Information Technology for Development

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The clinic-level perspective on mHealth

implementation: a South African case study

Brendon Wolff-Piggott, Jesse Coleman & Ulrike Rivett

To cite this article: Brendon Wolff-Piggott, Jesse Coleman & Ulrike Rivett (2017): The clinic-level
perspective on mHealth implementation: a South African case study, Information Technology
for Development, DOI: 10.1080/02681102.2016.1233858

To link to this article: http://dx.doi.org/10.1080/02681102.2016.1233858

Published online: 06 Jan 2017.

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INFORMATION TECHNOLOGY FOR DEVELOPMENT, 2017
http://dx.doi.org/10.1080/02681102.2016.1233858

The clinic-level perspective on mHealth implementation:

a South African case study
a
Brendon Wolff-Piggott , Jesse Colemanb,c and Ulrike Rivetta
a
Department of Information Systems, University of Cape Town, Cape Town, South Africa; bWits Reproductive
Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa; cFaculty of Public
Health Sciences, Karolinska Institute, Stockholm, Sweden

ABSTRACT KEYWORDS
This exploratory investigation presents a case study of the mHealth; Activity Theory;
deployment of an mHealth service in established public clinics, empirical study; exploratory
and assesses the findings using Activity Theory. We contribute to study; maternal health; South
Africa
the limited empirical research on mHealth implementation in
established public facilities, and build on work on the use of
Activity Theory to frame investigations of ICT4D interventions.
The study investigates the perspective of clinic staff responsible
for registering women for a free maternal health messaging service.
Open-ended interviews and observation sessions were used to
reveal staff experiences of the implementation, and their work
practices. Activity Theory analysis was adopted to help interpret
the data, and identify likely dynamics leading to these specific
practices.
Some themes that emerged were the hierarchical nature of the
medical profession and implications for task shifting, the influence
of technical design choices on use patterns and issues arising
from the developing-country context.

Introduction
The concept of mHealth as a way to improve health care in developing countries has sub-
stantial support from international consultants (Vital Wave Consulting, 2009), donors
(Rockefeller Foundation, 2010), the mobile phone industry (Tomlinson, Rotheram-Borus,
Swartz, & Tsai, 2013) and public health authorities (Kelly & Minges, 2012). mHealth, or
the delivery of healthcare services via mobile communication devices (Torgan, 2009),
may be regarded as a subset of eHealth, which is defined as the transfer of health
resources and health care by electronic means (World Health Organization, 2016).
Concern has been expressed by development bodies that mHealth needs to integrated
into broader eHealth strategies to be effective (World Health Organization and Inter-
national Telecommunication Union, 2012). Some scholars have also questioned whether
there is sound evidence of improved long-term health outcomes, and whether it can be
scaled up effectively and in a financially sustainable way (Aranda-Jan, Mohutsiwa-Dibe,
& Loukanova, 2014; Tomlinson et al., 2013). Developing an understanding of how

CONTACT Brendon Wolff-Piggott brendonwp@gmail.com

Kweku-Muata Osei-Bryson is the accepting Associate Editor for this article.
2017 Commonwealth Secretariat
2 B. WOLFF-PIGGOTT ET AL.

mHealth is used in practice within existing health care delivery institutions is an important
contribution to this debate.
The South African National Department of Health (NDoH) started rolling out the Mom-
Connect national mHealth initiative in August 2014 (MomConnect to link expectant
mums with vital info, 2014). This service provides information to pregnant women on
maternal health tailored to the different stages of pregnancy, and for up to a year after
birth, using free text messaging. While mothers can start the registration for the service
themselves, it needs to be completed at a clinic after a nurse has confirmed the pregnancy.
The registration is a rapid process in comparison to the other procedures that need to be
followed, such as information sessions on health promotion during pregnancy, physical
examination, HIV testing.
Although mHealth projects have proliferated in recent years in developing countries
(Asangansi & Braa, 2010; Sanner, Roland, & Braa, 2012), national-level rollouts are scarce
and little is known about the practical implications of such initiatives, particularly for
routine work practices (Chib, van Velthoven, & Car, 2015). A detailed understanding of
how the MomConnect implementation affects daily work practices at clinic-level fills a
gap in knowledge about the dynamics of mHealth implementation, and has the potential
to inform improvements to the implementation process, including management pro-
cesses, training and other aspects of the rollout.
In this exploratory study we collected empirical data on how clinic staff incorporated
MomConnect into their daily routines, based on open-ended interviews and observation
sessions. These qualitative data were then analyzed, and situated within the framework of
Activity Theory (Engestrm & Glveanu, 2012; Kaptelinin & Nardi, 2012; Karanasios & Allen,
2013). This enabled us to draw in broader contextual concerns specific to mHealth adop-
tion in a developing country (Chib, 2013; Karanasios, 2014), in line with the recommen-
dations of recent review articles on health information systems implementation
(Fitzpatrick & Ellingsen, 2013; Romanow, Cho, & Straub, 2012).
In the next section we review the literature on mHealth in developing countries, and
identify implications for conceptualising mHealth implementation. This is related to
issues raised in the broader health information systems literature, as there is currently
little published research on large-scale mHealth implementations to frame empirical
enquiry. Following this we present details of the research setting, and set out our meth-
odology. Next we present the results emerging from our empirical study, and discuss
them in the context of Activity Theory. Finally we summarize our contribution in the con-
cluding remarks, and identify avenues for future research.

