing from a HIS to UHC-HIS involves a radical shift from an aggregate
routine reporting system to what resembles a community-based, electronic medical record that focuses on
individuals and tracking them continuously over the care cycle. While the traditional system focused on
routinely reporting aggregate maternal and child health data, under UHC, ANMs also had to screen the
entire population in their catchment area for eight additional conditions (diabetes, hypertension, anaemia,
oral cancer, etc.) and maintain and share this information electronically. In the UHC-HIS pilot, ANMs
received a tablet to register this information in and synchronize with the facility’s database, which stored the
information. With this tablet, the ANMs also had to electronically refer cases to the primary healthcare
doctor’s system, which further linked with the district hospital. Both hospitals and primary healthcare facilities
also had to electronically back-refer patients after a consultation to ANMs for follow-up home-based care.
To actually comprehensively screen an entire population necessarily took time, and, in the meanwhile, one
could only cover a certain number of people. As such, it would take time to register all potential patients in
the new system, which would result in the need to maintain a dual set of work processes in the clinic. In a
visit to one of the primary healthcare facilities, we found the staff there had created two categories of
patients: “UHC group” and “non-UHC group”. The former included those patients that the ANMs had already
screened and the rest that the ANMs had not. Only 10 percent of the daily outpatients (of total 60) were in
the “UHC group”. In terms of the information flow, we saw that a patient who visited the primary healthcare
facility would first go to the pharmacist who maintained the computer system and showed their health card,
which included an identification number. A UHC-HIS assumes that the primary healthcare facility computer
has a patient’s record prior to the patient’s visit based on the rationale that, after screening all patients in an
area, the ANMs electronically register the information in a tablet that constantly synchronizes with the
primary healthcare system. However, we found that this information did not exist in all cases, and, as a
result, the pharmacist had to enter the registration details.
Further, the infrastructural constraints that challenged the UHC-HIS’s usability in practice impeded the way
it should have worked. Once the pharmacist registered a patient’s case record, it appeared on the doctor’s
screen for an outpatient consultation. But, due to the poor Internet, the doctor required many minutes to log
on to the system. Filling the case record in the system while examining the patient could take about 10
minutes, which led a frustrated patient to say: Doctor, why don’t you do your personal work on the computer
later and first deal with me?”. In the case of electricity failures, the doctor would note case details on paper;
however, due to long power outages and the continuous stream of patients, they seldom had time to enter
these details into the system afterwards. Over time, this practice contributed to a growing number of
unrecorded cases. After A consultation, the doctor could not take a printout due to a lack of printing paper
and so noted everything on paper, gave it to the patient, and also entered the same details in a local register.
Additionally, the patient showed the slip to the pharmacist who maintained a similar register of outpatient
cases for statistical reporting. When asked if work had become simpler, the doctor replied: No, it has
become a torture”. Further, in the case that the primary healthcare system did have information about a
patient, the system could not automatically synchronize data with the ANMs tablets. As such, only the
particular doctor could access the record via that doctor’s desktop computer. To take this data to the tablet,
the patient needed to show the outpatient slip to the ANMs, but patients rarely did so, which contributed to
a rising number of incomplete and unsynchronized records and undermined continuity of care (i.e.,
undermined the ANMs ability to follow up on patients that needed it).
While UHC focuses on strengthening continuity of care, we found that the doctor did not use the UHC-HIS
to view patients’ history. As for why, the doctor reported that [he/she] found the search function cumbersome
since it required [him/her] to search record rather than allowing [him/her] to view aggregated patient profiles.
Further, patients’ records did not normally contain historical data related to drugs because primary
healthcare facility doctor had the mandate to prescribe only certain medicines from an approved medicine
list. If unavailable or if the doctor wanted to prescribe something not on this list, they would write it on a slip,
and not in the computer, to escape possible reprimand for not following the norms. As a result, the doctor
had a skewed perception about the system’s utility in terms of continuity of care.
The system did also not stimulate or support an intended shift to a population-oriented and preventive-
planning practice. For example, the doctor could not see summarized outputs (by graphs and charts) that
showed, for example, the total number of hypertensive cases by village. Similarly, the system could not
generate referral linkages, so the district hospital would start a new record for every new patient even though
they may come through the primary healthcare that already had a record for the patient’s medical history.
We found that the doctor did not use the readily available functionality in the UHC-HIS to schedule follow-
up visits since the doctor believed it was the patients’ responsibility to come and not theirs to follow up.
In one subcenter, we met the two ANMs responsible for the UHC-HIS who regarded themselves as
competent in using tablets. One ANM’s tablet had not functioned for many months and had not been fixed
despite her multiple requests. As a result, she made entries on paper to later enter into the tablet when
fixed. Both ANMs struggled with bad network connections, and, in the two hours that we observed them,
could not log in despite multiple attempts. They also reported that they found it difficult to use the tablet
outdoors due to sun glare. As a result, they did their outdoor work on paper and later when indoors they
entered the data into the tablet, which duplicated their work. After initially screening the patients on eight
UHC conditions, the ANMs did not update their base records until a later time due to their high workload.
As a result, the records often became outdated.
ANMs reported a significant increase in their workload with the advent of the UHC-HIS, which required them
to spend about 60 percent of their time on data-related activities. They entered data in multiple places such
as primary registers, the health management information system for aggregate reporting, and the mother
and child tracking system for tracking pregnant mothers and children by name, which another system (called
RCH +) had recently replaced and included about 100 extra entries. The UHC-HIS was the latest addition
to their workload, and they still had to continue to use the earlier systems. They first noted most work on
paper and then entered it into the tablet. Overall, doctors and ANMs expressed frustration because they
obtain extra value but rather additional work from the UHC-HIS.
5 Analysis
The case study illustrates both challenges that [who] typically face when working with institutions and
information infrastructures in a primary healthcare context in a low- and middle-income country. These
generic challenges include multiple overlapping systems and practices that contribute to double reporting
and fragmentation both technically and institutionally. Specific challenges relate to technical infrastructure
(e.g., Internet, electricity, technical support) that constrain system use and data-sharing across unevenly
and poorly resourced contexts. In this section, we analyze these challenges using the three categories of
institutional work (i.e., creating, maintaining, and disrupting) that Lawrence and Suddaby (2006) suggest.
Further, we discuss the institutional contradictions that the new requirements of a UHC-HIS cause and how
[who] can positively leverage them for change.
