Accepted Manuscript

Title: Stakeholder influence in public sector information

systems strategy implementation—The case of public
hospitals in South Africa

Authors: Boroto Hwabamungu, Irwin Brown, Quentin

Williams

PII: S1386-5056(17)30414-8
DOI: https://doi.org/10.1016/j.ijmedinf.2017.11.002
Reference: IJB 3590

To appear in: International Journal of Medical Informatics

Received date: 28-1-2017

Revised date: 28-3-2017
Accepted date: 3-11-2017

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Stakeholder influence in public sector information systems strategy implementation – The case of
public hospitals in South Africa

1st Author:

Boroto Hwabamungu

School of Public Health

University of the Western Cape

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South Africa

Email: boroto.hwaba @gmail.com<https://protect-za.mimecast.com/s/akpRBeCM64a1t4>

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2nd Author:

Irwin Brown
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Department of Information Systems
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University of Cape Town

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South Africa
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email: irwin.brown@uct.ac.za<mailto:irwin.brown@uct.ac.za>
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3rd Author:
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Quentin Williams
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Meraka Institute

Council for Scientific and Industrial Research

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South Africa

Email: QWilliams@csir.co.za<mailto:QWilliams@csir.co.za
 Highlights

 The paper responds to the call for greater emphasis on individuals (stakeholders) and what
they do in the process of information systems strategy implementation.
 The public sector needs to engage with a diversity of stakeholders at local, regional and
national levels when strategizing, hence presents an opportunity to better understand the
influence of stakeholder relations on IS strategy implementation.

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 Public hospitals in developing countries are beset by problems related to lack of policy and

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strategy implementation and stakeholder dynamics which impede implementation
 Findings reveal that Information Systems (IS) strategy implementation in public hospitals

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involves a large and complex network of stakeholder groups at different levels, and over

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different time periods. These stakeholder groups act in accordance with formal and informal
roles, rules and modalities.

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Various contextual conditions together with the actions of, and interactions between
stakeholder groups give rise to the situatedness of stakeholder relations dynamics and
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strategy implementation.
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 The multiple actions and interactions over time lead to the realisation of some aspects of
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the IS strategy in public hospitals. Given the complexity and dynamism of the context there
are also certain unplanned implementations as well.

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The relationships identified are captured in a Stakeholder Relations Influence (SRI)

framework.
 The SRI framework can be assistive in the assessment and mapping of stakeholders and
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stakeholder relations, and the assessment of the implications of these relations for effective
IS strategy implementation in public hospitals.
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 The framework can also provide the basis for the development of appropriate corrective
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measures in the implementation of strategies and policies in public institutions such as

public hospitals.
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Abstract
Recent literature on organisational strategy has called for greater emphasis on individuals
(stakeholders) and what they do in the process of strategizing. Public sector organisations have to
engage with an array of heterogeneous stakeholders in fulfilling their mandate. The public health
sector in particular needs to engage with a diversity of stakeholders at local, regional and national

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levels when strategising. The purpose of this study is to investigate the influence of stakeholder
relations on the implementation of Information Systems (IS) strategy in public hospitals in South

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Africa. An interpretive approach using two provinces was employed. The Activity Analysis and

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Development (ActAD) framework, an enhanced form of activity theory, was used as the theoretical

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framework. Data was collected using semi-structured interviews, meetings, documents analysis,
physical artefacts and observation. The collected data was analysed using thematic analysis. Findings
reveal that IS strategy implementation in public hospitals involves a large and complex network of

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stakeholder groups at different levels, and over different time periods. These stakeholder groups act
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in accordance with formal and informal roles, rules and modalities. Various contextual conditions
together with the actions of, and interactions between stakeholder groups give rise to the
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situationality of stakeholder relations dynamics and strategy implementation. The multiple actions
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and interactions over time lead to the realisation of some aspects of the IS strategy in public hospitals.
Given the complexity and dynamism of the context there are also certain unplanned implementations
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as well. These relationships are captured in a Stakeholder Relations Influence (SRI) framework. The
SRI framework can be assistive in the assessment and mapping of stakeholders and stakeholder
relations, and the assessment of the implications of these relations for effective IS strategy
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implementation in public hospitals. The framework can also provide the basis for the development of
appropriate corrective measures in the implementation of strategies and policies in public institutions
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such as public hospitals.

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Keywords

Stakeholder relations, information systems strategy, strategy implementation, activity theory, public
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hospitals, South Africa

Introduction
Stakeholders can be defined as “any group or individual who can affect or is affected by the
achievement of the organisation’s objectives” (Freeman, 1984, p. 46). Understanding these

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stakeholders (Wickramasinghe & Goldberg, 2005), understanding their influence (Atun & Sheridan,

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2007), engaging with them (Juciute, 2009), involving them in a participatory manner (Byrne & Sahay,
2003) and ensuring multi-level interactions between them (Norris, Stockdale, & Sharma, 2009) are

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critical to IS implementation. Traditionally IS strategy formulation and implementation (also referred

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to strategic IS planning or IS strategizing) has been seen as the preserve of top management. Recent
research however has recognised the importance to strategy of the “everyday practices of the range

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of stakeholders (practitioners) involved in the context of interest” (Marabelli et al., 2015). This stance
points to the importance of examining stakeholder relations in IS strategizing processes such as IS
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strategy implementation.
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An understanding of these stakeholders and the relationships between them is important for IS
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strategy implementation in public hospitals in developing countries where many policies and
strategies get formulated, but few get implemented. As argued by Scott, Golden, & Hughes (2004) it
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is essential to understand stakeholder relations when IS implementation is envisaged in the public

sector, a peculiar environment where social, cultural and political issues intermingle. The public health
sector is generally reported to be an even more complex environment. The public hospital
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environment, it follows, presents attributes of a complex public sector environment (Piotti & Macome,
2007). South Africa furthermore has attributes of both a developed and developing country, but with
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stark contrasts between rich and poor. The wealthy tend to be well-served by a sophisticated private
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healthcare sector while the public healthcare sector is focused mainly on serving the needs of the
poor. This study hence focuses on the public healthcare sector in South Africa, given the critical
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imperative to provide services to the poor and help eradicate inequalities (Banderker & Van Belle,
2006).