Literature review
Mobile handset use in developing countries
A recent review of mHealth interventions in sub-Saharan Africa concluded that overall,
the current evidence is not strong enough to warrant large-scale implementation of exist-
ing mHealth interventions (p. 1; Betjeman, Soghoian, & Foran, 2013). This assertion is sup-
ported by Tomlinson et al. (2013), who state that no large-scale, well-designed efficacy and
effectiveness trials of mHealth have been carried out as yet.
In contrast to the cautions noted above, numerous studies cite the significance of the
wide availability of mobile phones and the ease with which many people are able to use
 INFORMATION TECHNOLOGY FOR DEVELOPMENT 3

their standard features in the developing world (Donner, 2008; Kelly & Minges, 2012;
Tamrat & Kachnowski, 2012). In a similar vein, a number of scholars have discussed the
potential of mHealth to improve health outcomes as a result of the ubiquity and accessi-
bility of this technology (Bloomfield et al., 2014; Chib, 2013).
Over 70% of mobile subscribers are located in developing countries (Naef et al., 2014),
and the rate of mobile phone penetration has been increasing more rapidly in developing
than developed countries for some time (GSMA Intelligence, 2016; Ladd, Datta, Sarker, &
Yu, 2010). In addition, mobile services are generally associated with less need for user
training, end-user support staff and dedicated desktop software, as the complex technol-
ogy that supports the infrastructure is centrally managed by large corporate organizations.
This suggests that these services may be in a position to overcome some of the barriers
that have impeded the widespread use of non-mobile information systems in developing
countries (Heeks, 2002).
Research on mobile phones and applications in the workplace outside the developing
world has tended to focus on transformations: enabling work while on the move (Enges-
trm, 2008; Srensen et al., 2008) or spatially dispersed work (Wiredu & Srensen, 2006).
The question remains, how will the use of mobile phones and applications influence (or
fail to influence) workplaces where they are used in a relatively minor, routine role, particu-
larly in the developing world? While the barriers to mobile adoption are relatively low even
in developing countries (Donner & Escobari, 2010), realities such as uneven access, limited
levels of literacy and other obstacles will influence the interplay between technology fea-
tures and the specific physical and cultural setting. Price-sensitivity is one example that
leads to the prearranged use of missed calls or beeping (Donner, 2008), and the use
of multiple SIM cards to minimize call costs on different networks (Robinson, Marsden,
& Jones, 2014).

Approaches to conceptualizing mHealth

There are numerous studies that describe mHealth implementations (Tomlinson et al.,
2013). Few of these studies have attempted to apply or develop a conceptual framework
within which to situate this phenomenon (Chib et al., 2015). Some researchers with experi-
ence of Health Information Technology (HIT) in developing countries have proposed typol-
ogies of mHealth interventions (Braa & Sanner, 2011; Sanner et al., 2012) that have drawn
on the theory of Information Infrastructures (Hanseth & Lyytinen, 2010). Information Infra-
structure theory proposes a metaphor of cultivation rather than an engineering design
approach (Ciborra, Braa, & Cordella, 2000). The wide availability of mobile phones and their
deep penetration even into rural areas of the developing world is seen as constituting an
installed base that offers important opportunities, while also constraining the kind of sol-
utions that are practical (inertia) (Asangansi & Braa, 2010).
The Information Infrastructures literature emphasizes the importance of considering
the sociotechnical nature of the installed base (Aanestad & Jensen, 2011), including the
physical and social context of work, existing technologies and routines, and the
workers skills and beliefs (p. 162). It argues that technological interventions need to
align with existing ways of working, and understandings of the nature of work, if they
are to be successful. This position is supported by a well-established research tradition
(Ciborra et al., 2000; Edwards, Bowker, Jackson, & Williams, 2009; Star & Ruhleder, 1996).
4 B. WOLFF-PIGGOTT ET AL.

Activity Theory also takes a sociotechnical perspective on information systems inter-

ventions (Hkkinen & Korpela, 2007; de la Harpe, Lotriet, Pottas, & Korpela, 2013;
Korpela, Mursu, & Soriyan, 2002). It has only relatively recently been proposed as a
theory-based framework for understanding ICT4D interventions (Karanasios, 2014;
Karanasios & Allen, 2013), and has received less attention that the Information Infra-
structures approach.

Issues emerging from health information technology research

The mainstream of HIT research suggests a number of insights of relevance to mHealth
studies. HIT research is a well-established field (Romanow et al., 2012), and a number of
priorities have been identified to further this research. One such priority is that of bring-
ing health-specific contextual information into theorizing of HIT (Romanow et al., 2012),
or in this case, mHealth. The literature on HIT tends to deal with hospital-based
implementations rather than clinic-level deployments. A number of dynamics have
been identified that are worth noting. The health professions are hierarchical (van der
Geest & Finkler, 2004), with medical specialists and consultants senior to more general-
ized medical doctors, who in turn are deferred to by nurses and their juniors. The spread
of innovations in this kind of environment can be blocked if teams of different medical
professions are unable to work harmoniously together (Ferlie, Fitzgerald, Wood, &
Hawkins, 2005).
Health professionals tend to view the use of information systems for data capture as a
low-status task, and is often delegated by doctors to nurses (Jensen & Aanestad, 2007;
Kane & Labianca, 2011; Lluch, 2011). This has been interpreted as user resistance (Wu,
Li, & Fu, 2011), which has been identified as a major issue that requires improved under-
standing if HIT deployment is to be successful (Romanow et al., 2012). In alignment with
Takian, Petrakaki, Cornford, Sheikh, and Barber (2012), we argue that it is more useful to
conceptualize this kind of behavior in terms of user priorities and aims, which may vary
between sites and over time.