5.1 Creating Institutions
Lawrence and Suddaby (2006) categorize institutional work involved in creating institutions into three
subsets: 1) advocacy, defining, and vesting represents overt political work where actors define access to
material resources based on rules, property rights, and boundaries (e.g., how interest organizations lobby
for resources or new legislations); 2) constructing identities, changing normative associations, and
constructing normative networks represents work towards reconfiguring belief systems (e.g., developing
new professions and creating private-sector approaches in interventions in the public sector); and 3)
mimicry, theorizing, and educating represent alterations of abstract categorizations (e.g., associating new
practices with existing practices and establishing common concepts).
The UHC model that the state implemented implied that ANM and doctors had to change their work
practices. For ANMs, they needed to acquire new forms of knowledge (e.g., screening for diabetes and oral
cancer) when previously they had primarily dealt only with pregnancies and immunizations. Further, they
had to refer at-risk patients to the primary healthcare facility doctor for consultation. The nurses typically did
not have to refer such patients previously since the patients themselves initiated the referrals. The ANMs
also had to receive “back-referrals” (follow up with patients after consultation from the primary healthcare
facility at home). The UHC model also placed new expectations on doctors related to continuity of care. The
model assumed that the doctor would establish a longitudinal relationship with the patient in a way that
involved using both the functionality for reviewing patients’ history data and for scheduling future
appointments with them. These work tasks represent novel institutions since the doctors were not used to
referring to written history or to scheduling patient visits.
UHC requires ANM and doctors to perform institutional work to reorient their identity related to continuity of
care. They needed to learn to see themselves as having the responsibility to follow up with patients over
time through reviewing history, scheduling future appointments, and handling referrals. [Who?] also needs
to perform institutional work to help ANM in providing an expanded basket of services in terms of identity
and to educate them so they can establish the new practices.
5.2 Maintaining Institutions
Lawrence and Suddaby (2006) argue that few institutions have the strength to operate without maintenance,
and, to ensure social compliance, [who] must support, repair, and recreate [what?]. They categorize
institutional work involved in maintaining institutions into two subsets: 1) enabling work, policing, and
deterring focus on ensuring adherence to rule systems (e.g., using sanctions and incentives to ensure
compliance) and 2) valorizing and demonizing, mythologizing, and embedding and routinizing focus on
reproducing existing norms and belief systems (e.g., public displays of normative foundations and
embedded routines and practices).
While the UHC model introduced new ways to work, many of the existing work practices prevailed. Due to
sun glare and the tablets limited connectivity, ANMs added the new UHC-related information-gathering
activities to the already institutionalized paper-based practices. For some of the primary healthcare doctors,
they had used computers to enter details of patient encounters in real time for the first time. However,
because severe limitations in power supply and Internet connectivity made doing so difficult, the doctors
reverted back to a known institutionalized practice: maintaining local, paper-based documentation. Also,
other institutional conditions such as the limitations of the approved drug list and absence of printing paper
meant that they often did not use the system and, when they did, also entered the details on paper. As a
result, their workload significant increased; instead of a paperless system, the reverse occurred: doctors
generated more paper, such as through the local register they had to maintain to record out-patient
In reverting back to their paper-based practices, the ANMs and the doctors reproduced and extended them
and, thus, compensated for the weak infrastructure.
5.3 Disrupting Institutions
Lawrence and Suddaby (2006) also describe activities. They describe this work as disconnecting sanctions,
disassociating moral foundations, and undermining existing assumptions and beliefs (e.g., non-state actors
working ).
Introducing UHC requires disruptive work related to the institutionalized practices that the ANM and doctors
followed and to the way in which patients understand their responsibility for own health and care. First, the
ANMs largely catered to the population who came to them either in their facility or during their field visits.
However, UHC meant they had to screen the entire population in their homes, which took time and required
travel support and ubiquitous access to infrastructure. Second, and in addition to the shift to a population-
oriented practice, preventive planning and continuity of care form UHC’s core, which differs from episodic
care where patients themselves have a responsibility to go see healthcare practitioners. In our case, doctors
refused to specify repeated visits through the system because they believed that the responsibility to return
lied with the patients. Third, the existing and deeply rooted reporting regime enabled upward reporting rather
than reporting between care givers to enable local action.
To change the institutionalized practices that we describe, [who?] could focus on undermining the existing
assumptions and beliefs of demand-driven and episodic care, which includes enhancing patientsrole in
taking care of their own health. [Who?] could also change the deep-rooted upward-reporting regime by
changing existing incentives and sanctions related to reporting and information use.
5.4 Institutional Contradictions
In the analysis above, we focus on how introducing the UHC model led to different kinds of institutional work
and how it would require further institutional work to. Motivated by the extreme challenges that different
healthcare staff we interacted with experienced in dealing with the new and old systems, we now elaborate
on and analyze these challenges as contradictions emerging from different and potentially conflicting
institutional arrangements. In Section 6, we return to these contradictions and discuss how one can use
them as opportunities for institutional work and change. First, the technological infrastructure did not support
the new responsibilities that the ANMs and doctors had to contend with. For example, the tablet that ANMs
had to use promised mobility but various practical challenges (e.g., charging, sun glare, and the demand
for an online connection) undermined its use in practice. Similarly, the absence of printing paper and limited
electricity and connectivity undermined doctors’ work. Second, and as a consequence of the infrastructure
challenges, the new system became just another system that often overlapped with and duplicated data
that already existed on paper. As a result, the ANMs’ workload significantly increased without appropriately
adding value in terms of supporting their everyday work with more granular information on people, diseases,
and costs over time. Because the UHC system became just yet another reporting system and did not
adequately consider the linkages between systems, significant contradictions arose between the expected
and provided value for its different users. Third, and again related to the infrastructure, since it ignored actual
conditions in the design phase, the system (e.g., the ANMs’ tablets and the medical records the primary
healthcare doctors used) did not become the expected tools. While the UHC system focused on providing
connectivity between the ANMs’ tablets and the primary healthcare doctors’ computers, in practice, the
design, infrastructure conditions, and work practices made the different units act in a standalone manner.
Fourth, and again related to the inadequacies of the technical system, the ANMs did not meet their new
responsibility to follow up on back-referred patients. The institutionalization of these new practices could not
happen without concurrent support from the technology, which required two-way information
synchronization about patients’ trajectory. Fifth, while the UHC-HIS had a readily available functionality to
schedule follow-up visits, doctors did not use it since they believed the patients themselves had the
responsibility to come. Patients themselves also lacked any expectation that doctors would follow up with
6 Discussion
As the case study and its analysis reveal, the new UHC-HIS suffered many difficulties and contradictions.
At first sight, we could conclude that these contradictions contributed to the system’s overall failure.