The rest of this paper is structured as follows: firstly we provide a review of the literature with an
emphasis on IS strategising in the health sector, stakeholders in the implementation of IS in the
healthcare sector, and the South African public health sector. Secondly the theoretical framework is
presented followed by the research methodology, then the findings of the study. The findings are
discussed in relation to existing literature and recommendations and conclusions are drawn.

Conceptual Background
Information Systems Strategising
Information systems (IS) are broadly recognised as social systems in which information and
communication technologies (ICTs) play a key role in supporting purposeful action in organisations
(Checkland & Holwell, 1998). The enabling role of ICT and potential for health care service delivery

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improvement in developing countries is widely recognised (Avgerou, 2008; Heeks, 2002; Kanter et al.,

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2009; Kwankam, Mendez, & Kay, 2009; Lippeveld, Sauerborn, & Bodart, 2000; Simba, 2004; Walsham

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& Sahay, 2006). Given large investments are channelled towards ICT in the health care sector, IS
strategising is essential in order that ICT potential is fully realised (Lee, Ghapanchi, Talaei-Khoei, & Ray,

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2015). The health care sector is complex (Avison & Young, 2007) and requires of strategists to take its
peculiarities into consideration (Gelssbuhler, 2011, Marabelli et al., 2015).

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Many organisations engage in IS strategising (Marabelli & Galliers, 2016), a process in which
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implementation of strategy is a key focus (Lederer & Salmela, 1996, Marabelli et al, 2015). IS strategy
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implementation has been a persistent organisational challenge (Bell, Dean, & Gottschalk, 2010;
Gottschalk, 1999) including in the health care environment (Berg, 2001). IS scholars have proffered
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different approaches to IS strategizing and consequently strategy implementation (Henfridsson &

Lind, 2014; Lederer & Salmela, 1996; Lederer & Sethi, 1988; Pollack, 2010; Ward & Peppard, 2002). In
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the context of healthcare the Health Metrics Network (2009) proposes a three phase process
consisting of: (1) the leadership, coordination and assessment phase; (2) the priority-setting and
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planning phase; and (3) the implementation phase. One of the many challenges to the
implementation of ICTs in the healthcare sector is the many stakeholders who have diverse values,
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interests, and visions (Cain & Mittman, 2002, Heeks, 2006). To address such challenges at strategic
level there have been calls for IS strategy researchers to focus on the doing of strategy by different
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stakeholders, termed strategy-as-practice (Peppard et al., 2014).

Stakeholders and Stakeholder Relations

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Multiple stakeholders with varying values, interests, professional backgrounds and priorities are
characteristic of complex health care systems (Atkinson, Eldabi, Paul, & Pouloudi, 2002; Korpela et al.,
2004; Wickramasinghe & Goldberg, 2005). This is no exception for developing countries. In this
environment, the consideration of these stakeholders is essential when any health information
systems intervention is envisaged (Atkinson et al., 2002). In this regard Cain and Mittman (2002)
identify the following stakeholder groups: the policy makers, the payer, the provider organisation, the
patient, and the vendor. Multi-level interactions between these stakeholders are essential (Norris et
al., 2009), as is their involvement in a participatory fashion in different processes (Byrne & Sahay,
2003). A broad approach to the implementation of ICTs in a complex context such as healthcare sector
should therefore not only be limited to the technical and technological, but be inclusive of the
interplay between the technology, the stakeholders, the clinical and managerial processes, as well as
the organisational culture and politics (Atkinson et al., 2002, Heeks, 2006, Ngwenyama et al., 2014).

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Stakeholder theory concepts (Freeman, 1984; Mitchell et al., 1997; Reeds et al., 2009; Savage et al.,

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1991) have been widely used in various fields including the health sector (Blair & Fottler, 1991). These
include concepts such as stakeholder analysis - a process through which stakeholders, their role and

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influence are explored – and stakeholder relations (Brugha & Varvasovky, 2000). Stakeholder relations

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emerge from a network of influences between the different stakeholder groups (Rowley, 1997).
Although the concept of stakeholder relations has received much attention in the business literature,
the concept has received less attention in IS in developing countries research (Hosman & Fife, 2008)

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or public healthcare sector research (Murdock, 2004). There is hence a gap in research concerning
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stakeholder relations in the implementation of IS strategy in the public healthcare sector of developing
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countries.
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IS strategizing in the South African public health sector

The South African public health sector is part of the broader South African Healthcare system which
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consists of the following four components: (1) the public sector, (2) the private sector, (3) the African
traditional medicine sector, and (4) a “relatively small number of practitioners of complementary and
alternative medicines such as Ayurveda, traditional Chinese medicine, osteopathy, chiropractice,
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homeopathy, naturopathy, physiotherapy, aromatherapy, massage therapy and reflexology”

(Harrison, Bahna, & Ntuli, 2007, p. vii). The public health sector provides care to 80% of the population
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(DoH, 2010). The sector has been going through major transformation since the dawn of the post-
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apartheid democratic era in 1994 (Braa & Hedberg, 2002). Implementing a decentralised health IS
through the Health Information Systems Program (HISP) has since been a major driving force for the
provision of better healthcare to all (Braa & Hedberg, 2002). IS implementation offers opportunities
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for service improvement in the South African public health sector (Banderker & Van Belle, 2006). The
potential for ICTs to address the challenges that affect the public health sector in South Africa is clearly
evident (Ojo, 2006). Innovative ICTs such as telemedicine (Gulube & Wynchank, 2001; Jithoo,
Govender, & Nathoo, 2003) and mHealth (Curioso & Mechael, 2010; Chigona et al., 2012) have been
explored as potential solutions. Kachienga (2008) for example suggests that telemedicine offers great
opportunities for healthcare service delivery in South African rural areas which face even greater
challenges in providing healthcare services than in urban areas.