Implications for conceptualizing mHealth implementation

The literature review has highlighted a number of issues of relevance when considering
mHealth use in a developing country context. First of all, mobile handset use is
common in developing countries, but the specifics of the context, particularly resource
constraints, will influence the precise patterns of use. A framework that is effective at
taking account of the nature of the technology as well as the social context of use is
essential.
In addition to the above, a sociotechnical approach asserts that an understanding of
existing ways of working is important. This implies that the actual conditions under
which work is carried out, rather than an abstract model, should be the point of departure.
HIT research has emphasized the importance of bringing in health-specific contextual
information. An important factor is the perception by medical professionals of data entry
and technology use as low-status activity, with associated task shifting. Finally, local priori-
ties and goals need to be taken into account when considering implementation in such an
environment.
 INFORMATION TECHNOLOGY FOR DEVELOPMENT 5

Research setting
Public health care in South Africa
South Africa is one of the few countries where child mortality has increased since the base-
line set for the Millennium Development Goals in 1990 (Chopra et al., 2009). While destruc-
tive historical policies such as apartheid have contributed greatly to the challenges
currently facing the South African health system, failures in leadership and management
have compounded the impact of the HIV/AIDS epidemic (Coovadia, Jewkes, Barron,
Sanders, & McIntyre, 2009). There has also been a substantial increase in non-communic-
able diseases such as hypertension and diabetes that impact negatively on maternal
health (Coovadia et al., 2009).
South Africa has a two-tier health system; a free public health system available to all,
and private health care available for a fee. Private health care insurance can be purchased
to cover fees associated with these private health sites, with many South African employ-
ers mandating a minimum private health insurance package for their staff. Approximately
80% of the South African population utilize the public health care system, which is chroni-
cally under-resourced (Lafemine, 2012). Minimum public health care standards and pol-
icies are mandated by the NDoH (Department of Health, 2011).
Public health care services in urban areas are offered by both provincial and municipal
authorities; primary health care clinics are provided by the city authorities, and urban-
based tertiary hospitals are run by the province. Primary health care services include, but
are not limited to, HIV testing and treatment, sexually transmitted infection testing, family
planning, antenatal care (ANC), postnatal care (PNC) and chronic illness management.
The HIV/AIDS epidemic has led to the introduction of nurse-initiated management of
anti-retroviral treatment (NIMART), something that was the preserve of medical doctors
previously (Georgeu et al., 2012). This has had a positive impact on health outcomes,
but has further burdened the clinic staff. Another implication of high rates of HIV is that
prevention of mother-to-child transmission at birth is an important priority at clinics.

Public clinic-based ANC

The setting of this research is selected clinics in the inner city of Johannesburg, South
Africa, in Health Region F. Johannesburg is the business capital and industrial and com-
mercial hub of both South Africa and the southern African region. The greater Johannes-
burg area has a population of approximately 8 million and has been growing rapidly for a
number of years (Statistics South Africa, 2011). Major industries include mining, manufac-
turing and a large service sector. Apartheids legacy has left obvious separation between
blacks and whites geographically and economically. The unemployment rate for the black
African population is on average 3.5 times higher than for whites (South African Institute
for Race Relations, 2015).
As the center of a regional hub, Region F is densely populated and has a large popu-
lation of migrants from within and outside South Africa, with high levels of poverty. The
official population of Region F is 400,000 individuals; however, research suggests the
actual number is between 800,000 and 1,200,000. Unemployment rates are high and
most of the population utilizes the public health system. There are 15 ANC clinics and
three labor wards which service over 32,000 pregnant women annually. Over 60% of
6 B. WOLFF-PIGGOTT ET AL.

pregnancies in the area are unplanned and access to maternal health services can be a
challenge, especially for individuals who are HIV positive, under 18 or foreign (Solarin &
Black, 2013).
The South African national maternal health protocol aims to have all first ANC visits
prior to 20 weeks of pregnancy to minimize poor birth outcomes. Unfortunately, all
three sites have seen at least two-thirds of women having their first ANC visit after their
20th week of pregnancy since records have been kept. Reasons for this have been
described elsewhere (Solarin & Black, 2013). South Africa as a whole has a high level of
facility-based deliveries and Johannesburgs Region F is no different.
All three study clinics are based in Johannesburgs Region F and each offer similar
health services which predominantly focus around HIV and maternal health services.
Maternal health is divided into ANC and PNC/vaccination (PNC/EPI) services. ANC services
are offered four days a week (Monday to Thursday) at each site and pregnant women are
expected to attend at least 4 ANC visits prior to their estimated date of delivery. Over the
2014 calendar year, the three clinics under study had an average of 90, 100 and 120 first
ANC visits, per month.