However, institutional theory notes that these contradictions need not always be negative because they may
carry in them the potential for change. In this section, we discuss possible approaches to leverage their
potential through “judicious design”.
6.1 Design Guidelines based on Institutional Contradictions and Emerging
One can develop design guidelines or principles to transform descriptive case studies into a more normative
design theory (Walls, Widmeyer, & El Sawy, 1992; Markus, Majchrzak, & Gasser, 2002). (e.g., Miller,
Cafazzo, & Seto, 2014; Sultan, Kuluski, McIsaac, Cafazzo, & Seto, 2018) and IS research in particular (e.g.,
Aanestad & Jensen, 2011; Nguyen, Nielsen, & Braa, 2016) has used it. In this paper, we do not develop a
complete design theory for UHC-HIS. Our design guidelines are socio-technical and not limited to describing
user requirements and system features or to giving guidance in system-development processes. Rather,
they give broad guidance on where [who] needs to focus [whose?] design efforts to support system
designers but also other actors involved in the institutional work needed to establish a well-functioning UHC-
When the existing and new institutions meet, contradictions will inherently arise. First, while UHC requires
health workers to put more time into care, it also enhances their data-related work. Second, the work (care
and data related) demand a working infrastructure that may not yet exist adequately in practice. And third,
UHC puts new and demanding responsibilities on both doctors and patients that historically did not exist.
However, these contradictions also create opportunities for change. First, [who] has an opportunity to revise
and rationalize what data gets collected and for whom. Second, [who] has the opportunity to better accept
the integrating systems due to the increasing burden of data-related work. Third, doctors and patients have
an opportunity to build awareness about their responsibilities. Fourth, [who] has an opportunity to recognize
the acute need for a more appropriate infrastructure that can assist healthcare workers in their work.
Implementing UHC-HIS entails new forms of institutional work. This work should necessarily seek to
maintain and add value to established work practices and support new ones. One cannot implement UHC-
HIS in a void, and one should design it to leverage what already exists in the primary healthcare system
(e.g., institutionalized practices for collecting data). We observed that the institutionalized data-collection
practices salvaged the care the ANMs and doctors provided from a complete breakdown in the face of an
insufficient system. However, [who] needs to disrupt and challenge these institutions in that they allow data
collection for only upward reporting. In deliberately redesigning institutions, one needs to address the
rationale and emphasize the value of information to strengthen care rather than control and to design
systems that enable work and support more efficient care practices.
We argue that effectively introducing a UHC-HIS requires four new forms of institutional work that also
leverage the potential of the contradictions that arise when existing and new institutions meet. First, the
UHC-HIS needs to strengthen ANMs’ care practices, such as through training in new knowledge domains
(e.g., dealing with non-communicable diseases). Second, it requires work practices and supporting
infrastructure that connect patients and information (e.g., referrals between outreach and primary healthcare
facilities). Third, to expand ANMs capacity to reach out to the entire population, they need more travel
support and better infrastructure, such as Internet coverage. Fourth,(see also Table 4 below).
UHC requires the delegitimization of some current institutions and the creation of new and redefined ones.
For example, it requires aggregate systems for upward reporting and new information for patient-based
care. In terms of Oliver’s (1992) different organizational responses to institutional change, . When primary
healthcare and UHC-HIS come together, inconsistencies between institutional expectations and internal
objectives related to efficiency or autonomy emerge, which require organizations to find compromises in
building new and redefining existing institutions. The different stakeholders involved (e.g., health ministry,
ministry for civil registration and vital statistics, donors, and software developers) need to come together to
discuss the various contradiction and opportunities that arise and identify the optimal compromised
approach to meet needs of both the primary healthcare and UHC-HIS.
6.2 6.2 Judicious Design of HIS
The term judicious design (Mukherjee, Aanestad, & Sahay, 2012) reflects an approach that does not seek
to obliterate the past to create something new but to cultivate what exists, the installed base, to achieve the
new in an incremental manner. This design approach reflects the principle of “airplanes don’t fly, airlines
do”, which emphasizes the interconnected nature of the technical and social domains and the need to build
them as heterogeneous networks (Hanseth & Lyytinen, 2010). We find. Further, a judicious design
acknowledges that one cannot design and implement all functionality in one go but that one has to build it
through small-scale and incremental steps. Therefore, UHC-HIS requires an open architecture to allow
system development and use to evolve in a way that can easily support future changes.
Traditional HIS inherently conflict with UHC-HIS because the former does not support localized care.
Further, one should not design UHC-HIS based on sharing data with other existing (and future) systems
technically and across institutional borders. At its core, the system must allow health workers to deliver
essential care and also help to reduce the burden they experience in recording, tracking, and reporting data
(e.g., digitized primary registers could reduce data redundancies). At core, UHC-HIS requires a population
database, to support clinical care, and enable health workers to generate all required reports. This approach
will support the “build once, use multiple times” design principle. Beyond supporting local work, UHC-HIS
should also support information sharing across organizational boundaries (e.g., to enable interoperability
and data sharing with other systems such as hospital systems and births and deaths registration). Such
systems must further allow health workers to generate required referral linkages across levels to strengthen
continuity of care services. Building interlinkages with systems requires one to understand integration on a
case-by-case approach and to materialize that integration in an incremental manner. Both semantic (i.e.,
business logic and nomenclature) and syntactic (i.e., technical protocols to exchange data across systems)
[what] require defined standards based on multi-level and multi-sector coordination and governance across
institutions. However, a lack of regulation related to freely flowing information between institutions and
authority levels presents a key challenge in developing such standards. Finally, the UHC-HIS must cater for
the challenging work context that ANM and doctors experience (e.g., fluctuating Internet connections and
an unreliable electricity supply). These uneven and often technology-sparse contexts need hybrid solutions
that combine information technology and paper, online digital solutions that also offer offline support,
uninterruptible power supply solutions, and affordable and functional mobile units (phones and tablets). We
summarize these contradictions, opportunities, and design guidelines in Table 4.
Table 4. Institutional Contradictions, Emerging Opportunities, and Design Guidelines
Design guidelines
-Train ANMs
-Establish the required travel support
Establish the required Internet
Care and data work assumes non-
existing infrastructure.
Develop the supporting infrastructure
necessary for information and
paitnets to flow between outreach
and primary healthcare centers.
Differing views on whether the
responsibility of care lies with the
doctor or the patient.
To build awareness about doctors
and patients’ responsibilities.
Develop public awareness about
individuals’ responsibilities for their
own health and care.
Table 4. Institutional Contradictions, Emerging Opportunities, and Design Guidelines
System design must simultaneously
support new and existing evolving
systems and work practices.