South Africa formulated a national eHealth strategy which was the outcome of many years of strategic
thinking on health systems (Masilela, Foster, & Chetty, 2013/14). This eHealth strategy forms the basis
for IS strategizing in public hospitals. As new strategic health care decisions are taken, new policies
such as the current South African National Health Insurance (NHI) policy emerge. These new decisions
and policies have a knock-on effect as inevitably they require IS strategy in public hospitals to be

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revised. Ward and Peppard (2002, p. 188) note that a “business strategy may exist in a variety of forms:

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as formally recorded corporate, business unit or functional area strategy documents or less formally in
other documents and/or in the head of individuals. In the later stage it can be understood and

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confirmed through discussions with senior management”. IS strategy is hence dynamic and can take

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on various shapes and forms (Marebelli et al., 2015). IS strategy for public hospitals, prior to the
eHealth strategy, is hence considered to have been existing in an informal form for several years.

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Theoretical foundation: activity analysis and development (ActAD)
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framework
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There have been calls for IS strategy research to shift “from traditional concepts of strategy as
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something an organization has to something that people do” (Marabelli et al., 2015). Investigating
stakeholder relations (interactions) in the implementation of IS strategy is in line with this call.
Stakeholder actions and interactions in IS strategy implementation can furthermore be viewed as an
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activity system. Activity theory (Engestrom, 2001) has been used by various IS scholars (Mursu,
Luukkonen, Toivanen, & Korpela, 2007) given its relevance for IS (Engestrom, Miettinen, & Punamaki,
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1999). So has its enhanced version, the Activity Analysis and Development (ActAD) framework
(Korpela, Soriyan, & Olufokunbi, 2000, Mursu et al., 2007) which is often used in investigating IS in the
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healthcare environment (Korpela et al., 2004). ActAD will be used to guide the assessment of the
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influence of stakeholder relations on the implementation of IS strategy in public hospitals in South

Africa.

In an activity system, a network of actors are involved in a network of sub-activities whose joint
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outcomes contribute to the attainment of the outcome of a joint activity (Mursu et al., 2007). Figure
1 below provides an illustration of how ActAD has been adapted for the purpose of this study. The
figure shows that the implementation of IS strategy is an activity whereby an object [strategy] is
“transformed” into outcomes [implemented strategy elements]. The transformation is done in a
systemic way by a network of selected stakeholder groups who use tools [mediating artefacts] in
individual and group processes. Historical events influence the implementation process. In this activity
system there is a network of intertwined activities that complementarily contribute to the overall IS
strategy implementation process and the attainment of the final objectives of the implementation of
the IS strategy. Although there are means and modalities of coordination, communication and work,
there always exist contradictions that are inevitable in any real-world activity system.

Research Methodology

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The study adopted an interpretive qualitative stance using a case study approach (Olivier, 2009; Yin,
2009) with activity theory as the analytical framework. Interpretive research tools such as semi

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structured interviews, meetings and documents analysis (Myers, 1997; Myers & Newman, 2007) were

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used to collect data. This allowed us to develop a deep understanding of the social and cultural context
within which research subjects are active (Myers, 2009; Myers & Newman, 2007) and to generate
conclusions through the interpretation of societal realities in their context and the assigned meanings
(Klein & Myers, 1999; Walsham, 1995).
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Two provinces in South Africa were selected as case studies - the Western Cape and the Kwazulu Natal
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provinces. These two cases were selected for their similarities, as well as their differences, with
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hospitals in Kwazulu Natal having to serve a larger rural community. Public hospitals in these two
provinces were selected based on the following criteria: firstly, public hospitals had to have computer-
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based IS in place and some form of IS strategy that guided the implementation of the IS; secondly,
approval to conduct the study in the selected public hospitals was necessary. Lastly, accessibility to
and availability of information and cost-effectiveness of conducting research in the selected public
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hospitals was a consideration. A total of 33 interviews were conducted (17 in the Western Cape
province and 16 in the Kwazulu Natal province with the following respondent groups between October
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2012 and April 2013: Hospital CEO/CEO representatives, IT professionals (not necessarily IT Manager)
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at hospitals, IT/Health Provincial Departments, IT suppliers (in-house and outsourced) and IT users at
hospital level (also called super users). Additional data was collected through meetings with the
provincial departments, districts within provinces, and hospital IT suppliers. Data was also gathered
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through the analysis of documents such as provincial vision and strategic documents, the Health Act,
and publications on the District Hospital Information Systems (DHIS). These documents were accessed
on provincial health department websites or were provided under strict confidentiality and for
research purposes only. The collected data was analysed using thematic analysis techniques (Braun &
Clarke, 2006; Fereday & Mui-Cochrane, 2006; Ritchie & Lewis, 2003) in a systematic iterative manner
as illustrated in Figure 2 below.

As Figure 2 shows, raw data was analysed using the ActAD framework of Figure 1 as the conceptual

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lens. Data from each case was analysed separately, termed within-case analysis. The preliminary

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emerging concepts were grouped into developed themes. These developed themes were further
grouped into higher level summarised themes. Thereafter cross-case analysis was performed to yield

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the combined case study findings. Further refinement lead to key summarised findings. At the final

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stage of analysis relationships between thematic elements were established to yield the final
theoretical framework.