The MomConnect service and registration process

The MomConnect service uses the Unstructured Supplementary Service Data (USSD) pro-
tocol to register users. This is available on almost all mobile handsets, except for some
entry-level Windows phones. MomConnect registration involves entering a standard
code to initiate the registration process. The key piece of information to be entered
next is the phone number for SMS message delivery (not necessarily the same as the
number of the handset being used for the registration process). A unique clinic code
must also be entered, identifying the facility where registration is taking place and con-
firming the pregnancy on the central MomConnect database. Afterwards, the babys
expected date of delivery and the womans passport or identity document number
need to be entered before she can start receiving biweekly messages. A woman registered
on the MomConnect service also has the ability to send free requests for additional infor-
mation, and register compliments or complaints about the treatment she received at the
clinic.

Methodology and theoretical framing

A case study design (Flyvbjerg, 2006) is used in order to examine MomConnect registration
practices in different clinic settings. We aim to develop conceptual understanding by
drawing on Activity Theory in interpreting the cases, and have therefore not attempted
statistical sampling (Yin, 2002).

Data collection and analysis

Ethics approval for the study was obtained from the University of Cape Town. Background
interviews with various project stakeholders were held to obtain an overview of the Mom-
Connect initiative. Publically available documentation was also consulted, including press
releases, websites promoting the project and training materials. The three clinics included
 INFORMATION TECHNOLOGY FOR DEVELOPMENT 7

in the research were selected on the basis of their ease of access, through an association
with the Wits Reproductive Health and HIV Institute. All of the clinics fall under the City of
Johannesburg Health Department, and are based in the inner-city region.
Open-ended interviews were held with the facility manager at each clinic, with the
nurse responsible for providing antenatal services, and with any other staff involved in
MomConnect registration that were identified by the nurse. Each interview was recorded
with the permission of the informant, and professionally transcribed.
Focused observation sessions were negotiated with the informants, typically for the
first half of a morning, as this was when MomConnect was presented to clients, and
some registrations took place. Where the actual registration process was conducted
outside formal clinic hours, the process of interaction with mothers to collect the
required information was observed. Notes were taken during the interview and obser-
vation sessions, and reviewed and consolidated shortly after each observation session.
Following the presentation, each client was attended to personally by the ANC nurse,
after which various tests were performed that could take up most of the day on first
ANC visits.
The number of interviews (summarized by staff member level) as well as the number of
focused observation sessions is given in Table 1. The number of interviews and obser-
vation sessions was limited by the availability of the staff, given their workload and pro-
fessional obligation to give attention first to client needs.
The interview transcripts were loaded into Atlas.ti Version 7.5 (Atlas.ti, 2015). Initially
the transcripts were coded using open coding. The initial codes were then grouped
according to themes emerging from the data. The codes and themes were then refined
with reference to relevant literature and key concepts from Activity Theory. Hermeneutic
analysis (Klein & Myers, 1999) was used to move between the transcripts codes, the
themes, the literature and the theoretical framework.

Activity theory
The most fundamental concept in Activity Theory is that of activity (Kaptelinin & Nardi,
2012; Korpela et al., 2004; Vygotsky, 1978). An activity happens when a subject (a
person or group of people) interacts with an object using a tool, in a social context (Kap-
telinin & Nardi, 2009). A tool is not necessarily a physical object such as a hammer; a tool
may be a concept that is used to advance ways of reasoning or an information system that
is used to enter and manipulate information (Leonardi, 2012).
Activity Theory holds that the cultural-historical context of an activity is important to
understanding the characteristics and dynamics of an activity (Engestrm & Glveanu,
2012). In other words, activity systems exist in an organizational and societal context.
This is an important consideration when looking at a developing-country context

Table 1. Summary of numbers of interviews and focused observation sessions conducted.

Type of data collection Staff level
Facility managers ANC nurses Support staff
No of interviews 4 3 5
No of focused Observation sessions 6 at each of the
three clinics (18 in total)
8 B. WOLFF-PIGGOTT ET AL.

Figure 1. The activity system model (Engestrm, 1999).

(Karanasios, 2014), and also helps in addressing the concern of HIT research to introduce
health-specific contextual issues.
Engestrm (1999) proposed an expanded version of Activity Theory that includes the
concept of community together with the subject, object and tool originally present in
Activity Theory, in order to apply it in organizational context. He proposed a conceptual
model that has found acceptance in the Activity Theory community as a useful device
(Kaptelinin & Nardi, 2009). Engestrm separated out different aspects of the social world
that offer resources for activities in his model shown in Figure 1.
Another important concept in Activity Theory is that of contradictions (Allen, Brown,
Karanasios, & Norman, 2013). Activity Theory holds that Activity Systems generally
contain contradictions that place stress on the system, and give rise to changes (Enges-
trm, 2001). An organization may also be understood as a series of nested Activity
Systems. These systems may contain contradictions both within themselves and
between the different systems (Kaptelinin & Nardi, 2012).