Combine information technology and
paper, support information sharing
across organizational boundaries,
and reduce the work burden of
healthcare workers.
Develop systems with an open
architecture, with the ability to share
data across institutional borders,
using hybrid solutions that combine
information technology and paper,
and using online solutions that also
offer offline support.
7 Conclusions and Contributions
Where previous research on information infrastructures primarily has focused on the challenges of achieving
integration processes based on top-down approaches, we focus on practice-based approaches and on how.
This approach to achieving UHC also differs from global initiatives such as the Health Data Collaborative
and the Open Health Information Exchange
, whose integration strategies begin at the top and not at the
community level even though healthcare organizations at the community level need strengthened care
practices. Where [what/who?] discusses integration as a technical issue, we also focus on the challenge of
integrating new and old work practices (since one can never start on a clean slate) and the institutional work
that supports such integration. In this process of standardizing work practices in uneven and often
technology-sparse contexts, we show that the unique and new UHC phenomenon will remain tangled with
the past. Institutional work in this setting involves bridging the new and old and releasing the potential of
new practices in rationalizing the old.
In this paper, we specifically address the research question: “What type of change do institutions need to
undergo to use the new technologies and associated work processes that universal health coverage
entails?. We identify and discuss central contradictions and three key challenges that arise with UHC:
increased work burden for health workers, a lack of working infrastructure, and uncertainties regarding the
responsibility of the patients’ wellbeing. Leveraging these contradictions, we further identify four new forms
of work to establish the required institutions to support new UHC-HIS-related technologies and practices:
training ANMs in diverse and new domains, developing the supporting infrastructure necessary to support
the flow of patients between outreach and primary healthcare centers, establishing travel support and
Internet infrastructure for ANM, developing public awareness about patients’ responsibilities for their own
health and care, developing systems with open architecture, using hybrid solutions including technology
and paper, and providing online and offline support. The contradictions we analyze in this paper help to
explain the inherent complexities in UHC-HIS design and implementation, and the design principles should
offer guidance to actors involved in developing and implementing UHC-HIS in a similar context. We also
contribute to existing work on institutional theory by using the concept of institutional work to discuss how
the material properties of technology can influence how actors adopt new institutions at the expense of
existing ones (e.g., a UHC-HIS that features an open architecture can enable interoperability and data
sharing among systems). As institutional work, this has the potential to change existing reporting practices
and reduce data redundancy across systems. Further, research on the creation of new institutions has
focused on the role of actors in establishing institutions and primarily on institutional entrepreneurs and
under which conditions entrepreneurship thrives (Lawrence & Suddaby, 2006). In this paper, we extend
such research by providing detailed accounts of the work that actors do when they create, maintain, and
disrupt institutions.
Our analysis suggests that one needs to anchor UHC-HIS in the routine facility HIS that exists in the primary
healthcare sector to prevent it from becoming “yet another reporting system”. If one can do so, the UHC-
HIS can also provide an opportunity for change by helping to rationalize existing facility HIS and revitalizing
it with the new focus that UHC provides. Such a unified system can arguably meet both the demands for
routine facility and new UHC reporting. We can see an example in which a country effectively integrated
UHC into its primary healthcare sector in Thailand. Based on expanding the existing primary health care,
the country incrementally built its HIS on its existing platforms (e.g., the well-working civil-registration and
vital statistics systems) to ensure the HIS covered and provided services to all citizens
(Tangcharoensathien, Limwattananon, Patcharanarumol, & Thammatacharee, 2016). The community
forms the backbone of a UHC (Schneider & Lehmann, 2016), and a UHC-HIS needs a design that focuses
on community-based electronic medical records, which fundamentally differs from a typical electronic
medical record (which one typically sees in large private hospitals). This difference arises because UHC
encounters do not take place in a hospital but in a geographically spread community. The community
electronic medical record needs to capture individual-based data on services needed and received
associated costs incurred while simultaneously generating population profiles of health service coverage
and financial protection, the two vital pillars of UHC, with the necessary stratifications..
HIS that appropriately and relevantly integrate the old with the new can support health workers practices
and reduce their burden in terms of the time they spend on entering and reporting data and add value to
their ability to take local action. Strong and flexible linkages between the UHC-HIS and other systems can
enable a more comprehensive UHC. Further, different functions will provide value to different actors (e.g.,
ANMs, medical doctors, pharmacists and administrators).
Achieving UHC and measuring its progress represent global priorities. Currently, measurement models
typically rely on survey data and not on UHC monitoring frameworks. While UHC must build on existing
primary healthcare, [who?] inadequately discusses its implications for UHC-HIS.. UHC-HIS must feature a
strong architectural framework to support these evolving informational needs. With its implications on health
workersworkload,. At the core of this, the UHC-HIS must support work practices at different levels and link
to other relevant systems on a case-by-case basis, such as for civil registration and vital statistics and
hospital systems. In this paper, we discuss how this alignment work inherently relates to existing socio-
technical structures and requires institutional work that contributes to changing existing norms and practices
even as it introduces new ones.
This research has several limitations. First, it builds on empirical insights from a project that designed and
implemented a UHC-HIS pilot in India. While one can likely find the challenges and contradictions that we
discuss here across the healthcare system in India, other contexts may differ. Scaling the system to the
state level would likely introduce further contradictions and require new kinds of institutional work. To release
the full potential UHC-HIS, one must implement it at the state or national level, and further research should
follow such initiatives. Second, . While we do not develop a complete design theory for UHC-HIS, empirical
research needs to examine how health workers and organizations use the design principles in the same or
other contexts to validate them. Future research could also develop a proper information systems design
theory for UHC-HIS that pertains to the different contexts in India, to developing countries, and to developed
countries. Doing so would require more research to underpin each principle with theory and to develop them
further to offer more specific guidance to practitioners (Walls et al., 1992).
Communications of the Association for Information Systems
Aanestad, M., & Jensen, T. B. (2011). Building nation-wide information infrastructures in healthcare through
modular implementation strategies. The Journal of Strategic Information Systems, 20(2), 161-176.
Berger, P. L., & Luckmann, T. (1991). The social construction of reality: A treatise in the sociology of
knowledge (No. 10). UK: Penguin.
Boerma, T., Victoria, C., & Abouzahr, C. (2018). Monitoring country progress and achievements by making
global predictions: Is the tail wagging the dog? The Lancet, 392(10147), 607-609.
Boerma, T., Eozenou, P., Evans, D., Kieny, M.-P., & Wagstaff, A. (2014). Monitoring progress towards
universal health coverage at country and global levels. PLOS Medicine, 11(9), 1-8.