Results and Findings U

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The findings of this study reveal the influence of stakeholder relations on the implementation of IS
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strategy in South Africa through a theoretical framework (see Figure 3). This Stakeholder Relations
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Influence (SRI) framework depicts the relationship between the following major themes: (1)
Stakeholder groups for IS strategy implementation, (2) Modalities and flows of influence, (3)
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Stakeholder groups’ interactions, (4) Stakeholder groups’ actions, (5) Situationality of relations and
implementation, and (6) IS strategic achievement. Table1 and Figure 3 illustrate the identified
categories and the integrated framework respectively.
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In the sections below each of the major themes and sub-themes depicted in Figure 3 will be discussed
in turn.
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A. Stakeholder groups for IS strategy implementation

A1. Stakeholder group hierarchies and networks and roles
There are different stakeholders/stakeholder groups that are relevant in the implementation of IS
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strategy in public hospitals in South Africa. These stakeholders include but are not limited to: the
government, international bodies, research institutions and universities, national level stakeholders,
provincial level stakeholders, hospital management, hospital staff members, ICT service providers, and
patients. The stakeholder groups are responsible for different activities regarding the implementation
of the IS strategy in public hospitals of South Africa. From a hierarchical perspective the following six
stakeholder groups were identified: National stakeholders, Provincial stakeholders, Intermediate
stakeholders, Provincial Department of Health stakeholders, Service provider stakeholders, and Public
hospitals level stakeholders. Associated with this hierarchy is the hierarchy of related IS strategy
implementation activities. The grouping of these stakeholders should be further understood based on
other classification parameters such as the level and type of involvement which is not easily captured
by the proposed vertical structures of influence and responsibility.

A.2 Stakeholder groups’ associated activities’ hierarchy

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The activities related to the implementation of the IS strategy in public hospitals in South Africa occur

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at hierarchical levels and are associated with respective stakeholder groups’ hierarchical levels, roles
and responsibilities. Some stakeholder groups are at times inadequately involved in the IS strategy

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implementation process due to the lack of direct interaction. The implication of the inadequate or

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non-involvement is the omission of stakeholder groups’ implementation considerations leading to
challenges in the implementation of the IS strategy. In this regard, a key challenge is the definition of
the extent of involvement of different stakeholder groups, at different levels in the vertical and

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horizontal hierarchy of activity and division of responsibilities.
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B. Modalities (rules and contextual factors) and flow of influence
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B1. Modalities of engagements between stakeholder groups and IS strategy implementation
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There are modalities for the engagement between the stakeholder groups and the implementation of
IS strategy in public hospitals. These modalities are in some instances the result of previous
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stakeholder engagements and agreements between stakeholder groups. In general these modalities
are defined in pre-existing policies and documents which can be national or provincial and contractual
agreements. These pre-existing policies and documents include: the health act, the national e-
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strategy, provincial IT strategy and vision, the contracts and service level agreements (SLAs between
stakeholder groups, project management frameworks, IS/IT implementation guidelines, etc.). These
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are established rules and regulations that can be explicit or implicit. Explicit modalities are predefined
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or developed through mutual agreements between stakeholder groups. Implicit modalities are a result
of non-adherence to explicit rules and regulations. Implicit modalities can also be context-based rules
and regulations. These explicit and implicit modalities of engagement and IS strategy implementation
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lead to practical modes of engagement for the implementation of IS strategy in public hospitals in
South Africa. These include the different established body/committees of internal communication and
their scheduled meetings, and various other meetings, forums, workshops, telephonic calls and
emails. The interactions between stakeholder groups and their actions are determined by two major
factors: the established rules/regulations and the role that each stakeholder groups is to play in the
implementation of the IS strategy.

B2. Contextual factors affecting the engagements between stakeholder groups and the
implementation of IS strategy
There are various contextual factors that affect not only the engagement between stakeholder groups
but also the implementation of IS strategic initiatives in public hospitals in South Africa. These include
(1) the complexity and peculiarities of the public sector, (2) the hierarchical and political structures,

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(3) the healthcare environment, (4) the long term nature of IS for health projects, (5) public hospital
ICT infrastructure readiness, (6) level of awareness of existing strategic documents, (7) stakeholder

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groups awareness of IS strategy, and (8) the maturity level of the public hospitals. In the various

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activities regarding the implementation of IS strategic initiatives in public hospitals in South Africa it is

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imperative to take cognisance of these contextual factors and to adhere to their consequential
requirements.

B3. Mode of deployment of IS strategic initiative

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The deployment of IS strategic initiatives in public hospitals is undertaken following a particular
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approach or mode. The approach provides guidelines regarding aspects such as the IS strategy
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implementation approach, the approach to the implementation of the related IS for deployment at
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public hospitals, the associated approach to change management, training of staff, etc. At the
provincial level, the approach is centralised and can have some variations in the levels of centralisation
depending on the provincial strategy of implementation. The centralised approach is a direct
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consequence of the federal political system in South Africa. One of the key considerations regarding
the mode of deployment of IS strategic initiatives is the approach of each province. Although the
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general approach is centralised each province has a different approach to the implementation of the
IS strategy in terms of the level of centralisation, the structure and composition of the implementation
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team and the housing of the IS strategy implementation team. In both cases there exists an in-house
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team that is responsible for all or some aspects of the IS strategy implementation. In some instances
certain services are outsourced to service providers. In other instances there is a combination of both
approaches depending on the department/ provincial approach and the availability of the necessary
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skills and resources required for a certain type or level of service.

B4. Model of funding of IS strategic initiatives

The model of funding of implementation of IS strategy and/or strategic initiatives in public hospitals
in South Africa is critical in the operationalization of the IS strategy. Unlike the private health sector
where the funding decisions are taken at the hospital level, in public hospitals of South Africa, funding
decisions are taken at higher hierarchical levels following established protocols and based on national
and provincial budget allocation models. Although there is a model of funding for IS strategic initiatives
in public hospitals in South Africa, there are concerns regarding the appropriateness, the rigidity and
flexibility of the funding approach used.