An activity theory perspective on MomConnect

The MomConnect system was designed and launched by the NDoH, with the intention of
improving the health of pregnant women and young children. Clinic ANC nurses were
identified as key staff members in the registration process, as they are responsible for
physically examining women, confirming pregnancies and calculating the estimated
due date of delivery (EDD).
When pregnant women are registered on MomConnect, their contact mobile number,
EDD and other details are required to complete the process. The registration can be per-
formed by a nurse or member of the ANC support staff as long as they have access to all
this information, as well as the unique code that identifies the clinic on the MomConnect
system.
Figure 2 below shows the MomConnect implementation activity, indicating the object
as messaging for pregnant women and the desired outcome as improved health for the
women and their children. MomConnect registration at clinics is the process that sets
the activity in motion for individual women, who may not return to the clinics until
 INFORMATION TECHNOLOGY FOR DEVELOPMENT 9

Figure 2. MomConnect implementation activity.

requiring immunization for the child the overall activity of messaging takes place
without requiring further involvement from the clinic.

Results
This section presents the results obtained through interviews and observation. First activi-
ties and roles are discussed, then handset-related issues and finally constraints related to
technical design decisions.

Activities and roles

Interviews at facility manager, ANC nurse and support staff levels revealed different areas
of focus at each level. The facility manager was concerned with ensuring that all units of
the clinic were providing adequate care, and balancing resources across the clinic to
ensure that critical shortages were addressed.
ANC nurses had fixed offices that they worked from, with queues of pregnant women
directed to them for physical examination and the calculation of the EDD. In some clinics
women who were not sure of their HIV status were scheduled to visit on separate
days from those who were aware that they were HIV+, as these two groups needed differ-
ent care. The policy of the NDoH is to attend to all clients that present themselves at the
clinic.
Some of the support staff working in the ANC section and working with MomConnect
registration were certified as Health Promoters, but in some cases were less qualified. Their
focus in the ANC section was on preparing the women before they entered consultation
with the ANC nurse, presenting a relatively standardized health promotion lecture cover-
ing safe sex practices, health management issues such as a sound diet, and the identifi-
cation of warning signs signaling the need to seek medical advice. Table 2 below
summarizes the core focus at different levels in the clinic.
One respondent commented that MomConnect registration was not seen as in line
with the scope of professional work of a nurse: The way I take it, its undermining. Pro-
fessionals dont do this, really. This sentiment was not verbalized by other respondents,
10 B. WOLFF-PIGGOTT ET AL.

Table 2. Focus areas at different levels in the clinic.

Unit of analysis Subject Focus
Clinic Facility manager Activity: Curative and preventive care delivery
Antenatal care ANC sister Activity: Physical examination, calculation of EDD, and referral for further
section test as required
ANC health Health promoter/ Activity: Health Management Presentation and MomConnect Registration
promotion volunteer

but the observed work practices showed that nurses did not carry out the registrations
themselves in any of the clinics. This agrees with the general sentiment coming from
the literature that data entry is not seen as an appropriate part of a medical professionals
daily work (Romanow et al., 2012). Shortage of professional nursing staff and time were
also mentioned as constraining the involvement of nurses in MomConnect use: The
work is being added (to) every day. Thats how we nurses feel. Work is added (by)
this Mom Connect, its on top of other things.
The responses pointed to professional nurses time being seen as a scarce resource that
needed to be used optimally. This suggests why most of the actual registration work is
carried out with minimal involvement from the nursing staff.
All three of the clinics visited provided antenatal services, and MomConnect regis-
tration. The work practices around MomConnect registration differed in each case, but
many of the same themes appeared across clinics. In the one case where there was a
nursing sister present when registration was taking place, it was in a clinic where the
health promoter and nursing sister typically saw patients together. This meant that the
nurse was able to expand on key points raised by the health promoter. Mothers were
asked to enter the registration information themselves, in a group setting.
In the other clinics, a health promoter or volunteer worker would provide an edu-
cational talk to the mothers, and close off by introducing MomConnect as an important
source of information. The support staff member would write down the mothers details
if they were interested in registering, and do the registration on a personal handset
later in the day.
This had the advantage that the staff member worked with a known (own) handset, as
one of the issues raised in the other clinics was that working with the pregnant womens
handsets meant having to navigate a wide range of devices every day. This was felt to be a
wasteful expenditure of time, particularly in the case of the nurses.

Handset-related issues
The literature suggested that mobile phone use, certainly in urban areas such as Johannes-
burg, should not present problems. This was not found to be the case, with informants
reporting that clients not infrequently either did not have a phone, or else there was a per-
ception that they were not able to use it effectively.
Several possible reasons were advanced for the non-availability of mobile phones. One
reason was related to safety when queuing early in the morning, which in winter could be
in the dark: some of them . they say they cant have these telephones because they
come very early. It was explained that women queuing in the dark might be targets for
criminals. Another reason suggested was that women from informal settlements
 INFORMATION TECHNOLOGY FOR DEVELOPMENT 11

without electricity cannot recharge a phone readily, and therefore would not have a
reason to possess one.
The statements that clients were not able to use their phones effectively were puzzling:
when they have a cell phone but they dont know how to use them, that bothers me
the most. If a person is the owner of the phone but doesnt know where to press, what to
do. Urban South Africa has a high percentage of cell phones in use, with many in the hands
of lower-income population represented at the clinics. A perception cited by the staff about
client trust regarding medical confidentiality, as well as handset use, could explain this:
Some antenatal patients are sceptical when it comes to registration process. Because some of
them are HIV positive so they are scared that we will be sending information on HIV, and some
of them havent disclosed and sometimes they share the phones.

