Grafting Information Infrastructure: Mobile Phone‐based Health Information System Implementations in India and Malawi

Abstract

In the wake of ‘the mobile revolution’ there has been an immense upsurge in mobile phone based health innovations, or mHealth for short. Expected efficiency gains and health benefits with such innovations, however, have been notoriously difficult to realize in the resource sparse settings of less developed economies. Scholars and industry specialists have found the implementation of a large portion of mobile phone-based innovations unsustainable beyond short term pilot projects.

This dissertation is positioned within the information systems (IS) research tradition and develops a nuanced understanding of so called mHealth sustainability challenges through two qualitative and exploratory interpretive case studies, one in India and one in Malawi.

Both mobile phonebased implementations under study were commissioned by health authorities to strengthen routine reporting of public health data. A ‘big-bang’ roll-out to 5000 community-based health workers was initiated in India while incremental ‘baby-steps’ were favored in Malawi. The two empirical cases highlight different technical, infrastructural, socio-political, and institutional hurdles. The dissertation draws theoretical inferences from both cases through the proposition of information infrastructure grafting, whereby complex and fragile multi-stakeholder ICT implementation processes are conceptualized analogously with horticultural grafting (read: gardening).

There is one simple maxim to plant grafting – the grafted branch or shoot has to take hold before it can grow. The merge between congenial plant parts can be assisted, but not asserted, by a gardener’s careful application of appropriate grafting techniques. The grafting metaphor foregrounds the need for care and tenderness in information infrastructure development, particularly in resource sparse settings. Information infrastructure grafting, then, is a fragile process whereby innovative ICT capabilities merge and coevolve with extant technologies, work practices, physical and digital infrastructure, and social institutions.

This dissertation explores how congeniality between innovative ICT capabilities and extant socio-technical arrangements, and not merely ‘technology fit’ or ‘organizational readiness’, paves the road towards more sustainable implementations. This has practical implications for health information system policy makers and strategists, international funding agencies, ICT project managers and mHealth practitioners. Based on empirical investigations and an ecological conceptualization of socio digital change, this dissertation engages constructively with the discourse on sustainable development as it pertains to ICT based implementations in general and mHealth research and practice in particular.