B5. Model of management of contracts

There are various contracts and contractual agreements that exist between stakeholder groups
involved in the implementation of IS strategic initiatives in public hospitals in South Africa. These

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contracts are essential in defining the obligations of the stakeholder groups. However there are

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challenges in ensuring adherence to contractual agreements and in applying adherence/compliance
enforcement measures. Associated with this are difficulties in attaining IS strategy implementation

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goals due to non-compliance with contractual obligations. Hence there is a need for an effective model

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of management of contracts.

B6. Approach to continuity of projects and IS strategic initiatives

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In an environment where there are unavoidable changes in stakeholder group team dynamics and
where the deployment of IS strategic initiatives is a long term endeavour, there is a need to have
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measures in place to ensure continuity of initiated projects in the absence of the initiator stakeholder
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groups, particularly taking into consideration the long term benefits of these strategic initiatives. The
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public sector is generally prone to structural and leadership changes at different hierarchical levels.
These changes might occur at the hospital level, at provincial level, or at national level while various
relevant IS strategic initiatives have been initiated and different agreements with certain stakeholder
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groups reached beforehand. In this regard there are challenges that arise in ensuring that these
relevant strategic initiatives are not discarded or abandoned as a result of the changing team
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dynamics. This brings to fore the notions of continuity of IS strategic initiatives and the approach to
ensure continuity of these strategic initiatives.
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B7. Flow of influence

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The flow of influence concerns the engagements between the stakeholder groups at different
moments or stages in the implementation of the IS strategy, the related stakeholder groups’ actions,
the progress in activities and processes and the finality of the IS strategy implementation activities.
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There are two major flows of influence: the one-dimensional linear flow of influence and the multi-
dimensional interactive flow of influence. The one-dimensional linear flow of influence block (see
Figure 3) depicts the hierarchical, time factors, progress factors and can be vertical or horizontal. The
vertical flow is across the stakeholders; hierarchical groups and the activities hierarchical levels. The
horizontal flow is across the IS strategic activities and the IS strategy operationalization processes.
There are challenges in maintaining this one-dimensional flow of influence due to changes in teams
and the associated difficulties in the transmission, the delay and the follow up of previous activities,
decisions, projects and initiatives. The multi-dimensional interactive flow of influence depicts other
complex factors that are not obvious and that are like an influential hidden-hand. Just as with the one-
dimensional linear interaction flow of influence (see Figure 3), there are vertical and horizontal multi-
dimensional interactive flow of influence. The vertical flow is across the stakeholders’ hierarchical
groups and the activity hierarchical levels. The horizontal flow is across the IS strategic activities and
the IS strategy operationalization processes. The multi-dimensional interactive flow of influence is

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critical and captures the negative influence of non-conforming factors such as corruption, malpractice

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and abuse of political power.

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C. Stakeholder groups’ interactions

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C1. The Level and motive of interaction, involvement and participation in activities and processes
The stakeholder groups have different roles and responsibilities in the implementation of the IS
strategy. Stakeholder groups can therefore be involved in different activities at different hierarchical

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levels with different levels of inputs. The roles that the stakeholder groups/actors play can be in the
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following two groups of activities: strategic level or IS strategy operationalization level. In both cases
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the engagement between and the relationships between the interacting stakeholder groups/actors is
critical. However the level of involvement in these activities differs and has implications on the IS
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strategy implementation process. In some cases certain stakeholder groups are not involved in
activities that they should be involved in. Generally when stakeholder groups/actors feel that they
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were not involved in activities that they should have been involved in, they tend to become
disengaged from other processes.
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C2. Timeliness of stakeholder groups’ activities deliverables and impact on the attainment of IS
strategy implementation objectives
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The timeliness of deliverables of stakeholder groups’ respective activities is critical in ensuring a

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smooth flow of activities and the attainment of IS strategy implementation goals. There are often
delays by certain stakeholder groups in completing their tasks on time. These delays can occur at
different levels of the hierarchies of stakeholders or activities. As such the timeliness of deliverables
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from every activity affects the state of IS strategy implementation as unplanned changes occur as a
result of the delays. The delays are generally related to stakeholders’ own internal policies, non-
adherence to modalities of engagement and IS strategy implementation, and contextual factors.
D. Stakeholder groups’ actions
D1. Group of activities and processes related to IS strategy implementation
There are various activities that are undertaken by stakeholder groups as each stakeholder group
undertakes to execute its respective IS strategy implementation-related tasks. These activities occur
at different hierarchical levels. These activities can be grouped into two major groups: the strategic
activities and the IS strategy operationalization activities. There are different factors that are essential
to the execution of these activities. Among these factors are the following: timeliness of engagement
between stakeholders and the extent of involvement of stakeholder groups, the competencies of

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different stakeholder groups/actors and the extent of adherence to the regulations. Associated with

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these groups of activities is the timeliness of their respective deliverables. These activities and

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processes are necessary throughout the IS strategy implementation process but also in related IS
strategy processes such as the IS strategy formation process.

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D2. IS strategy form, formulation, scoping, revision and development of IS strategic initiatives
The IS strategy for public hospitals in South Africa exists in a peculiar form. Its scoping and the

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identification of IS strategic initiatives for public hospitals is a complex, intricate and critical endeavour
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that entails the integration of various strategic objectives, guidelines from international, national,
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provincial and hospital levels into practical ICT-related strategic initiative for public hospitals in South
Africa. It also entails planning the deployment of not only hospital IS but also other health IS at hospital
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level. Hence the strategy scoping includes objectives for the deployment of DHIS, Hospital
management systems, clinical systems and specialized IS but also new strategic initiative such as the
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NHI. This is a key stage in the IS strategy implementation process that calls for the practice of IS
strategising in the health care sector.
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D3. Adherence to modalities, contractual obligations and contextual requirements

Taking cognisance of the modalities of engagements and IS strategy implementation, the defined
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contractual obligations and the contextual factors are critical in the engagements and the
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implementation of IS strategy in public hospitals in South Africa. So is the adherence to these

modalities, contractual obligations and contextual requirements. Poor adherence or non-adherence
to modalities, contractual obligations and contextual factors have negative implications on the overall
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implementation of the IS strategy in public hospitals in South Africa. The implications are multiple and
include aspects such as the following: delayed deliverables, inability to make good progress on the
various IS strategy implementation related activities and tasks, poor stakeholder group performance
and non-attainment of stakeholder group engagement and IS strategy implementation goals. It is
therefore critical to develop measures to ensure and enforce adherence to the modalities, contractual
obligations and contextual factors to avoid the abovementioned negative implications and to ensure
that the sought stakeholder engagement and IS strategy implementation goals are achieved.