Bump, J., Cashin, C., Chalkidou, K., Evans, D., González-Pier, E., Guo, Y., Holtz, J., Htay, D. T., Levin, C.,
Marten, R., Mensah, S., Pablos-Méndez, A., Rannan-Eliya, R., Sabignoso, M., Saxenian, H.,
Feachem, N. S., & Soucat, A. (2016). Implementing pro-poor universal health coverage. Lancet
Global Health, 4, e14-e16.
Braa, J., Hanseth, O., Heywood, A., Mohammed, W., & Shaw, W.(2007). Developing health information
systems in developing countries: The flexible standards strategy. MIS Quarterly, 31(2), 381-402.
Chan, M. (2007). Opening remarks at the fourth global meeting of heads of WHO country offices. Geneva:
World Health Organization.
Chilundo, B., & Aanestad, M. (2004). Integrating the information systems of disease-specific health
programmes: Negotiating multiple rationalities. The Electronic Journal of Information Systems in
Developing Countries, 20(2), 1-28.
Currie, W. L. (2012). Institutional isomorphism and change: The national programme for IT10 years on.
Journal of Information Technology 27(3), 236-248.
Devadasan, N., Ghosh, S., Nandraj S., & Sundararaman, T. (2014) Monitoring and evaluating progress
towards universal health coverage in India. PLOS Medicine, 11(9), 1-3.
DiMaggio, P. (1988). Interest and agency in institutional theory. In L. G. Zucker (Ed.), Research on
institutional patterns: Environment and culture (pp. 3-21). Cambridge: Ballinger Publishing.
Eisenstadt, S. N. (1980). Cultural orientations, institutional entrepreneurs, and social change: Comparative
analysis of traditional civilizations. American Journal of Sociology, 85(4), 840-869.
Gawer, A., & Phillips, N. (2013). Institutional work as logics shift: The case of Intel’s transformation to
platform leader. Organization Studies, 34(8), 1035-1071.
Hanseth, O., & Lyytinen, K. (2010). Design theory for dynamic complexity in information infrastructures: The
case of building Internet. Journal of Information Technology, 25, 1-19.
Jepperson, R. L. (1991). Institutions, institutional effects, and institutionalism. In P. DiMaggio & W. W. Powell
(Eds). The new institutionalism in organizational analysis (pp. 143-163). Chicago: University of
Chicago Press.
Kimaro, H. C., & Sahay, S. (2007). An institutional perspective on the process of decentralization of health
information systems: A case study from Tanzania. Information Technology for Development, 13(4),
Lawrence, T., & Suddaby, R. (2006). Institutions and institutional work, In S. R. Clegg, C. Hardy, W. R.
Nord, & T. Lawrence, & (Eds.). Sage handbook of organization studies (pp. 215-254). Thousand
Oaks, CA: Sage.
Markus, M. L., & Silver, M. S. (2008). A foundation for the study of IT effects: A new look at DeSanctis and
Poole's concepts of structural features and spirit. Journal of the Association for Information
Systems, 9(10-11), 609-632.
Majchrzak, A., & Markus, M. L. (2013). Methods for policy research: Taking socially responsible action (vol.
3). Thousand Oaks, CA: Sage.
Communications of the Association for Information Systems
Markus, M. L., Majchrzak, A., & Gasser, L. (2002). A design theory for systems that support emergent
knowledge processes. MIS Quarterly, 26(3), 179-212.
Maurice, J. (2016). Measuring progress towards the SDGsa new vital science. Lancet, 388, 1455-1458.
Miller, A. S., Cafazzo, J. A., & Seto, E. (2014). A game plan: Gamification design principles in mhealth
applications for chronic disease management. Health Informatics Journal, 22(2), 184-193.
Mukherjee, A. S., Aanestad, M., & Sahay, S. (2012). Judicious design of electronic health records: Case
from public health system in India. Health Policy and Technology, 1(1), 22-27.
Mukherjee, A. (2017). Empowerment: The invisible element in ICT4D projects? The case of public health
information systems in India and Kenya (doctoral thesis). Department of Informatics, University of
Nicholson, B., & Sahay, S. (2009). Deinstitutionalization in the context of software exports policymaking in
Costa Rica. Journal of Information Technology, 24(4), 332-342.
Nguyen, T. N., Nielsen, P., & Braa, J. (2017). Scaling information infrastructures: The case of the medical
licensing system in a Southeast Asian country. Australasian Journal of Information Systems, 21, 1-
Noir, C., & Walsham, G. (2007). The great legitimizer: ICT as myth and ceremony in the Indian healthcare
sector. Information Technology & People, 20(4), 313-333.
North, D. (1990). Institutions, institutional change and economic performance. Cambridge: Cambridge
University Press.
Oliver, C. (1992). The antecedents of deinstitutionalization. Organization Studies, 13(4), 563-588.
Orlikowski, J. (2000). Using technology and constituting structures: A practice lens for studying technology
in organizations. Organization Science, 11(4), 404-428.
Patel, V., Parikh, R., Nandraj, S., Balasubramaniam, P., Narayan, K, Paul, V. K., Kumar, A. K., Chatterjee,
M., & Reddy, K. S. (2015). Assuring health coverage for all in India. Lancet, 386, 2422-35.
Rajão, R., & Hayes, N. (2009). Conceptions of control and IT artefacts: An institutional account of the
Amazon rainforest monitoring system. Journal of Information Technology, 24(4), 320-331.
Sahay, S., Sundararaman, T., & Mukherjee, A. (2014). Building locally relevant models for universal health
coverage and its implications for health information systems: Some reflections from India. Journal of
Health Informatics in Africa, 2(2), 80-87.
Sanner, T. A., Manda, T. D., & Nielsen, P. (2014). Grafting: balancing control and cultivation in information
infrastructure innovation. Journal of the Association for Information Systems, 15(4), 220-243.
Schneider, H., & Lehmann, U. (2016). From community health workers to community health systems: Time
to widen the horizon? Health Systems & Reform, 2(2), 112-118.
Seo, M., & Creed, W. E. D. (2002). Institutional contradictions, praxis, and institutional change: A dialectical
perspective. The Academy of Management Review, 27(2), 222-247.
Srivastava, S. C., & Shainesh, G. (2015). Bridging the service divide through digitally enabled service
innovations: Evidence from Indian healthcare service providers. MIS Quarterly, 39(1), 245-267.