In addition, staff reported being unwilling to use their personal handsets, in part because of
a concern that their airtime might be used: I dont want to use my phone for work related
things, especially if it will use my airtime. So I got relieved when we are told that its free.
While the staff interviewed understood that MomConnect would not use their airtime, low-
income clients sensitive to the risk of fraud may be put off entering sensitive information.

Constraints related to technical design issues

The use of the USSD service for the registration process was familiar to the clinic staff, as
pay-as-you-go airtime (credit) is topped up using this mechanism. USSD is the lowest pri-
ority protocol handled by cell phone towers, and when a tower is starting to approach
capacity USSD service suffers first as a result. USSD sessions are also dropped if they are
not concluded within approximately three minutes.
Registration sessions were often disrupted by various technical errors, which were
cryptic to the end users. These disruptions made it necessary to restart the registration
process. Once the mothers cell number had been entered, the system would offer the
option to continue the interrupted session and it was no longer necessary to start the
registration process from scratch. While this was useful, informal testing suggested that
more than 50% of registration attempts are interrupted in this way in the clinics under
study. This was not only time-consuming, but has financial implications for the project
as well as the mobile service providers charge for interrupted USSD sessions (N. Sundar,
personal communication, 2015).
Responses to this constraint varied. Where support staff were solely responsible for per-
forming MomConnect registrations they collected most the available information in the
mornings when the women were waiting to see the ANC nurse, noted the EDD once
the nurse had diagnosed the pregnancy, and performed the registration process later
on when the clinic was less busy. The other mode of registration identified was where
clients were requested to carry out the registration process with support from the clinic
staff, where the aim seemed to be to complete the process in parallel as far as possible.

Discussion
Activity systems provide a useful way to depict and relate the dynamics described in the
previous section.
12 B. WOLFF-PIGGOTT ET AL.

The clinic experience in context

The clinic experience of MomConnect registration needs to be understood in the context
of the national project, and the relationship of the activities in the clinic to the overall
system. MomConnect is an initiative lead by the NDoH of South Africa, and is composed
of a number of partners. These include USAID as the seed funding agent, software devel-
opment companies that maintain the messaging and database systems at the back end of
MomConnect, and the different mobile service providers who receive registration requests
and distribute messages to individual handsets.
The clinic staff interact directly with the registration menu of MomConnect, in the
context of ANC delivery. ANC is one of a number of services delivered in a public clinic,
and the clinics fall under the management of local authority or provincial government
health departments, rather than the national department itself. This situation may be rep-
resented in simplified form as a set of nested activity systems, as set out in Figure 3. The
relationship between activity systems is indicated with an arrow (instead of nesting the
diagrams) for clarity.
The national Minister of Health launched MomConnect in August 2014 together with
media conferences, and the establishment of a dedicated unit within the national head
office to manage the project. At the clinic level, formal training courses were provided
to ANC nurses and promotional materials were distributed, but this was one initiative
among a number that may be launched in a year.
It was therefore not surprising that MomConnect registration was seen as a peripheral
activity in the clinics, to be accommodated between the host of other tasks to be

Figure 3. MomConnect implementation activity: clinic-level registration in context.

 INFORMATION TECHNOLOGY FOR DEVELOPMENT 13

completed by nurses and support workers in the course of a day. It could be argued that in
time MomConnect will contribute to improved maternal health, and indirectly lighten the
burden on the clinics by providing an alternate source of information on pregnancy and
related health issues. This was not reported by the clinic staff as a practical benefit that
they expected to experience, however.
Figure 3 emphasizes the separation between the clinic-level delivery of ANC, and the
overall process of MomConnect delivery as envisaged by the NDoH. It foregrounds the
practical issue of how motivation can be sustained at the clinic level, given the gap
between the vision at the national level and the reality of implementation at the clinic.
MomConnect has a number of functions to ensure feedback between the system and
the clinic level, primarily in response to the compliments and complaints channel available
to clients. While the national MomConnect team had some contact with facility managers
regarding compliments or complaints from clients, departmental health managers did not
regularly provide feedback to facility managers on the progress of MomConnect
implementation at the time the field study was being carried out. One practical rec-
ommendation suggested by the Activity System representation would be to strengthen
the feedback to the facility managers, to help sustain motivation to manage and encou-
rage clinic staff to continue MomConnect registrations.

ANC provision
Moving focus to the ANC activity within the clinic, it may be conceptualized as shown in
Figure 4. Figure 4 emphasizes the many resources an ANC nurse draws on to deliver ANC

Figure 4. The ANC activity.

14 B. WOLFF-PIGGOTT ET AL.

care every day, including the contextual issues that constrain this effort. Contextual issues
are represented by the outside circle annotated with different contextual influences.
The ANC nurse is the subject of this Activity System, as the nurse is responsible overall
for this function in the clinic. The object of activity is the delivery of ANC care. The tools
that the nurse needs to draw on include their professional training and experience, the
physical infrastructure of the ANC office and the instruments used to perform physical
examinations.
Resource constraints, and in particular time constraints, were identified as critical issues
that cause tension between different goals within the clinic. In Activity System terminology
these are termed contradictions. The shifting of tasks from professional to support staff is
an example of one such response to meeting conflicting demands on the time of pro-
fessional nurses, bolstered by the position occupied by qualified nursing staff in the clinic.
The support staff responded to the increased demand on their time in two ways. The
one was to collect client consent and information prior to them seeing the nurse and
obtaining their EDD, and then entering the data at a later date when the morning rush
was over. The other was to involve the mothers in registering themselves. The above
responses can be considered as coping strategies for dealing with contradictions within
the ANC activity system. Other contextual factors that increased pressure on the ANC
care activity were the high prevalence of HIV/AIDS among the clients, and the late
stage at which women often attend the clinic ANC facility (Solarin & Black, 2013).