E. Situationality of relations and implementation

E1. IS strategy implementation decisions
There are various IS strategic initiatives for public hospitals in South Africa and implementation
decisions that are taken as a result of the engagements and interactions that occur between various
stakeholder groups at different levels. These decisions pave the way forward in attaining the IS

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strategy implementation objectives. These decisions address issues at strategic as well as operational

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levels. The decisions taken cover IS strategy implementation aspects such as: the appointment of
leadership teams, the choice of funding and deployment mechanism, the selection of service

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providers, the approval of IS strategic initiative, the choice of the model of deployment, and the

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selection of innovative IS to be deployed at public hospitals in South Africa. These decisions are a
major contributor to the situationality of stakeholder relations and IS strategy implementation.

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E.2. Situational dynamics of stakeholder relations and situational IS strategy implementation
N
This situational dynamics of stakeholder groups’ relations and situational IS strategy implementation,
observable and assessable at any level or time of the IS strategy implementation, emerge from the
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outcome of the engagement between stakeholder groups and the intertwinement of the other related
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activity systems elements over a period a time. This is an essential aspect that depicts the types of
relationships that exist between the different stakeholder groups and the related influence on the
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implementation of the IS strategy in public hospitals in South Africa. Stakeholder relations are formed
based on the engagement between the various stakeholder groups that directly or indirectly affect
the implementation of the IS strategy in public hospitals in South Africa. The engagement between
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stakeholder groups is guided by implicit and explicit regulations. The relations between stakeholder
groups are also formed based on the extent of stakeholder groups/actors involvement in different
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processes or levels of the implementation process and through contact establishment between
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various stakeholder groups. This leads to the definition, development and application of more
regulations that guide/dictate/inform the actions and responsibilities of each stakeholder group
regarding the execution of their respective activities and their contribution towards achieving the
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general aim of the broad activity system of implementing the IS strategy in public hospitals in South
Africa at any point in time. In many instances the imbalance between regulations, deliverables of
related activities, stakeholder groups dynamics, destabilizes the ideal flow of activities and leads to
corrective/palliative actions or activities targeted at achieving minimal IS strategy implementation
objectives.
F. IS strategic achievement: attainment of IS strategic goals
The implementation and use of IS at public hospitals are among the IS strategic objectives. In
comparing the ideal and the actual state of the IS strategy implementation, it was noted that there
were alternative unplanned actions that were taken, alternative unplanned regulations that had been
developed or defined directly or indirectly. These alternative activities and regulations are strongly
ingrained in the stakeholder groups’ actions and lead to a questionable state of the implementation
of IS strategy. Although implementation of the IS strategy will have been questionable, it is not
surprising to note that the minimal steps towards attaining the strategic objectives will have led to the

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implementation of some form of IS in public hospitals in South Africa. Depending on the role, needs

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and expectations of the different stakeholder groups there are differing views of the achievability of

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IS strategic goals as the situationality of IS strategy implementation and the consequential progress in
the implementation of the IS in public hospitals in South Africa are interpreted differently by different

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stakeholder groups.

Discussion and Implications

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N
There are stakeholder groups at different hierarchical levels who are involved at different levels of the
implementation of IS strategy in public hospitals in South Africa. Although these stakeholders can be
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grouped according to Mitchell et al. (1997) into a power, urgency and legitimacy attributes
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stakeholder typology, other additional factors determine the potential role and level of involvement
of each stakeholder group in the case of public hospitals in South Africa. Stakeholder groups/actors
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are involved in different processes at different levels of IS strategising in a hospital environment (Haux,
Ammenwerth, Winter, & Brigl, 2004). The involvement of stakeholders is often highlighted as critical
to achieve success in IS implementation. In the healthcare environment the involvement of
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stakeholders in the different IS implementation processes is deemed critical for the acceptance and
use of the system (Tan, 2011). Sanderson (2007) argues that it is imperative to identify the
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stakeholders across the different levels and to take into consideration their respective needs and
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requirements for better IS implementation results. This is essential for ensuring adequate involvement
of stakeholder groups in the IS strategic activities and IS strategy implementation processes. In the
case of the National Health system in the UK, Bullas and Bryant (2007) argue that “common structures
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and processes” are needed for the engagement between stakeholder groups/actors so as to assist in
the implementation of IS regardless of how complex the systems can be.

These stakeholder groups interact at different levels in various activities related to the
implementation of the IS strategy, hence forming relationships between them. There exists a need for
management of the interactions between the different stakeholder groups/actors. In this regard,
Murer, Bonati, and Furrer (2011) reiterate the need for an appropriate governance model that can
assist in the management of stakeholder interactions, and in clarifying the roles and responsibilities
of the stakeholder groups. They further advocate the need for an appropriate model of governance
that is not only constant and immune to organisational change and stakeholder group structural
changes, but that is also a guiding tool in the decision making process. A common approach to the
management of stakeholder interactions is SLAs (Keller & Ludwig, 2003). The formation of stakeholder
relations in the implementation of IS strategy is governed by modalities of engagement, both explicit
and implicit, and the various contextual factors. The concept of modalities was discussed by Giddens

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(1984) three decades ago in the discourse on structuration theory. He argued that modalities of

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structuration are essential to the formation of systems. Similarly, regarding the implementation of IS
strategy in public hospitals, these modalities guide stakeholder groups/actors actions throughout the

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IS strategy implementation activity system. While there exist related strategy implementation

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mechanisms, the quality of these mechanisms have implications on the success of implementation
(Premkumar & King, 1994). Some of the identified modalities include the approach to IS strategy

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implementation, IS strategy implementation mechanisms, the contextual factors and other
parameters such as the flow of influence. While the implementation can follow a centralised or
N
decentralised approach, it is argued by Wager, Lee, and Glaser. (2005) that there are no prescriptive
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rules for the appropriateness of a centralised or decentralised approach as each has its advantages
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and disadvantages. Waema and Walsham (1990) argue for a consideration of contextual factors.
Consideration of the environment and organisation context within which implementation is envisaged
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is essential in IS strategizing (Newkirk & Lederer, 2006; Teubner, 2013).