Srivastava, S. C., Teo, T., & Devaraj, S. (2016). You can't bribe a computer: Dealing with the societal
challenge of corruption through information technology. MIS Quarterly, 40(2), 501-526.
Stigler, F., Macinko, J., Pettigrew, L., Kumar, R., & van Weel, C. (2016). No universal health coverage
without primary health care. Lancet, 387, 1811.
Sultan, M., Kuluski, K., McIsaac, W. J., Cafazzo, J. A., & Seto, E. (2018). Turning challenges into design
principles: Telemonitoring systems for patients with multiple chronic conditions. Health Informatics
Communications of the Association for Information Systems
Tangcharoensathien, V., Limwattananon, S., Patcharanarumol, W., & Thammatacharee, J. (2014).
Monitoring and evaluating progress towards universal health coverage in Thailand. PLOS Medicine,
11(9), 1-3.
Thorseng, A. A., & Grisot, M. (2017). Digitalization as institutional work: A case of designing a tool for
changing diabetes care. Information Technology & People, 30(1), 227-243.
Vikkelsø, S. (2010). Mobilizing information infrastructure, shaping patient-centred care. International Journal
of Public Sector Management, 23(4), 340-352.
Walls, J. G., Widmeyer, G. R., & El Sawy, O. A. (1992). Building an information system design theory for
vigilant EIS. Information Systems Research, 3(1), 36-59.
World Health Organization. (n.d.). What is universal coverage? Retrieved from
... The disparity between countries in the use and development of digital innovation, as well as in its impact [2,3], allows frugal innovation to be considered as a stimulator of positive potential in the adoption and exploitation of digital innovation in developing countries. Sahay et al. [4] present frugal innovation as the best way to contextualize digital innovation. In fact, frugal innovation, as demonstrated by the majority of related research, permits the individual or group to do more with less. ...
... The key to success in this type of innovation is related to the context in which it is adopted and operationalized [4]. Avgerou [10] adds that the effectiveness of digital innovation depends on social embeddedness to foster and enable it. ...
Agribusiness is currently facing many challenges related to frugal innovation in the era of digitalization. The aim of this study is to explore and analyse the existing literature on agribusiness and digital innovation from all relevant studies published in the Web of Science and Scopus databases between 2011 and 2020 in order to identify the opportunity of such concept as well as its development. Bibliometric methods were used in order to define the main research lines within this field and identify the gap in the existing literature to consider the future research agenda in agribusiness. To visualise the network analysis adopted here, VOSviewer software was used. Through this methodology the existing literature reporting on frugal innovation, digitalization and agribusiness is explored to explain the development of frugal digital innovation in agribusiness and delimit the future research axis. The results allow some determinant lines of research related to agribusiness and digital innovation to be established.KeywordsFrugal innovationDigitalizationAgribusinessBibliometric technique
... Institutional work has been extensively used in IS research as a framework to analyze processes of institutionalization, institutional change, and sustainability [26,27]. For example, Sahay et al. [28] studied the new forms of institutional work required to support [29] examined the relationship between design decisions taken and intended changes in the practices of diabetes care. ...
... In the context of digital AMR monitoring, similar to the study on UHC [28], represents the need to create new forms of institutional work, which however is inter-connected with existing manual processes and the situated context of capacities [30], infrastructures [31], workloads [32] and policy responsiveness [33]. Institutional work helps to understand how information practices need to navigate between the old and new to highlight new or redefined forms of institutional structures. ...
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Antimicrobial resistance is described as a “slow-moving Tsunami” and a top global health threat, particularly affecting low and middle-income countries. A key strategic tool to engage with this challenge is effective monitoring to improve knowledge and awareness and support evidence-based interventions. However, LMICs have an inadequate capacity, resources, infrastructure, and culture to implement digital interventions. To engage with this challenge within the context of a public hospital in India, a global AMR hotspot, empirical work is carried out in studying the design and implementation of an AMR monitoring system and in understanding the process of antibiotics use and associated challenges in their digitization. A practice-based perspective informs understanding of these empirical problems, and how practices evolve into institutional work. This paper contributes to understanding the challenges and approaches to implementing AMR digital monitoring systems.
... Institutional theory has useful tools to describe how technology and society interact and influence each other (Lawrence et al., 2009). There is also an increasing body of literature of how technology change drives change in institutions (Gawer and Phillips, 2013;Sahay et al., 2019). We use the institutional work forms mimicry and educating and theorizing presented in Lawrence and Suddaby (2006) as a theoretical frame when we discuss how digital transformation of contact tracing has affected the contact tracing institution in the Norwegian health care sector. ...
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With rising numbers of COVID-19 positive patients in March 2020, Norwegian municipalities, who are responsible for contact tracing, struggled to register all the infected and their close contacts. This was partly due to the scale of the pandemic and partly because the only tools they had were pen and paper and in some cases spreadsheets. To address this situation, some municipalities started exploring how digital health information systems could support them in handling the rapidly changing and unforeseen complexity of the covid-19 contact tracing work. Drawing on an ongoing case study of disease surveillance in Norway, we first explain how contact-tracing work has undergone a rapid digital transformation. Then we offer an institutional analysis by using a perspective of institutional work forms to illuminate how the digital transformation has brought about long term institutional changes. We then argue that we have seen an institutionalization of digital contact tracing while manual contact tracing is still ongoing. Thus, both the new and the old institution stay alive and are central for different purposes. With this paper, we are contributing to research on digital transformation by theorizing how technology and more particularly digital transformations are intertwined with institutional change. We further contribute to research on institutional work by illustrating how this is a relevant lens to understand digital transformations.
Academic performance of the student in higher education are among of the important data for educators and employers in this new era. The issue to analyse a large number of data has always been a constraint to most employers and educators. Data mining techniques were seen as one of the suitable approaches to reduce the delay in the analysis and the generation of output. However, proper, and high accurate techniques that serve as best fitted models for student performance prediction have yet to be found Therefore, an effective automated student performance prediction mechanism for higher education is very much in demand. This paper reviews the data mining techniques that are specific for the student performance evaluation. Data mining techniques that are reviewed include the SVM, KNN, Naive Bayes and Decision Tree. These techniques are evaluated for accuracy and the best fitted models for the student performance are higlighted.KeywordsStudent performanceAcademic performanceHigh educationData mining
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Due to the spread of COVID-19 virus, the Palestinian government imposed strict lockdown, panned vehicular travel, and imposed paying the government sectors’ employees through ATMs only on specified paydays to limit traveling and avoid crowding. This paper investigates the performance of queuing at ATM machines during the emergency period in Nablus city, Palestine and optimizes the service while maintaining the required health instructions. Field observations and analysis showed high congestion levels and long queues at ATMs, which is contrary to what the government planned for. Under the specified payday schedule and the current ATMs, waiting time extended to two hours and queues reached up to 39 persons. It is concluded that by redistributing the paydays based on demand and the spatial distribution of demand and ATMs, as well as adding mobile ATMs to meet excessive demand, waiting time and queue length will be considerably reduced with various levels from one payday to another. This will reduce the risk of spreading the virus due to crowding at ATMs. Keywords: Queuing Analysis; ATM; Quarantine; COVID-19; Spatial model.