MomConnect registration activity

The training material presented MomConnect registration as a series of technical steps to
be followed in terms of entering USSD codes, with an overview of different possible ways
of allocating the work in the clinic. The interviews and observation revealed that clinic-
level experiences of using MomConnect were deeply influenced by institutional and con-
textual issues, as well as the technical processes presented in the training material. Con-
cerns around staff use of their own handsets, and from clients regarding the privacy of
their health information were important influences on the MomConnect registration
process, as well as the technical issue of frequently dropped USSD sessions.
Figure 5 represents the MomConnect Registration Activity. Including the staff and client
concerns in the MomConnect registration activity system makes it clearer how these issues
impact the seemingly technical process of registration. If the MomConnect registration
activity is considered as nested in the ANC activity, the response to dropped USSD sessions
as either delaying registration or resulting in parallel (group) registration makes more
sense.

Contributions
This study has contributed to both research and practice. We discuss the specific contri-
butions below.

Contribution to research
This study has contributed to research by demonstrating how Activity Theory concepts
may be used to analyze empirical data on mHealth implementation. Previous research
 INFORMATION TECHNOLOGY FOR DEVELOPMENT 15

Figure 5. MomConnect registration activity.

using Activity Theory has tended to draw on the principles as a guide to information
systems development (de la Harpe et al., 2013; Korpela et al., 2004), while analysis has
been a more recent application (Karanasios, 2014; Karanasios & Allen, 2013).
Our use of Activity Theory as a lens on mHealth has enabled us to analyze the mech-
anisms underlying individual-level appropriation in MomConnect registration (Chib
et al., 2015). Activity Theory provides a basis for understanding how employing technology
can alter work practice, and concepts such as the Activity System can help to generalize
from a specific case to other similar examples (Burrell & Toyama, 2009). We drew on the
concept of contradictions to suggest how resource constraints affect local-level activity
systems. Karanasios (2014) discusses the contribution of the concept in terms of being a
source of change. In the case of clinic-level use of MomConnect, we drew on contradic-
tions to help explain the different configurations that the Activity System took under
the influence of medical hierarchy and resource constraints.
Future mHealth research should draw more rigorously on structuring frameworks, so
that empirical findings may be generalized more widely. Wolff-Piggott and Rivett (2016)
have proposed concepts for comparing different studies of mHealth use based on empiri-
cal data analysis, which could be extended for wider use in mHealth studies. Further to this
we suggest that there are a number of approaches to mobile research that deserve to be
explored further including the infrastructural view (Horst, 2013), broader Activity Theory-
inspired approaches (Ekbia & Nardi, 2012; Wiredu & Srensen, 2006) and frameworks such
as information infrastructure (Igira & Aanestad, 2009; Sahay, Monteiro, & Aanestad, 2009).
We argued previously that mobile research has tended to study the transformation of
work practices through new technological interventions. Our focus in this paper has been
on the use of a mobile system as part of public health service delivery, in the spirit of calls
to study computing as part of everyday practices (Lyytinen et al., 2004; Yoo, 2010). We
16 B. WOLFF-PIGGOTT ET AL.

propose that mHealth research would benefit from drawing on this perspective further, for
example by examining how the public and private are blurred (Dourish & Bell, 2011), and
invisible work (Nardi & Engestrm, 1999) contributes to mobile system use.

Contributions to practice
The South African Department of Health sees MomConnect as a contributor to the overall
goal of establishing a National Health Insurance scheme, providing cover to all citizens
(Department of Health, 2015). Keeping this in mind, MomConnect has been designed to
provide benefits to pregnant women with as little impact as possible on the busy facility
staff. We have explored how even this light touch intervention has affected existing work
practices, although it was resourcefully accommodated in the facilities under study.
Based on these findings, we recommend to practitioners that mHealth interventions
should be carefully incorporated within health system strengthening initiatives, to avoid
unexpected negative impacts. Asangansi (2012, 2013) has commented on how different
management styles (institutional logics) may influence HIT implementation, for instance
the hierarchical bureaucracy associated with the logic of public health care delivery, and
the network logic of mHealth solutions where data and management information is deliv-
ered rapidly to a central information system without involvement from middle management.
The lack of information received by facility managers on registrations at the time of the field
work suggested that such a disconnect might be starting to happen with MomConnect.
Our results also support previous suggestions on the contribution that initial implemen-
tation at pilot sites with in-depth evaluation could make (Leon, Schneider, & Daviaud,
2012). Ideally, system development should involve representative users and incorporate
their feedback at the design stage to ensure that the rollout meets the intended aims,
with as little disruption of existing service provision as possible. The MomConnect
project has incorporated elements of this approach, but as noted by Sahay and
Walsham (2006), there are underlying conflicts between the public health imperative for
large-scale coverage and a gradual scaling approach.
Facility staff occupy a central role in any large-scale mHealth rollout. They can be
approached as an important resource, or neglected in the implementation planning.
MomConnect used experiences at pilot sites to set out examples of work flows in the train-
ing material. We recommend that mHealth projects give attention to engaging with the
responsible facilities with respect, and in a manner that supports them in carrying out
their duties (Walker & Gilson, 2004).
This research also highlights issues of sustainability. Facility staff should receive regular
feedback regarding the results that are being achieved based on their efforts, to ensure
that the initiative does not disappear among the welter of other priorities facing them. Of
particular concern are emerging patterns of sometimes shifting mHealth work outside
normal working hours due to resource constraints, as also highlighted by Kumar et al.
(2015). Future mHealth research and practice needs to ensure that on-the-ground realities
of implementation are well understood to minimize unintended, destructive consequences.