The peculiarities of the public hospital environment are a distinctive consideration. In an investigation
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of the practice of strategic IS planning in the public sector Dufner, Holley, and Reed (2002) identified
that organisations in the public sector faced more difficulties in comparison to organisation in the
private sector. These include public sector wide IS strategy definition and formulation challenges, poor
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participation of stakeholders at higher structural hierarchical levels and the lack of involvement of
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different stakeholder groups/actors. As highlighted in the SRI framework from our study, the flow of
influence can be mono-dimensional (in cases of hierarchical and chronologic flow/progress factors) or
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multi-dimensional and interactive in the case of more complex factors of interaction and IS strategy
implementation. An essential consideration for IS strategy implementation is ensuring strategic
alignment, proper communication and leadership. Cognisance of the historical nature of the process
and the different influential factors is essential for the achievement of strategic alignment as argued
by Peppard and Breu (2003) in their co-evolutionary theory. The need for proper leadership and
communication regarding the strategy process is essential (Osman et al., 2015).
The interactions between the different stakeholder groups and their respective actions translate into
the situationality of relations and implementation. This is mediated by the different modalities and
the associated flows of influence, and the related IS strategy implementation decisions. This brings to
fore the question of the relevance of traditional hospital structures and the strategic decision making
approach in a healthcare environment where constant change creates the need for complex IS
(McDaniel and Pashmos, 1996). Inadequate decision making processes have negative implications on
the IS strategizing process. Killingsworth, Newkirk, and Seeman (2006) argue that adequate
strategizing processes can spare hospitals the consequences of having obsolete strategies. Similarly

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Waema and Walsham (1990) argue that past IS strategy and related implemented IS that were

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relevant at a given point in time can have unplanned implications on future decisions such as the
choice of equipment suppliers whose equipment has become obsolete. The overall situational

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stakeholder relations dynamics influences the level of progress in the implementation of IS strategy in

SC
public hospitals in South Africa. This translates into the situational IS strategy implementation which
in turn will be indicative of the attainment of IS strategic goals. The SRI framework for IS strategy

U
implementation in public hospitals in South Africa is an answer to Sanderson's (2007) call for the
development of tools to understand the stakeholder relations in healthcare environment: a complex
N
environment where social and technical factors are intertwined. The SRI framework for IS strategy
A
implementation in public hospitals in South Africa has built-in in-depth analytical capabilities that can
M

allow the exploration of the complexity and intricacies of the interactions between different
stakeholder groups/actors and IS strategizing practice. It answers the call for IS strategy researchers
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to focus more on the micro-level practices of individuals (stakeholders), rather than on grand strategy
(Peppard et al., 2014).
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Conclusion
The findings of this study highlight the situationality of stakeholder relations and the implementation
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of IS strategy in public hospitals in South Africa, how this situationality is grounded in the dynamics of
CC

the stakeholder interactions and actions, and how these are governed by various modalities,
contextual factors and the related one-dimensional linear and multidimensional interactive flows of
influence. The developed framework provides a better understanding of stakeholder relations and
A

their implication on the implementation of IS strategy in public hospitals in South Africa. This
contributes to the development of knowledge in IS strategy implementation, IS strategising, ICT in
healthcare, stakeholder relations and ICT use in developing countries, ICT implementation and
strategy and policy implementation. The framework is relevant to an array of practitioners, scholars
and various individuals in different spheres of practice: public hospital managers, national leadership,
provincial leadership, government departments, governmental institutions, sponsors, the academia,
international institutions and the public. The framework can be assistive in the assessment and
mapping of stakeholders and stakeholder relations, and the assessment of the implications of these
relations for effective IS strategy implementation in public hospitals. The framework can also provide
the basis for the development of appropriate corrective measures in the implementation of strategies
and policies in public institutions in South Africa. This can contribute to more successful strategy and
policy implementation and the consequential implementation of appropriate IS in public hospitals in
South Africa and other public institutions. This can lead to service delivery improvement at public

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hospitals or other public institutions in South Africa and improved service provision to the vast

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majority of the South African population.

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The paper focuses mainly on the hierarchy of stakeholders from an organizational perspective

SC
(national, regional, local, public hospital) but less explicitly on the clinical perspective and on consumer
(patient) stakeholders. The clinical perspective also includes hierarchical relationships (e.g. clinics,
national medical associations, etc.) as well as the complex relationships at the intra-hospital level

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associated with clinical governance. This perspective is equally pertinent to IS strategy
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implementation and could be an exciting area for future research. Consumer stakeholders are the
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ultimate beneficiaries of IS strategy, and their role in IS strategy implementation is another area for
future research. By pursuing such research the interaction between organizational, clinical and
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consumer stakeholders in the context of IS strategy implementation can be better understood.

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Summary Points
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What is known
Strategic Information Systems (IS) Planning, as with the private sector is a necessary requirement for
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achieving value from IT in the public sector, including for public hospitals.
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IS Strategy implementation is fraught with difficulty and failures

Stakeholder involvement and participation is a necessary requirement for IS strategy implementation

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success.

