Contextually balanced engagement: Navigating paradoxes of localisation and cultural embedding in rural health information systems implementation

Although health information systems (HIS) play an important role in elevating health standards, a comprehensive understanding of how to effectively implement HIS in rural areas is lacking. This issue becomes more significant when considering that globally a majority of the approximately 1.5 million deaths of children under the age of five in 2019 that were attributable to vaccine-preventable diseases occurred in rural areas. Accordingly, we ask two questions. How does rurality influence the implementation of information and communication technology for development (ICT4D) projects? How do organisations navigate challenges associated with rurality during the implementation of these projects? Our findings, derived from an in-depth case study of a social enterprise in rural India, reveal two paradoxes that pose challenges to the effective implementation of HIS in rural settings: the localisation paradox and the cultural embedding paradox. We found that contextually balanced engagement was comprised of four organisational responses-prioritising; localising; cultural adjustment; and engaging stakeholders-that help navigate the challenges posed by the localisation and cultural embedding paradoxes. Synthesising these findings, we develop a process model that shows how the implementation of HIS in rural areas is shaped by the descriptive and sociocultural characteristics of rurality. Further, organisations require a dynamic approach, engaging in multiple responses over time to navigate the paradoxes inherent in HIS implementation. We suggest that organisational responses to paradoxical tensions stemming from the descriptive and sociocultural characteristics of rurality lead to the development of HIS enabled for rurality. Our findings contribute the understanding of ICT4D projects implementation.