Conclusions
We have contributed to the limited empirical literature on mHealth implementation in
existing public facilities. This was accomplished by exploring clinic staff perspectives on
 INFORMATION TECHNOLOGY FOR DEVELOPMENT 17

their direct role in a national project, and we used Activity Theory to gain further insight
into the processes at play.
This research also empirically identified several drivers influencing how MomConnect
was used in the public clinics under study. One influential driver, anticipated from the lit-
erature review, was the hierarchical relationships within the medical profession (van der
Geest & Finkler, 2004), in this case between professional nurses and support staff. This
lead to work arrangements where the support staff were primarily responsible for Mom-
Connect registration in all of the clinics under study, although the nurses recorded
whether expectant mothers had been MomConnected in their documentation. The per-
ipheral relationship of maternal messaging to the immediate, pressing tasks seen as core
to delivering ANC care probably also contributed to the shift of MomConnect registration
to support staff.
The registration process itself was intended to not burden the staff, but the resource-
constrained nature of public health care in South Africa has meant that the impact has
been noticeable for those responsible. The clinics under study have nonetheless shown
resourcefulness in adapting to incorporate MomConnect registration into their existing
work practices, even though they experienced no direct benefit. Various task-sharing
arrangements were arrived at to ensure that the burden on existing services was mini-
mized. The patterns of adaptation differed between clinics, depending on the profile of
staff available and established ways of working.
There are a number of limitations to the work presented here that point to oppor-
tunities for future research. The empirical research drew on observations between six
and twelve months after the formal launch of the MomConnect project. The arrange-
ments observed here may still reflect initial enthusiasm with the system, and should
be followed up at a later date to determine whether the new work practices have
become a persistent part of organizational routine. Another limitation is that the
clinics studied were all situated in densely populated urban areas. The dynamics
observed here might not be evident in rural clinics, which should be explored in
future research.
The elements of the Activity System that were explored in most detail in this
research were the object of activity, the subjects striving to achieve outcomes via
these objects, and the division of labor used. In addition, the concepts of contradiction
and networks of activity systems were employed. More attention to the tools, formal
rules and the community might well provide further valuable insights. In addition, com-
bining Activity Theory with complementary frameworks such as Information Infrastruc-
tures (see, e.g. Igira & Aanestad, 2009) could be fruitful. An investigation of different
technological means of information delivery (tools) such as Integrated Voice Response
could also be illuminating (Ananya - Ananya News Life Call, 2013), as this can be used
to overcome problems with illiteracy preventing women from understanding text
messages.

Acknowledgements
The authors would like to acknowledge the kind cooperation of the Department of Health of the City
of Johannesburg in providing permission to access clinics, and the clinic staff who made time avail-
able in their busy schedules.
18 B. WOLFF-PIGGOTT ET AL.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
Funding from the National Research Foundation in the form of a Scarce Skills Doctoral Scholarship
helped to make this research possible.

Notes on contributors
Brendon Wolff-Piggott is a doctoral candidate in the Department of Information Systems at the Uni-
versity of Cape Town. His prior experience as an information systems practitioner has given him a
keen interest in how users appropriate and make use of information technology in their everyday
routines. While his current focus is on qualitative investigation, he also has expertise and experience
in quantitative analysis. Brendons current research interests include mHealth in low resource
environments, eHealth more broadly, and the mutual implications of information systems
implementation and work practices at multiple levels of scale, including policy implementation
issues.
Jesse Coleman is the mHealth Programme Manager at Wits Reproductive Health & HIV Institute (RHI)
based in Johannesburg South Africa. He is a Public Health PhD candidate at Karolinska Institute in
Stockholm, Sweden and is also a Researcher at the University of the Witwatersrand in Johannesburg,
South Africa. Jesses research interest areas include mHealth, global public health, maternal health,
PMCTC, HIV care and support, Information and Communication Technology (ICT) for health and ran-
domized clinical trials.
Ulrike Rivett is a Professor in the Department of Information Systems at the University of Cape Town.
Her research contribution over the last decade has been to connect the dots between the aca-
demic knowledge of ICT4D and the creation of solutions that offer an innovative approach to exist-
ing problems. She heads up the iCOMMS research team, which focuses on understanding the use of
ICT systems for the benefit of society. Her work and publications have been in the field of mHealth,
ICT4D and ICT in the Water and Sanitation sector.

ORCID
Brendon Wolff-Piggott http://orcid.org/0000-0002-2351-4157

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