What this study adds

The study offers an account of stakeholder relations in IS strategy implementation and their
actions/interaction in the context of public hospitals in developing countries
The study explains how the dynamics of stakeholder relations lead to the situatedness of IS strategy
implementation, and ultimate IS strategic achievement, taking into account modalities and contextual
conditions.

Acknowledgement
This study has been fully sponsored by the Council for Scientific and Industrial Research (CSIR) Meraka

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Institute, South Africa.

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Author Biographies

Boroto Hwabamungu holds a PhD in Information Systems from the University of Cape Town. He
completed his PhD in 2014. He completed a Masters degree in Informatics from the University of
Pretoria with a distinction for his Masters’ thesis in 2009. He completed the BCom and Honours
Degrees in Information systems from the University of the Western Cape (UWC) in 2005 and 2006
respectively. He is presently undertaking the establishment of a not for profit organisation (NPO)

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focusing on health systems strengthening in Africa through multiple health systems’ actors

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participatory engagements. His research interests are: Health Information Systems, Strategic
Information Systems Planning (SISP), mHealth, Information and Communication Technology (ICT) for

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development (ICT4D) and ICT for sustainable development.

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Boroto is the primary author of the paper, which is derived from his PhD thesis work on the same
topic.

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Irwin Brown is a Professor in the Department of Information Systems (IS) at UCT, and Deputy Director
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of the Centre for IT and National Development in Africa (CITANDA). He graduated with a Masters in IS
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(Curtin University) in 1995 and PhD (UCT) in 2005. Irwin holds positions as SAICSIT Deputy President,
M

IS Associate Editor of Information & Management journal, and Editor of the African Journal of IS. His
research interests relate to the use of grounded theory methodology in IS studies, and issues around
IS in developing countries. He has published more than 30 journal articles in outlets such as the
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European Journal of IS, IT for Development, Communications of the AIS, Journal of Global Information
Management, and the International Journal of Information Management. He has also published more
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than 50 peer-reviewed conference papers in outlets such as ECIS, AMCIS, ACIS, IFIP WG9.4, IFIP WG8.2
and SAICSIT.
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Irwin served as Main Supervisor for the PhD thesis, and contributed to writing up the paper by
CC

reviewing literature on IS strategizing and strengthening the conceptual background, defining the line
of argumentation, and refining the structure and language.
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Quentin Williams focuses on the formulation and implementation of research strategy within the
information and communications (ICT) domain and in particular, he facilitates data science skills
programmes across the national ICT research and development ecosystem for the CSIR, South Africa.
He completed a BEng in Electronic Engineering at Stellenbosch University, followed by a PhD in
Engineering from the University of Oxford in the United Kingdom with emphasis on using medical
image analyses to understand cardiac disease.
Quentin served as Co-Supervisor for the PhD thesis, and contributed to writing up the paper by
assisting in the analysis and interpretation of data and framework development.

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SC
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A
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 Collective groups

Information system strategy implementation

Means of coordination and communication Elements
of work
activity
Actors: Subjects
Stakeholders’ relations

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Individuals

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Means of work/Tools Groups
Actions
Work process

R
Object

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Transforms into
Outcome

U
N
Mode of operation: historical phases
A
Relations with other activities: network of activities

Contradictions
M

Figure 1: ActAD framework adaptation for the purpose of the study

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 Raw data or interview excerpts

Activity theory and thematic analysis level 1 of each case study data

First level: Preliminary emerging concepts

Coding and grouping and of preliminary concepts from each case

Second level: Developed themes

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Coding and grouping and summarising of themes from each case

IP
Third level: summarised themes

R
Coding, combination and grouping of findings from both cases

SC
Fourth level: Combined case study findings

Summarising of final develop themes

U
N
Firth Level: Findings
A
Identification and development of relations between framework’s elements
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Sixth level: FRAMEWORK DEVELOPMENT

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Figure 2: Data analysis: thematic analysis approach

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 A. Stakeholder groups for IS strategy implementation

A1.Stakeholder group hierarchies and networks and roles

A2.Stakeholder groups’ associated activities’ hierarchy

Flow of influence

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B. Modalities (Rules & contextual factors) &
Flow of influence

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SC
E. Situationality of relations and
groups’ interactions

implementation
C. Stakeholder

groups’ actions
D. Stakeholder
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E1. IS strategy implementation decisions
N
E2. Situational dynamics of stakeholder
relations
A
Situational IS strategy implementation
M
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F. IS strategic achievement:
Attainment of strategic goals
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Figure 3: The Stakeholder Relations Influence Framework

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Table 1: Outcome of final iteration of thematic analysis

Major Themes Sub-Themes

Stakeholder groups for IS strategy Network, hierarchy of the relevant stakeholder groups and their
implementation respective hierarchical roles

The hierarchical levels of activities related to the implementation of IS

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strategy

IP
Situationality of relations and Situational dynamics of stakeholder relations and situational IS strategy
implementation implementation

R
Decisions regarding various aspects of IS strategy implementation

Modalities (rules and contextual Modalities of engagements between stakeholder groups and IS strategy

SC
factors) and flows of influence implementation

Contextual factors affecting the engagements between stakeholder

groups and the implementation of IS strategy

U
Model of funding of IS strategic initiatives
N
Model of management of contracts
A
Approach to continuity of projects and IS strategic initiatives
M

Stakeholder groups’ Interactions Level and motive of interaction, involvement and participation in
activities and processes

Timeliness of stakeholder groups’ activities deliverables and impact on

ED

the attainment of IS strategy implementation objectives

Stakeholder groups’ actions Group of activities and processes related to IS strategy implementation
PT

IS strategy form, formulation, scoping, revision and development of IS

strategic initiatives

Model of deployment of IS strategic initiative

E

Adherence to contractual obligations, modalities and contextual

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requirements

IS strategic achievement Attainment of strategic goals

A