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The current study aimed to identify the extent of the use of information and communication technology on the quality of higher education at Palestine Technical University Kadoorie, where a sample was selected deliberately from the deans of faculties and quality staff at the university and the study sample consisted of (12) of a dean and an employee. The descriptive analytical approach was used through the formulation of an open paper questionnaire to obtain information, and the results were reached after analyzing the interviews and the most important of which was the consensus of everyone that the university uses media and communication technology in the educational process, and interested in ensuring the quality of higher education, and the results of the repetitions showed that the majority of obstacles are represented by the weakness of the Internet and networks and the lack of modern computers, and one of the most important recommendations is the need to work to find a radical solution to the problem of Internet interruption and replace it with the connection of an alternative fiber line to the Internet and work to hold training courses on how to use technology for lecturers, administrators, and students.KeywordsInformation and communication technologyQuality of higher educationPalestine Technical University Kadoorie
Implementation of digital health in low- and middle-income countries is susceptible to influences of several institutional dynamics, through interactions of technological artefacts, political and other environmental conditions. These dynamics may lead to contradictions, not always obvious nor easily acknowledgeable. History can be valuable to understand and pursue explanations around why and how a technology gets adopted and institutionalized or not in particular settings. This study is part of a project focusing on a longitudinal case, where history is reconstructed over twenty years, in three phases: introducing digital health in post conflict Mozambique (2000–2007), disruption of initial efforts to introduce District Health Information Systems (DHIS) platform (2008–2014) and, adoption and scaling up of DHIS2 nationally (2015–2021). For the purposes of this paper, we conduct analysis to the initial period, with institutionalist lenses, aiming to identify the set of contradictions raised within the context of study and discuss implications for the future.
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Background Conventional and complementary treatments are often used in rehabilitation for persons with stroke. Conventional treatment makes use of medications, physiotherapy, occupational, speech and diet therapies while complementary treatment makes use of homeopathy, naturopathy, massage and acupuncture. The structure, process and outcomes of stroke rehabilitation using conventional or complementary treatments have not been empirically investigated in Ghana. Aim To investigate the structure, process and outcomes of stroke rehabilitation at the Korle Bu Teaching Hospital (KBTH) in Accra and Kwayisi Christian Herbal Clinic (KCHC) in Nankese-Ayisaa, Ghana and to explore experiences of persons with stroke. Methods A mixed methods approach involving a cross sectional, hospital-based cohort and qualitative exploratory studies. The objectives of the study will be achieved using three phases: Phase one will recruit health professionals and gather information on the structure and process of stroke rehabilitation at conventional and complementary hospital using adapted questionnaires. Phase two will determine outcomes of persons with stroke attending a conventional and complementary hospital facility at baseline, two, three- and six-months follow-up using outcome measures based on the International Classification of Functioning, Disability and Health (ICF) model. Phase three will explore experiences of persons with stroke who use complementary or conventional treatment using an interview guide. Data Analysis IBM SPSS Statistics Version 27 will be used to analyse the data using descriptive and inferential statistics. Repeated measures of ANOVA analysis will be used to determine differences between varaibles at baseline, one, three- and six-months post stroke. The qualitative data will be transcribed and entered into Atlas Ti version 9.0. The data will be coded and analysed using thematic areas that will be generated from the codes. Conclusion The study protocol will provide a comprehensive overview of structure, process and outcomes of stroke rehabilitation in Ghana: incorporating both conventional and complementary treatment and rehabilitation into the stroke recovery journey. It will also inform clinical practice, with new insights on the experiences of persons with stroke based on their choice of rehabilitation pathway.
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The purpose of this paper is to explore digital global public goods (DGPG) as a foundation for theorizing platforms for development. Global public goods (GPG) are widely accepted as fundamental for socio-economic development due to non-rivalry, non-exclusivity and global relevance. However, the challenges of extending the ideals of GPG to the digital platform domain are poorly understood and further theoretical developments are needed to advance our current knowledge of this relationship. To theorize the challenges, we draw on the GPG, digital platforms literature and concepts related to paradoxes. We illustrate the value of these ideas in making sense of the case study of the DHIS2 digital platform for health information primarily used in developing countries. Furthermore, the case analysis provides some practical implications on DGPG platforms.
Conference Paper
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The organisational adoption and use of Enterprise Architecture (EA) are pursued by enterprises aiming to improve their digital services and overall performance by aligning IT with processes. Nevertheless, despite the increasing interest in EA, it is still not widely used. Prior research provides explanations of institutional elements enabling or inhibiting EA adoption and use but does not provide concrete suggestions on facilitating EA adoption. This paper suggests different types of institutional work that can strengthen the use of EA, addressing central challenges met by EA initiatives. Specifically, the paper presents evidence from a longitudinal case study on the introduction of EA in the hospital sector in Norway. We show how institutional work can mitigate the inherent challenges of EA initiatives and thereby speed-up and strengthen the use of EA in organisations.
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Scaling health information system from small scale pilots to national systems in developing countries poses a key challenge to system designers and health managers. As a consequence, many projects dissolve and die before they reach the scale where they are useful for information management. The concept of bootstrapping from the Information Infrastructure literature has proven useful to discuss and understand how to initiate and grow large-scale, complex and networked information systems from scratch. We use this concept to analyze and discuss an empirical case of building a large scale medical licensing system in a Southeast Asian country. Beyond describing the process leading up to the success of the licensing system, we contribute by identifying a range of factors influencing the bootstrapping process and we suggest extensions to make the bootstrapping strategy relevant in this context.
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—Community health workers (CHWs) have reemerged as significant cadres in low- and middle-income countries and are now seen as an integral part of achieving the goal of universal health coverage (UHC). In international guidance and support, the emphasis is increasingly shifting from a focus on the outcomes of CHW-based interventions to the systems requirements for implementing and sustaining CHW programs at scale. A major challenge is that CHW programs interface with both the formal health system (requiring integration) and community systems (requiring embedding) in context-specific and complex ways. Collectively, these elements and relationships can be seen as constituting a unique sub-system of the overall health system, referred to by some as the community health system. The community health system is key to the performance of CHW programs, and we argue for a more holistic focus on this system in policy and practice. We further propose a definition and spell out the main actors and attributes of the community health system and conclude that in international debates on UHC, much can be gained from recognizing the community health system as a definable sphere in its own right.
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Universal health coverage (UHC) - the availability of quality affordable health services for all when needed without financial impoverishment - can be a vehicle for improving equity health outcomes and financial wellbeing. It can also contribute to economic development. In its Global Health 2035 report the Lancet Commission on Investing in Health (CIH) set forth an ambitious investment framework for transforming global health through UHC. The CIH endorsed pro-poor pathways to UHC that provide access to services and financial protection to poor people from the beginning and that include people with low income in the design and development of UHC health financing and service provision mechanisms.
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Successive Governments of India have promised to transform India's unsatisfactory health-care system, culminating in the present government's promise to expand health assurance for all. Despite substantial improvements in some health indicators in the past decade, India contributes disproportionately to the global burden of disease, with health indicators that compare unfavourably with other middle-income countries and India's regional neighbours. Large health disparities between states, between rural and urban populations, and across social classes persist. A large proportion of the population is impoverished because of high out-of-pocket health-care expenditures and suffers the adverse consequences of poor quality of care. Here we make the case not only for more resources but for a radically new architecture for India's health-care system. India needs to adopt an integrated national health-care system built around a strong public primary care system with a clearly articulated supportive role for the private and indigenous sectors. This system must address acute as well as chronic health-care needs, offer choice of care that is rational, accessible, and of good quality, support cashless service at point of delivery, and ensure accountability through governance by a robust regulatory framework. In the process, several major challenges will need to be confronted, most notably the very low levels of public expenditure; the poor regulation, rapid commercialisation of and corruption in health care; and the fragmentation of governance of health care. Most importantly, assuring universal health coverage will require the explicit acknowledgment, by government and civil society, of health care as a public good on par with education. Only a radical restructuring of the health-care system that promotes health equity and eliminates impoverishment due to out-of-pocket expenditures will assure health for all Indians by 2022—a fitting way to mark the 75th year of India's independence.
People with multiple chronic conditions often struggle with managing their health. The purpose of this research was to identify specific challenges of patients with multiple chronic conditions and to use the findings to form design principles for a telemonitoring system tailored for these patients. Semi-structured interviews with 15 patients with multiple chronic conditions and 10 clinicians were conducted to gain an understanding of their needs and preferences for a smartphone-based telemonitoring system. The interviews were analyzed using a conventional content analysis technique, resulting in six themes. Design principles developed from the themes included that the system must be modular to accommodate various combinations of conditions, reinforce a routine, consolidate record keeping, as well as provide actionable feedback to the patients. Designing an application for multiple chronic conditions is complex due to variability in patient conditions, and therefore, design principles developed in this study can help with future innovations aimed to help manage this population.
Purpose E-health tools for patients aim to change current care practices. However the role of IT in transforming health care is not straightforward. The purpose of this paper is to understand how this change process unfolds and what characterizes the process by which visions of new care practices become inscribed into digital tools. Design/methodology/approach The study adopted a qualitative research design and it is based on an interpretive case study on the digitalization of a tool for diabetes care used in a hospital in Norway. Data have been collected via interviews and observations. Digitalization activities are understood as institutional work in order to examine the relation between the decisions taken in the design process and the intended change of the practices of diabetes care. Findings The study identifies three types of activities of institutional work: inscription of self-reflection, inscription of legitimation and inscription of new usage. The analysis of these activities shows how the vision of patients’ more active, learning and reflection-oriented role is inscribed into digital technology; how institutional work strives both for change and for legitimation thus smoothing the transition to a new institutional arrangement; and how institutional work relates to digital materiality. Originality/value The study contributes to the institutional theory literature by conceptualizing digitalization as institutional work toward changing institutions. It also contributes to the IS literature on digitalization by providing an analysis of how the affordances of digital materials support the work toward new institutions.
Despite the influence of information and communication technologies (ICTs) on enhancing transparency and fairness, there is limited theoretical understanding of how ICT affects corruption. Adopting an institutional perspective, we conceptualize the mechanisms through which e-government influences corruption in a nation. Specifically, we theorize the relationship between e-government and corruption at two levels: (1) base corruption observed in national institutions (political, legal, and media institutions), and (2) permeated corruption in the national stakeholder service systems (business and citizen systems). Using panel data from 63 countries over a 4-year period, we test the direct and mediated effects of e-government on corruption in national institutions and stakeholder service systems, respectively. This exploratory study provides preliminary insights into the mechanisms through which corruption manifests in a nation and demonstrates how e-government can be helpful in alleviating it. In addition, the study offers important implications that we believe will be instrumental in stimulating future research on the subject.
The digital divide is usually conceptualized through goods-dominant logic, where bridging the divide entails providing digital goods to disadvantaged segments of the population. This is expected to enhance their digital capabilities and thus to have a positive influence on the digital outcomes (or services) experienced. In contrast, this study is anchored in an alternative service-dominant logic and posits that viewing the divide from a service perspective might be better suited to the context of developing countries, where there is a huge divide across societal segments in accessing basic services such as healthcare and education. This research views the prevailing differences in the level of services consumed by different population segments (service divide) as the key issue to be addressed by innovative digital tools in developing countries. The study posits that information and communication technologies (ICTs) can be leveraged to bridge the service divide to enhance the capabilities of service-disadvantaged segments of society. But such service delivery requires an innovative assembly of ICT as well as non-ICT resources. Building on concepts from service-dominant logic and service science, this paper aims to understand how such service innovation efforts can be orchestrated. Specifically, adopting a process view, two Indian enterprises that have developed sustainable telemedicine healthcare service delivery models for the rural population in India are examined. The study traces the configurations of three interactional resources—knowledge, technology, and institutions—through which value-creating user-centric objectives of increasing geographical access and reducing cost are achieved. The theoretical contributions are largely associated with unearthing and understanding how the three interactional resources were orchestrated for service-centric value creation in different combinative patterns as resource exploitation, resource combination, and value reinforcement. The analysis also reveals the three distinct stages of service innovation evolution (idea and launch, infancy and early growth, and late growth and expansion), with a distinct shift in the dominant resource for each stage. Through an inductive process, the study also identifies four key enablers for successfully implementing these ICT-enabled service innovations: obsessive customer empathy, belief in the transformational power of ICT, continuous recursive learning, and efficient network orchestration.